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71 Surgical Anatomy of the Esophagus
posterior pulmonary plexus (77% of right lung innervation). Lymph node station #7 and 10R are located anterior
to these branches. The left pulmonary plexus is composed
similarly.
Below the level of the main bronchi the vagus nerves
form the extensive peri-esophageal plexus. In general, the
nerve fibers rearrange at the level of the esophageal hiatus
in a vagal trunk anterior and posterior to the esophagus,
which course caudally to innervate the abdominal organs.
References
1. Esophagus. In Wikipedia. Retrieved April 3, 2018, from https://
en.wikipedia.org/wiki/Esophagus.
2. Boeckxstaens GE. The lower oesophageal sphincter.
Neurogastroenterol Motil. 2005 Jun; 17 Suppl 1:13–21.
3. Apaydin N, Uz A, Evirgen O, et al. The phrenico-esophageal liga-
ment: an anatomical study. Surg Radiol Anat. 2008;30:29–36.
4. Cuesta MA, Weijs TJ, Bleys RL, et al. A new concept of the
anatomy of the thoracic oesophagus: the meso-oesophagus.
Observational study during thoracoscopic esophagectomy. Surg
Endosc. 2015; 29:2576–82.
5. Guidera AK, Dawes PJD, Fong A, et al. Head and neck fascia and
compartments: no space for spaces. Head Neck. 2014;36:1058–68.
6. Weijs TJ, Goense L, van Rossum PS, et al. The peri-esopha-
geal connective tissue layers and related compartments: visualization by histology and magnetic resonance imaging. J Anat.
2017;230:262–71.
7. Grodinsky M, Holyoke EA. The fascia and fascial spaces of the
head, neck and adjacent regions. Am J Anat. 1938;63:367–408.
8. Liebermann-Meffert DM, Luescher U, Neff U, et al.
Esophagectomy without thoracotomy: is there a risk of intramediastinal bleeding? A study on blood supply of the esophagus. Ann
Surg 1987; 206:184–92.
9. Swigart LL, Siekert RG, et al. The esophageal arteries; an
anatomic study of 150 specimens. Surg Gynecol Obstet.
1950;90:234–43.
10. Weijs TJ, Toxopeus EL, Ruurda JP, et al. Leaving a mobilized thoracic esophagus in situ when incurable cancer is discovered intraoperatively. Ann Thorac Surg. 2015;99:490–4.
11. Butler H. The veins of the oesophagus. Thorax. 1951;6:276–96.
12. Sakata K. Uber die Lymphgefasse des Oesophagus und uber seine
regionalen. Lymphdrusen mit Berucksichtigung der Verbreitung
des Karcinoms. Mitt Grenzbeg Med Chizg 1903; 11:634–56.
13. Murakami G, Sato I, Shimada K, et al. Direct lymphatic drainage from the esophagus into the thoracic duct. Surg Radiol Anat.
1994;16:399–407.
14. Cuesta MA, van der Wielen N, Weijs TJ, et al. Surgical anatomy
of the supracarinal esophagus based on a minimally invasive
approach: vascular and nervous anatomy and technical steps to
resection and lymphadenectomy. Surg Endosc. 2017;31:1863–70.
15. Kajitani T. The general rules for the gastric cancer study in surgery and pathology. Part I Clinical classification. Jpn J Surg. 1981;
11:127–39.
16. Ziyade S, Pinarbasili NB, Ziyade N, et al. A. Determination of
standard number, size and weight of mediastinal lymph nodes in
postmortem examinations: reflection on lung cancer surgery. J
Cardiothorac Surg. 2013; 8:94.
17. Defize IL, Schurink B, Weijs TJ, et al. The anatomy of the thoracic duct at the level of the diaphragm: a cadaver study. Ann Anat.
2018;217:47–53.
18. Liebermann-Meffert DM, Walbrun B, Hiebert CA, Siewert
JR. Recurrent and superior laryngeal nerves: a new look with
implications for the esophageal surgeon. Ann Thorac Surg.
1999;67:217–23.
19. Yalcin B, Tunali S, Ozan H. Extralaryngeal division of the recurrent laryngeal nerve: a new description for the inferior laryngeal
nerve. Surg Radiol Anat. 2008;30:215–20.
20. Weijs TJ, Ruurda JP, Luyer MD, et al. Topography and extent
of pulmonary vagus nerve supply with respect to transthoracic
oesophagectomy. J Anat. 2015;227:431–9.
