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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
40 S. Morales-Conde et al.
• paraesophageal hernias
• “up-side down” stomach
Our goals of using a mesh has always been to guarantee
that there will be no complications related to the prosthetic
materials, avoiding recurrences at the same time. In order to
avoid these complications, that might lead to reoperations,
we follow the next considerations:
– In order to avoid stenosis, we never place the mesh
around the esophagus since most of the meshes show
some degree of shrinking. For this reason, we place the
mesh behind the esophagus with the lateral part covering
both crura.
– On the other hand, one of the key steps to avoid mesh
extruction into the esophagus is to avoid the direct contact of the mesh with it. For this reason, the mesh is fixed
to the crura with just one or two stitches and fibrin glue,
which will cover the whole mesh, especially in the area
where the prosthetic material is in close contact with the
esophagus. Fibrin glue will maintain the mesh in place
and it will create natural tissue that will cover the mesh
avoiding direct contact between the esophagus and the
mesh.
6.2.2 Patient and Trocars’ Position
The patient is placed in supine decubitus position, and five
trocars are placed (Fig. 6.1).
6.2.3 Reduction of the Sac and Its Contents
to the Abdominal Cavity
Reduce completely as it can or as much as possible the contents of the hernia to the abdominal cavity (Fig. 6.2):
– Make traction of the stomach toward the right leg of the
patient.
– Start dissection at the left crus, cutting the peritoneum at
the rim of the crus (this is the limit of the incision along
the hiatus).
In large paraesophageal hernias where the reduction of the
contents of the hernia is not complete, pull down the sac
with the herniated stomach.
6.2 Description of the Surgical Technique (Video 6.1)
6.2.1 Instruments and Equipment Required
• Five trocars are placed to perform this surgical proce-
dure: two 10–11 mm trocars, for the camera and for
the right working hand of the surgeon to introduce the
energy device and the sutures, and three 5 mm trocars,
for the left hand of the surgeon and for the assistant to
retract the liver and to pull the stomach
• A 10 mm 30º scope
• As energy devices, we prefer to use the ultrasonic scalpel
• Conventional laparoscopic instruments, including
endograspers, endoscissors, and endodissectors
• An endograsper to retract the liver
• Endostitch® suturing devices
• Suture: surgidac® 2/0
• Mesh: Omyra® or BioA® mesh, depending on the size of
the hernia as it has been previously mentioned
• Fibrin glue and its spray applicator
Fig. 6.1 Trocars placement
The key steps to perform a laparoscopic correction of a
paraesophageal hernia are.
Fig. 6.2 Reduction of the sac and its contents to the abdominal cavity. Schematic (a) and close view (b, c)
416 Minimally Invasive Surgery of Paraesophageal Hernias
6.2.4 Division of the First Short Vessels
Transect the first short vessels to reach the bottom of the
left crus (Fig. 6.3).
6.2.5 Dissection of the Sac, from the Left Crus Anti-Clockwise from Left to Right
Look for the surgical plane between the sac and the pleura
and continue anti-clockwise while reducing the sac by pulling down (Fig. 6.4).
6.2.6 Dissection Continues to the Dome of the Hiatus and the Right Crus
Maintain the traction of the sac, continue anti-clockwise, cutting the peritoneum at the rim of the hiatus and complete the
reduction of the sac until the bottom of the right crus (Fig. 6.5).
Fig. 6.3 Division of the first
short vessels. Schematic (a)
and close view (b)
6.2.7 The Sac (and Lipomas) is Completely Dissected from Mediastinum into the Abdominal Cavity
Adhesions of the sac to the pleura are completely released
and the sac and lipomas are completely descended to the
abdominal cavity (Fig. 6.5). The sac is only excised if it is
needed to create the fundoplication later.
6.2.8 Mobilization of the Esophagus by Pulling Down the Sac
If the sac is reduced from mediastinum, the esophagus is
dissected free from the sac (Fig. 6.6). The distal esophagus
is mobilized from the mediastinum, blunt dissection and
ultrasonic scalpel, in order to have enough length to come
free in the abdomen.
