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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
30 B. Dallemagne
a
Fig. 5.1 Trocars placement
Fig. 5.2 Exposure of operative field
5.2.6 Mediastinal Dissection and Esophagus Mobilization
By esophageal retraction, a complete mobilization of the
esophagus is performed in order to get enough intraabdominal esophagus (at least 3 cm) (Fig. 5.8).
b
Fig. 5.3 Division of the pars flaccida. Close (a) and schematic view
(b)
5.2.7 Construction of Floppy Wrap
To make a floppy fundoplication, gastric fundus should
be dissected by dividing the short vessels (Fig. 5.9). The
315 Laparoscopic Nissen Fundoplication
a
a
b
b
Fig. 5.5 Dissection of the esophagus from the left crus. Close (a) and
schematic view (b)
Fig. 5.4 Exposure of the crura. Close (a) and schematic view (b)
5.2.8 Crural Opposition
division of the short vessels must be performed from down
to up. After that, the gastro-phrenic ligament must be
divided (Fig. 5.10).
The crura are approximated by non-absorbable stitches.
Posterior crura are closed taking the whole muscular thickness (Fig. 5.11). Posteriorly, anterior portion is closed with
the same suture (Fig. 5.12).
32 B. Dallemagne
ab
Fig. 5.6 Circumferential exposure of the esophagus. Anterior (a) and posterior dissection (b)
5.2.9 Construction of Fundoplication
This step is divided into the next manoeuvres:
– Pulling the fundus: The mobilized fundus is widely
pulled through the window created behind the esophagus
(Fig. 5.13).
– Creating the fundoplication: A floppy 360° fundoplica-
tion is created by 3 stitches. Some stitch should be fixed
to the esophagus (Fig. 5.14).
– Fixation of wrap to the esophagus: The wrap should be
fixed to the esophagus in order to avoid any slippage
(Fig. 5.15).
Fig. 5.7 Taping of the esophagus for retraction
ab
Fig. 5.8 Mediastinal dissection and esophagus mobilization. Anterior (a) and lateral (b) dissection
335 Laparoscopic Nissen Fundoplication
34 B. Dallemagne
a
b
Fig. 5.10 Gastro-phrenic ligament division
c
Fig. 5.9 Fundus dissection. Close (a, b) and schematic view (c)
355 Laparoscopic Nissen Fundoplication
a
a
b
b
c
c
Fig. 5.11 Posterior crura closure. Close (a, b) and schematic view (c)
Fig. 5.12 Anterior crura closure. Close (a, b) and schematic view (c)
36 B. Dallemagne
a
a
b
b
c
Fig. 5.13 Pulling the fundus through the window created behind the
esophagus. Close (a, b) and schematic view (c)
c
Fig. 5.14 Creating the fundoplication. Close (a, b) and schematic
view (c)
375 Laparoscopic Nissen Fundoplication
a
b
Fig. 5.15 Fixation of wrap to the esophagus. Close (a) and schematic
view (b)
Fig. 5.16 Final view of the Nissen fundoplication
38 B. Dallemagne
ab
Fig. 5.17 Laparoscopic (a) and endoscopic (b) view of the fundoplication
5.2.10 Completed Procedure
When the fundoplication is completed, it is time to check
all the operative field (Fig. 5.16). Then, endoscopy is per-
formed in order to check neither stenosis nor perforation
has been done (Fig. 5.17).
2. Du X, Wu JM, Hu ZW, Wang F, Wang ZG, et al. Laparoscopic
Nissen (total) versus anterior 180° fundoplication for gastroesophageal reflux disease: a meta-analysis and systematic review.
Medicine (Baltimore). 2017;96:e8085.
3. Dallemagne B, Weerts J, Markiewicz S, Dewandre JM, Wahlen C,
Monami B, et al. Clinical results of laparoscopic fundoplication at
ten years after surgery. Surg Endosc. 2006;20:159–66.
4. Dallemagne B, Perretta S. Twenty years of laparoscopic fundoplication for GERD. World J Surg. 2011;35:1428–35.
References
1. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard
R. Laparoscopic Nissen fundoplication: preliminary report. Surg
Laparosc Endosc. 1991;1:138–43.
Minimally Invasive Surgery of Paraesophageal Hernias
Salvador Morales-Conde, Francisco Lopez Bernal
and Isaías Alarcón
6
6.1 Introduction
Paraesophageal hernia repair and the use of a mesh to avoid
any tension during repair is a controversial issue [1]. On
one side, due to complications related to those prosthetic
materials and, on the other side, about the type of mesh to
be used and where they should be placed.
The steps of the repair of the paraesophageal hernia are:
1. Dissection of the hiatus and the complete excision of the
sac;
2. An adequate mobilization of the esophagus;
3. The repair of the hiatus;
4. To perform an antireflux procedure.
The step 3 seems to be the most controversial one, and it concerns when can the crura be approximate with or without a
prosthetic mesh. According to the literature, it can be observed
that the use of a mesh is associated with excellent short term
results with a success rate of 90%, although in the long term,
some series report a high recurrence rate even of 100%.
The reason of these controversial results may be related
to the fact that the use of a mesh is the only factor analyzed
without taking in consideration other important factors
related to recurrence [2] such as excision of the sac, adequate mobilization of the esophagus, closure of the crura,
and the type of suture used.
The indication to use a mesh is under debate. In a survey
conducted by SAGES [3], there were different reasons that
lead surgeons to use a mesh: the size of the defect (some
of them when defects were larger than 3 cm, others when
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_6) contains
supplementary material, which is available to authorized users.
more than 5, cm and other groups of surgeons when the
defect is larger than 8 cm), tension detected at the crura,
poor crural tissue, obesity, or the age of the patient.
Prospective randomized trials comparing the use of a
mesh versus non-mesh repair have showed better results
when a mesh was used after one year of follow-up [4, 5],
but the systematic review published in 2016 [6] shows that
even when the results in term of recurrence are lower, the
reoperation’s rate is the same in both groups.
The reasons for reoperations in the mesh group are due
to complications related to the use of the mesh in the hiatus, such as stenosis or extrusion of the mesh through the
esophagus [7]. The use of absorbable mesh as an alternative
has an unacceptable recurrence rate in the long term [8–10].
Due to previous reasons, our protocol consists in the use
of a permanent or absorbable mesh depending on the size
of the hernia. The size of the hernia is based on the distance
from the gastro-esophageal junction to the cura measured
by the endoscopist, and it not based on the intraoperative
measurement of the distance between both crura, since this
distance could be very narrow even in large hernias. We do
not like either to base our decision on the subjective criteria used by some groups of the strength of the crura. If this
distance is not measured by endoscopist (for different reasons), we use the obtained, by the barium swallow perform
to evaluate the type and size of the hernia.
Based on this information different meshes are used in
the following situations:
Absorbable meshes:
• for sliding hernias from 3 to 5 cm or in case the endoscopist
does not offer this measurement, if just the fundus is herni-
ated in the image offered by the barium swallow.
Permanent meshes:
S. Morales-Conde (*) · F. Lopez Bernal · I. Alarcón
Unit of Innovation in Minimally Invasive Surgery, University
Hospital Virgen del Rocío, University of Sevilla, Sevilla, Spain
e-mail: smoralesc@gmail.com
© 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_6
• for sliding hernias larger than 5 cm; and in case the
endoscopist does not offer this measurement, if more
than the fundus is herniated in the image offered by the
barium swallow.
39