A Concentric-Structured Model for the Understanding of the Surgical Anatomy in the Upper Mediastinum Required for Esophagectomy with Radical Mediastinal Lymph Node Dissection
Hiroyuki Daiko
2
2.1 Introduction
Understanding the surgical anatomy is the key to reducing surgical invasiveness especially in the upper mediastinal dissection for esophageal cancer, which is supposed
to have a significant impact on curability and morbidity.
However, there is not yet a comprehensive development
of the surgical anatomy of the esophagus, although generally speaking the surgical anatomy in abdominal digestive
surgery has been developed on the basis of embryological
findings of intestinal rotation and fussion fascia [1, 2]. An
understandable concept will be of great value for the standardization of a radical esophagectomy and an adequate lymphadenectomy. Therefore, we developed a hypothesis of a
“concentric-structured model” of the surgical anatomy in
the upper mediastinum based on human embryonic development [3, 4].
2.2 Surgical Anatomical Model
This model is characterized by three factors: (1) a concentric and symmetric three-layer structured, (2) bilateral vascular distribution, and (3) an “inter-layer potential
space” composed of loose connective tissue. The concentric three-layer structure consists of the visceral layer, the
vascular layer, and the parietal layer in transversal and
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_2) contains
supplementary material, which is available to authorized users.
H. Daiko (*)
Department of Esophageal Surgery, National Cancer Center
Hospital, Chuo-ku, Tokyo, Japan
e-mail: hdaiko@ncc.go.jp
coronal sectional views (Figs. 2.1 and 2.2): the visceral
layer containing the esophagus, trachea and recurrent laryngeal nerves as the central core, the vascular layer of major
blood vessels surrounding the visceral core to maintain
the circulation, and the parietal layer as the outer frame of
the body. The bilateral vascular distribution consists of the
inferior thyroid arteries and bronchial arteries originating
from the bilateral dorsal aortae in an embryo. This bilateral vascular distribution may be related to the formation of
the proper mesentery of the esophagus and frequent lymph
node metastasis observed in the visceral layer around recurrent laryngeal nerves (Fig. 2.3). The three concentric layers
are bordered by loose connective tissue called the “interlayer potential space”. This inter-layer potential space is
the fundamental factor of our concentric-structured model
as the appropriate surgical plane of dissection. The peripheral blood vessels, nerves, and lymphatic transition between
each layer, thereby penetrating this loose connective tissue
forming the inter-layer potential space. Recurrent laryngeal
nerves also transition from the vascular layer after branching off from the vagal nerves and then ascend consistently
in the visceral layer.
2.3 Validation of the Surgical Procedure
We investigated the validity of this concentric-structured
model, confirming the intraoperative images and the surgical outcomes of thoracoscopic esophagectomy in a prone
position (TSEP) before and after the introduction of this
hypothetical anatomy model (Video 2.1). A total of 226
patients with esophageal cancer underwent this procedure
from January 2015 to December 2016. After the introduction of this model, the surgical outcomes in 105 patients
clearly improved for the operation time of the thoracoscopic procedure (160 min vs 182 min) and the incident
or recurrent nerve palsy (19.0 vs. 36.4%). Moreover, we
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_2
9
10 H. Daiko
Fig. 2.1 The concentric
three-layer structure of
the upper mediastinum
(transverse section).
Visceral in yellow, vascular
in red, and parietal in
blue. Abbreviations: Tra:
Trachea; Eso: esophagus;
RN: recurrent nerve; SCA:
subclavian artery; CCA:
common carotid artery; SNT:
sympathetic nerve chain; PN:
phrenic nerve
Fig. 2.2 A coronal sectional view of the upper mediastinum showing
the layer transition of both recurrent laryngeal nerves (RLNs). Both
RLNs transition from the vascular layer to the visceral layer immediately after branching off from the vagal nerves (VNs). We believe that
both VNs generally belong to the vascular layer in the upper mediastinum, although they follow the esophagus below the tracheal bifurcation. Similar to this neural transition of the RLNs and VNs, other
peripheral nerves or blood vessels also transition through the interlayer potential space composed of loose connective tissue as shown
in red arrows. Abbreviations: Ao: aortic arch; AzV: azygos vein arch;
Eso: esophagus; RLN: recurrent laryngeal nerve; Rt.B.Art: right bronchial artery; Rt.SCA: right subclavian artery; SNc: cardiac branch of
the sympathetic nerve; Tra: trachea; VN: vagal nerve; R: right; L: left.