42 S. Morales-Conde et al.
Fig. 6.4 Dissection of the sac from the left crus. Schematic (a) and close view (b, c)
Fig. 6.5 Dissection of the sac and the crura. Schematic (a) and close view (b, c)
Fig. 6.6 Mobilization of the
esophagus by pulling down
the sac. Schematic (a) and
close view (b)
Fig. 6.7 Creation of a
retroesophageal window.
Schematic (a) and close view
(b–d)
436 Minimally Invasive Surgery of Paraesophageal Hernias
6.2.9 Creation of a Retroesophageal Window
Creation of a retroesophageal window and to obtain a
correct traction of the gastro-esophageal junction to the
abdominal cavity with a goldfinger device (Fig. 6.7).
6.2.10 Approximation of the Pillars Using a Bougie (Foucher) for Calibration
In this step, a 32 Foucher is placed inside the esophagus as
tutor.
From the bottom of the crura where both join together
in order to decrease the tension when closing them
(Fig. 6.8). Non-absorbable sutures that include the
perimysium of the hiatal muscle, preserved during the
dissection.
First stich must be placed down at the junction of both
crura (Fig. 6.8). First two stitches are placed posteriorly to
the esophagus and the third one anteriorly before to continue with posterior sutures combined with some anterior
sutures when needed.
In order to close the hernia hole correctly, anterior suture
of the crura is required in many cases (Fig. 6.9).
Fig. 6.8 Approximation of the pillars (posterior side). Schematic (a) and close view (b,c)
44 S. Morales-Conde et al.
Fig. 6.9 Approximation of the pillars (anterior side). Schematic (a) and close view (b, c)
Fig. 6.10 Mesh placement.
Schematic (a) and close view
(b–d)
Fig. 6.11. 360 degrees fundoplication. Schematic (a) and close view (b, c)
456 Minimally Invasive Surgery of Paraesophageal Hernias
6.2.11 Mesh Placement
A “U” shaped mesh is placed, and fixed with two stitches to
the crura. Biological glue can also be used, as alternative, to
fix the mesh (Fig. 6.10).
6.2.12 Creation of 360 Degrees Fundoplication
Pull through the fundus behind the esophagus (retroesophageal window), to the right side. Create the fundoplication
by two or three fundus-to-fundus stitches, embracing the
intra-abdominal portion of the esophagus. In this way, a 360
degree fundoplication is performed (Fig. 6.11).
References
1. Targarona E, Bendahan G, Balagué C, Garriga J, Trias M. Mesh in
the hiatus. A Controversial Issue. Arch Surg. 2004;139:1286–96.
2. DeMeester SR. Laparoscopic paraesophageal hernia repair: critical steps and adjunct techniques to minimize recurrence. Surg
Laparosc Endosc Percutan Tech. 2013;23:429–35.
3. Pfluke JM, Parker M, Bowers SP, et al. Hiatal hernia repair
with mesh: a survey of SAGES members. Surg Endosc.
2012;26:1843–8.
4. Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective, randomized trial of laparoscopic polytetrafluoroethylene
(PTFE) patch repair vs simple cruroplasty for large hiatal hernia.
Arch Surg. 2002;137:649–52.
5. Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic
Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a
prospective randomized functional and clinical study. Arch Surg.
2005;140:40–8.
6. Tam V, Winger DG, Nason KS. A systematic reviw and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. 2016;211:226–38.
7. Memon MA, Memon B, Yunus RM, Khan S. Suture cruroplasty
versus prosthetic hiatal herniorrhaphy for large hiatal hernia. A
meta-analysis and systematic review of randomized controlled
trial. Ann Surg. 2016; 263:258–66.
8. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrences after laparoscopic paraesophageal hernia
repair. Ann Surg. 2006;244:481–90.
9. Watson DI, Thompson SK, Devitt PG, et al. Laparoscopic repair of
very large hiatus hernia with sutures versus absorbable mesh versus non-absorbable mesh. Ann Surg. 2015;261:282–9.