Fig. 2.3 Total meso-esophagus excision. Lymph nodes stations
(Japanese system of lymph node stations for esophageal cancer).
Yellow: esophagus; Green: dissection plane; Blue: carina
were able to identify the concentric and symmetric layer
structure through surgical dissection along the inter-layer
potential space between the visceral and vascular layers
(viscero-vascular space) in all 105 patients after introduction of the hypothetical model [4].
Previously, different concepts have been given to the
model of the meso-esophagus [5–7], adding clarity to the
surgical anatomy of the mediastinum.
Our model, the concentric-structured model based on
embryonic development is clinically beneficial for achieving less-invasive esophagectomy by ensuring a theoretical understanding of the surgical anatomy in the upper
mediastinum.
112 A Concentric-Structured Model for the Understanding …
References
1. Sadler TW. Langman’s Medical Embryology. North American:
Lippincott Williams & Wilkins; 2014.
2. Mukherji SK, Castillo M. A simplified approach to the spaces of the
suprahyoid neck. Radiol Clin North Am. 1998;36:761–80.
3. H. Fujiwara, J. Kanamori, Y. Nakajima, T.et al. An anatomical
hypothesis: a “concentric-structured model” for the theoretical
understanding of the surgical anatomy in the upper mediastinum
required for esophagectomy with radical mediastinal lymph node
dissection. Disease of Esophagus. 2018; 32:1–9.
4. Daiko H, Nishimura M. A pilot study of the technical and oncologic
feasibility of thoracoscopic esophagectomy with extended lymph
node dissection in the prone position for clinical stage I thoracic
esophageal carcinoma. Surg Endosc. 2012;26:673–80.
5. Hwang SE, Kim JH, Bae SI, Rodriguez-Vazquez JF, Murakami G,
Cho BH. Mesoesophagus and other fascial structures of the abdominal and lower thoracic esophagus: a histological study using human
embryos and fetuses. Anat Cell Biol. 2014;47:227–35.
6. Cuesta M A, Weijs T J, Bleys R L, van Hillegersberg R, van Berge
Henegouwen MI, Gisbertz SS, et al. A new concept of the anatomy of
the thoracic oesophagus: the meso-oesophagus. Observational study
during thoracoscopic esophagectomy. Surg Endosc 2015; 29: 2576–82.
7. Matsubara T, Ueda M, Nagao N, Takahashi T, Nakajima T, Nishi
M. Cervicothoracic approach for total mesoesophageal dissection in cancer of the thoracic esophagus. J Am Coll Surg.
1998;187:238–45.
A Surgical Concept for the Subcarinal Anatomy of the Esophagus and Mediastinum
Miguel A. Cuesta
3
3.1 Introduction
There are two important Minimally Invasive
Esophagectomy approaches, the three-stage McKeown
procedure with cervical anastomosis and the two-stage
Ivor Lewis procedure with intrathoracic anastomosis. The
second approach is performed increasingly in countries
where the predominant esophageal cancer is the adenocarcinoma frequently localized in the distal esophagus and
the Gastroesophageal Junction (type 1 and 2 according to
Siewert). The three-stage McKeown is performed in proximally localized Adenocarcinomas and in all squamous cell
cancers localized in the thoracic esophagus.
A comprehensive concept of the live surgical anatomy
is necessary for ensuring anatomical accuracy as well as
reproducible radical surgical resections for cancer. Heald
and Ryall’s definition of the total mesorectal excision
(TME) of the mesorectum has been of paramount importance for obtaining a radical resection of rectal cancers by
engaging an adequate surgical resection [1].
In the case of the esophagus, having a clear concept
regarding the resection margins and the relation with the
thoracic aorta is important for standardizing the operative
technique and optimizing the radicality of surgery.
Essential for realizing these goals is having accurate
knowledge of the embryological development of the esophagus, the respiratory tract, and the mediastinum. It seems that
the development of proximal esophagus (until the carina
level) may be different than the development of the distal one. Yet, in embryology, no complete agreement exists
on how the early foregut differentiates into the respiratory
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_3) contains
supplementary material, which is available to authorized users.