10. Antoniou SA, Pointner R, Granderath FA, Köckerling F. The use
of biological meshes in diaphragmatic defects—an evidence-based
review of the literature. Front Surg. 2015;2:56.
Minimally Invasive Treatment of Esophageal Leiomyoma
Donald. L. van der Peet and Miguel A. Cuesta
7
7.1 Introduction
Benign tumors of the esophagus are rare tumors, being
around 1% of all esophageal tumors. In children, cysts and
duplications cysts are rare congenital disorders of the foregut. In adults, the most frequent benign esophageal tumor is
the leiomyoma, submucosal located and formed by smooth
muscular fibers. They are most frequently located in the
lower and mid esophagus. Asymptomatic tumors are diagnosed during routine endoscopic examination or CT scan
performed for other reasons such as gastroesophageal reflux
or chest complaints. Symptoms are dysphagia, chest discomfort or pain, regurgitation, and weight loss [1].
Initial diagnosis is the endoscopic examination where
the diagnosis of intramural tumor (bulge) with intact
mucosa can be diagnosed. Endoscopic ultrasonography can
confirm the diagnosis of benign intramural tumor, penetration in the esophageal wall, and size of the tumor. CT scan
and barium swallow can help to locate the tumor and visualize its extension. Fine needle aspiration biopsy can confirm the smooth muscular fibers of the tumor, but its value
remains controversial because of the difficulty of the diagnosis and the fibrosis that can produce making enucleation
difficult. Differential diagnosis with GIST (gastrointestinal
stromal tumors) tumors may be difficult. Esophageal GIST
are very rare. PET scan can help to differentiate between
the two, the leiomyoma showing a negative PET scan
image.
In some cases, where the tumor is small and the diagnosis is certain, without symptomatology, the patient can
be followed conservatively. Symptomatic tumors, tumors
with uncertain diagnosis, and large size tumors should be
resected. In small tumors, endoscopic treatment is possible
and POEM (per oral endoscopic myotomy) treatment is one
of the treatment modalities. Enucleation via thoracoscopy is
the choice approach, lateral or in prone, depending on the
side of thoracoscopy, the location of the tumor. Concerning
the size of the tumor, it can be classified as small between 2
and 5 cm, and large more than 5 cm. Both can be treated by
thoracoscopic enucleation [2], being very large tumors difficult to manipulate during the enucleation. Lesions of
the mucosa have to be repaired and covered by muscular layer. Robot-assisted thoracoscopy can help to dissect
the large tumors [3]. If enucleation is not technically possible, esophageal resection should be considered. Tumors
located in the very distal part of the esophagus should be
approached by laparoscopy [4, 5].
7.2 Description of the Surgical Technique (See Videos 7.1 and 7.2)
If the tumor is located in the thoracic esophagus, two types
of enucleation can be considered in relation with the size of
the tumor: relative small size (2–5 cm) and giant leiomyoma (between 5 and 10 cm). We approach these tumors by
thoracoscopy in prone, depending on the side of the thoracoscopy where the tumor is located, right or left.
The key steps to perform a thoracoscopic tumor resec-
tion are:
1. Trocar placement. Thoracoscopy in prone position
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_7) contains
supplementary material, which is available to authorized users.
D. L. van der Peet · M. A. Cuesta (*)
Department of Surgery, Amsterdam UMC, Amsterdam,
The Netherlands
e-mail: ma.cuesta@amsterdamumc.nl
© 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_7
Three or four trocars are placed along the scapula. Single
intubation and thoracic insufflation (7–8 mm Hg). Trocars:
10 mm in the tip of the scapula for the 30 degrees laparoscope, two work trocars: 5 mm in the 4th intercostal space
and 10 mm in the 7th intercostal space. Another 5 mm may
be used for the assistant, placed in the 3rd intercostal space
(Fig. 7.1).