M. A. Cuesta (*)
Department of Surgery, Amsterdam UMC, Amsterdam, The
Netherlands
e-mail: ma.cuesta@amsterdamumc.nl
tract and the intestinal tract. In particular, the formation of
the early lung buds as well as the process of separation of
trachea and esophagus remains still unclear [2, 3]. Metzger
et al. studied this development using an electron microscope
to scan chicken embryos. They illustrated the steps of the
normal foregut development, which ultimately leads to the
development of larynx and trachea on the one hand, and
pharynx and esophagus on the other hand [4].
In this chapter, we will describe the surgical anatomy of
the infracarinal mediastinum in order to resect radically the
distal esophageal cancers. This description is based on the
findings acquired by (high definition) visualization during
esophageal resections by thoracoscopy in prone position.
3.2 Surgical Anatomical Observation
Minimally invasive surgical dissection of the esophagus by
thoracoscopy in prone position permits us to observe ‘‘live’’
with magnification of the anatomy as it really is (see Video
3.1). During the dissection, by retraction of the esophagus
(and the pleura covering it and the thoracic duct) gently from
the descending aorta, a thick fascia-like structure is visualized from the aorta arch (carina level) to the lower thoracic
aperture in all patients (Fig. 3.1). This fascia is encountered
between the whole length of the descending aorta and the
left aspect of the infracarinal esophagus. After division of
the superficial part of this fascia, both the bronchial arteries,
coming from the concavity of the aortic arch and between
two and ten esophageal vessels coming from the direction of
the thoracic aorta, are visualized between layers of this fascia
(Fig. 3.2 a and b), thereby suggesting that the fascia is a bilayered structure. Moreover, lymphatics and left vagal nerves are
also present. After division of this fascia (Fig. 3.3 a and b), the
left main bronchus, inferior left pulmonary vein, the pericardial sac, and the most distal part of the contralateral pleura
covering the left lung can be entirely visualized (Fig. 3.4).
On the contrary, on the right side of the esophagus along
the right lung, from the hiatus to the right bronchus, no vessels are encountered during the dissection. Between the
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_3
13
14 M. A. Cuesta
ab
ab
ab
Fig. 3.1 The meso-esophagus between the descending aorta and the thoracic subcarinal esophagus (a, b)
Fig. 3.2 The meso-esophagus between aorta and esophagus showing multiple vessels in between. The left pleura is visualized (a, b)
Fig. 3.3 Division of the meso-esophagus at the proximal level of the descending aorta (a, b). Abbreviations: oe: esophagus; ao: aorta; m-oe:
meso-esophagus
153 A Surgical Concept for the Subcarinal Anatomy …
a
b
Fig. 3.4 Comprehensive concept of the esophageal anatomy visual-
ized from the prone position of the thorax. Abbreviations: ps: pericard
sac; lu: right lung; vp: right pulmonal vein; meso-oe: meso-esophagus; ca: carina and right bronchus; az: azygos vein; ao: aorta; oe:
esophagus
c
level of the carina and the upper thoracic aperture, branches
from bronchial arteries (and vagal nerves, recurrent laryngeal nerves, and lymphatics) and from both inferior thyroid
arteries are encountered and divided on both sides of the
esophagus (Fig. 3.5 a–c). The fascia that encloses vessels
from the aorta to the thoracic esophagus, nerves, and lymphatics, we have named the meso-esophagus.
This subcarinal meso-esophagus is found in 100% of the
patients during ‘‘live’’ dissection. The anatomical concept
of the supracarinal mediastinum is depicted in the Chap. 2
Knowledge of these anatomical principles are essential
for a correct oncological esophageal resection. Fig. 3.4.
offers the comprehensive anatomical picture of the concept.
This novel anatomical concept observed in vivo was
confirmed by histologic findings in cadavers (Fig. 3.6a). In
microscopic sections from the aortic arch level, stained by
the Verhoef-von Giessen method, has showed the bilayer
structure from the aorta to the left lateral side of the esophagus with esophageal arteries inside (Fig. 3.6b). Moreover
MRI of this cadavers mediastinal slices have confirmed the
bilayer meso-esophageal fascia (Fig. 3.6c).
Prospective “live” study has showed that the neoadjuvant treatment with chemoradiotherapy, here used, has not
affected the correct visualization of the meso-esophagus in
all patients studied.