47
48 D. L. van der Peet and M. A. Cuesta
2. Localization of tumor
Localize the leiomyoma by visualization (Fig. 7.2) and if
needed by endoscopy.
3. Opening the pleura along the tumor
Open the pleura longitudinally along the tumor (Fig. 7.3).
Due to the localization of the tumor, in this case, the azygos
vein arch is divided.
4. Dissection of the tumor
We recommend to start the dissection around the tumor,
splitting muscular fibers (Fig. 7.4).
5. Retraction by stitch
Put a stitch through the tumor in order to pull it (Fig. 7.5),
helping for the blunt dissection, trying always to preserve
the integrity of the mucosa.
6. Mucosa inspection and if needed repair
At the end, it is necessary to check the mucosa by esophagoscopy (Fig. 7.6) and if it is open, then close the defect with
running suture with resorbable monofilament 4–0.
7. Approximation of muscular layer
Approximate the muscular layer by running suture (Fig. 7.7).
8. Specimen extraction
The specimen is removed into a bag through a small thoracotomy (Fig. 7.8).
9. Thoracic drain
It is recommended to leave a drain in the thorax.
10. Endoscopic control
To evaluate total resection and to check the aspect of the
mucosa, an esophagoscopy is performed after the tumor has
been resected.
Fig. 7.1 Trocars placement
Fig. 7.2 Localization of the
tumor. Schematic view (a)
and close view (b)
Fig. 7.3 Opening the pleura along the tumor
Fig. 7.4 Dissection of the tumor (a), splitting muscular layers (b, c)
Fig. 7.5 Stitch through
the tumor (a) to maintain a
correct traction (b)
497 Minimally Invasive Treatment of Esophageal Leiomyoma
Fig. 7.6 Mucosa inspection and repair. Schematic view (a), intrathoracic view without (b), and with transillumination (c)
50 D. L. van der Peet and M. A. Cuesta
Fig. 7.7 Opened muscular
layer (a). Approximation of
muscular layer (b)
In cases of leiomyomas located in intraabdominal esophagus, we start the procedure as any other upper laparoscopic
surgery around the hiatus and we follow these steps:
1. Dissection of the distal esophagus.
2. Localization of the tumor by visualization and palpation
and if needed by endoscopy.
3. Put a tape around the esophagus for traction.
4. Start splitting the muscular fibers on the tumor.
5. Stitch in the tumor for traction.
6. Hook and blunt dissection, preserving the mucosa.
7. Endoscopic control suturing the muscular layer.
Fig. 7.8 Specimen extraction
By large leiomyomas, the same technique is followed,
using for blunt dissection the hook, and sealing devices.
Manipulation of the tumor may be difficult because of the
size. Finding the mucosa is a good reference mark for dissection. In case of difficult dissection, conversion to thoracotomy should be considered. If enucleation is not possible
or mucosa is importantly damaged, an esophageal resection
should be done.
References
1. van der Peet DL, Berends FJ, Klinkemberg-Knol EC, Cuesta MA.
Endoscopic treatment of benign esophageal tumors: case report of
three patients. Surg Endosc. 2001;15:1489.
2. Coral RP, Madke G, Westphalen A, Tressino D, Carvalho LA,
Mastalir E. Thoracoscopic enucleation of a leiomyoma of upper
thoracic esophagus. Dis Esophagus. 2003;16:339–41.
3. Boone J, Draaisma WA, Schipper ME, Broeders IA, Rinkes IH, van
Hillegersberg R. Robot-assisted thoracoscopic esophagectomy for a
giant upper esophageal leiomyoma. Dis Esophagus. 2008;21:90–3.
4. Kent M, d'Amato T, Nordman C, Schuchert M, Landreneau R,
Alvelo-Rivera M, et al. Minimally invasive resection of benign
esophageal tumors. Thorac Cardiovasc Surg. 2007;134:176–81.
5. Samphire J, Nafteux P, Luketich J. Minimally Invasive techniques
for resection of benign esophageal tumors. Semin Thorac Cardiovas
Surg. 2003;15:35–43.