The pertaining new comprehensive anatomical concept
is unmistakeably significant. First, it defines the anatomical
Fig. 3.5 Supracarinal dissection showing the right bronchial
artery and the vessels between the esophagus and trachea (a, b):
Abbreviations: oe: esophagus; tr: trachea; m-oe: meso-esophagus.
Schematic supracarinal anastomy (c): Abbreviations: e: esophagus;
rrln: right laryngeal nerve; lrln: left laryngeal nerve; ao: aorta; lsbra:
left superior bronchial artery; rbra: right bronchial artery; av: azygos
vein; rb: right bronchus; lb: left bronchus; rpv: right pulmonary veins;
lpv: left pulmonary veins; svc: superior vena cava; tr: trachea; rv: right
vagus nerve; lv: left vagus nerve; R. lung: right lung
landmarks of the optimal resection by planes around the
esophagus.
The clear limit for this meso-esophagus is the carina
level. Therefore the left and right bronchial arteries may be
also located in this meso-esophagus and only the branches
to the esophagus have to be divided, preserving the vascular supply of the trachea and bronchi as much as possible.
16 M. A. Cuesta
Fig. 3.6 Cadaver cross
section showing the mesoesophagus (a): Abbreviations:
TD: thoracic duct; AV:
azygos vein. Schematic
section (b): Abbreviations:
Ln: lymph node; RMB: right
brochus; LMB: left bronchus;
TD: thoracic duct; AV:
azygos vein. MRI at the same
level confirming the bilayer
meso-esophagus between
the descending aorta and the
esophagus (c): Abbreviations:
TD: thoracic duct; AV:
azygos vein
a
b
c
173 A Surgical Concept for the Subcarinal Anatomy …
whereas in the case of esophageal resection it will be a difference of the specimen in the case of adenocarcinoma or
squamous cell cancer, being in the last case thinner with
less fat tissue. Therefore in all cases, the final appearance of
the mediastinum after resection will be important to define
the quality of the resection (Fig. 3.7).
Differing, yet learning from previous anatomy studies,
our definition of meso-esophagus derived from live surgical endoscopic anatomy will improve understanding of the
esophageal anatomy, leading to a more adequate and reproducible surgical resection.
Fig. 3.7 How the mediastinal anatomy should be left after esopha-
geal resection
At the level above the carina and on both sides, esophageal
vessels coming from bronchial arteries and from inferior
thyroid arteries can be identified and divided.
After division of this meso-esophagus, the left main
bronchus, the inferior left pulmonary vein, pericardial sac,
and contralateral left pleura can be visualized (Fig. 3.4).
Extension of the meso-esophagus concept supracarinally
has to be investigated, probably the different embryological
origin of this proximal esophagus will have necessary other
surgical anastomical concepts [5].
Other authors have defined the concept of meso-esophagus differently [5–11].
Our definition of meso-esophagus differs from others in
that it primarily defines the anatomical structure containing
the vessels, nerves, and lymphatics (from or to) the thoracic
esophagus. The term ‘‘meso’’ refers to mesentery; however,
classical definition of mesentery refers to two sheets of peritoneum with blood vessels, lymph vessels, and nerves in
between.
In the case of the rectum, as is the case with the esophagus, there is no peritoneal cover at all. Notwithstanding, we
stress the importance of a radical resection along the anatomical defined planes in all kinds of oncological resections: high quality oncologic surgery necessitates adequate
knowledge of these planes [8]. Difference with the mesorectum concept is that in the case of the rectum, the mesorectal fascia can be studied by the pathologist for integrity,
References
1. Heald RJ, Ryall RDH. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986;1:1479–82.
2. Kluth D, Fiegel H. The embryology of the foregut. Semin Pediatr
Surg. 2003;12:3–9.
3. Brugger PC, Weber M, Prayer D. Magnetic resonance imaging of the normal fetal esophagus. Ultrasound Obstet Gynecol.
2011;38:568–74.
4. Metzger R, Wachowiak R, Kluth D. Embryology of the early foregut. Semin Pediatr Surg. 2011;20:136–44.
5. Cuesta MA, Weijs TJ, Bleys RL et al. A new concept of the
anatomy of the thoracic oesophagus: the meso-oesophagus.
Observational study during thoracoscopic oesophagectomy. Surg
Endosc. 2015;29:2576–82.
6. Cuesta MA, van der Wielen N, Weijs TJ et al. Surgical anatomy of the supracarinal esophagus based on a minimally
invasive approach: vascular and nervous anatomy and technical steps to resection and lymphadenectomy. Surg Endosc.
2017;31:1863–1870.
7. Fujiwara H, Kanamori J, Nakajima Y, Kawano T et al. An anatomical hypothesis: a “concentricstructured model” for the theoretical
understanding of the surgical anatomy in the upper mediastinum
required for esophagectomy with radical mediastinal lymph node
dissection. Dis Esophagus. 2019 Aug 1;32(8):doy119. https://doi.
org/10.1093/dote/doy119.
8. Matsubara T, et al. Cervicothoracic approach for total mesoesophageal dissection in cancer of the thoracic esophagus. J Am Coll
Surg. 1998;187:238–45.
9. Marchand P. The anatomy and applied anatomy of the mediastinal
fascia. Thorax. 1951;6:359–68.
10. Riddell AM, et al. High-resolution MRI in evaluation of the surgical anatomy of the esophagus and posterior mediastinum. Am J
Roentgenol. 2007;188:37–43.
11. Izon AS, Jose P, Hayden JD, Grabsch HI. Significant variation
of resected meso-esophageal tissue volume in two-stage subtotal
esophagectomy specimen: a retrospective morphometric study.
Ann Surg Oncol. 2013;20:788–97.
270 Degrees Fundoplication
for Gastroesophageal Reflux
Esophagitis
Ivo A. M. J. Broeders
4
Pathologic reflux disease can be treated by repair of a hiatal
hernia and folding of the gastric fundus around the distaloesophagus just below the hiatal opening. The technique
of folding the fundus around the oesophagus is called fundoplication. It was originally promoted by Rudolph Nissen
and became known as a Nissen fundoplication [1]. In the
original Nissen fundoplication, the fundus is folded completely around the distal oesophagus, and sutured to itself,
usually with three sutures. This is called a 360 degrees
fundoplication.
Numerous variations have been developed and published,
such as the Toupet fundoplication, Thal, Nissen-Rosetti and
valvuloplasty. Most of these fundoplications are partial,
leaving a part of the oesophageal surface uncovered [2]. The
reason for this is the attempt to diminish the burden of one
of the major drawbacks, which is gas bloating [3].
Gas bloating is an expression for annoying postprandial
dyspeptic symptoms caused by trapping of air in the fundus. The surgically created valve does not allow air to pass
from the proximal stomach back to the mouth resulting in
a feel of compression and upper abdominal tension, and
resulting in increase of flatulence.
There is abundant high level scientific proof that partial
fundoplications result in less gas bloating while reflux control at long term is equal [4, 5].
Partial fundoplications should therefore be considered as
options of first choice. Nevertheless, the Nissen fundoplication is probably still the most common type of fundoplication
because of the traditional transfer of knowledge among surgeons and the ease of the procedure. A 270 degrees fundoplication takes more sutures and more in depth insight in local
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_4) contains
supplementary material, which is available to authorized users.
I. A. M. J. Broeders (*)
Meander Medisch Centrum, Amersfoort and University of Twente,
Enschede, The Netherlands
e-mail: IAMJ.Broeders@meandermc.nl
anatomy and will result in a slightly higher operating room
time. Nonetheless a lowering of gas bloating will result in
higher patient satisfaction and therefore this procedure may
be considered as technique of first choice in patients with
pathologic reflux disease and an absent or type 1 hiatal hernia.
4.1 Description of the Surgical Technique
The key steps to perform a laparoscopic 270 degrees fundoplication include the following (Video 4.1).
4.1.1 Patient and Trocar Position
Patient is placed in supine decubitus position. Five trocars
are used to perform this surgery (Fig. 4.1).
4.1.2 Position a Liver Retractor
There are many types of liver retractors available. Reusable
retractors are preferred from cost perspective. They can be
positioned coming from the upper abdomen through a trocar just below the xiphoid bone or through a trocar positioned in the upper and far lateral right abdominal wall.
Liver retractors are preferably placed in mechanical arm
resulting in a stable lift of the left liver lobe (Fig. 4.2).
4.1.3 Opening the Pars Flaccida of the Gastrohepatic Ligament
The procedure starts with opening of the translucent part
of the gastrohepatic ligament, the pars flaccida (Fig. 4.3).
The hepatic branch of the anterior vagal nerve crosses the
pars flaccida in the direction of the left liver lobe (Fig. 4.3).
Cutdown of this small branch allows complete opening of
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_4
19