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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
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M. Nessen and C. A. Galvani
– With/wo pyloroplasty (if conrmed gastroparesis)
• Conversion to RYGB anatomy
– Obesity and/or severe obesity in patients willing to undergo the surgery. Non-
obese patients with more than 2 prior failed fundoplications
– A large hiatal hernia
– Gastroparesis
– Esophageal dysmotility or dilation
– Fundus not suitable for fundoplication
– Nonobese patients with a clear anatomic reason for failure (i.e., wrap disrup-
tion, slipped fundoplication)
• Collis gastroplasty (patients with foreshortened esophagus after extensive mediastinal dissection)
Operative Principles: Robotic Revisional Foregut Surgery
The general principles of revisional procedures are similar regardless of the antireux procedure of choice:
• Access
• Adhesiolysis
– Between the left lobe of the liver and stomach, between the liver and the fun-
doplication, around the hiatus and the GE junction, and nally mobilization of
the fundoplication.
• Crural dissection (taking down the crural repair or not)
• Circumferential dissection of the esophagus in the mediastinum
• Take down the prior fundoplication
• Perform crural closure (mesh vs no mesh)
• Choice of antireux procedure
Presurgical Care: Optimization/Prehabilitation
The preoperative physical status of the patient, the risk of surgery and anesthesia
are important for preoperative risk mitigation [18]. Consideration of comorbid
conditions is equally important as the diagnosis is frequently made in older
debilitated patients and preoperative evaluation is essential for assessing the
operative risk in the individual patient. Special emphasis should be placed on
smoking cessation and alcohol, adjusting antihypertensive and antidiabetic treatment, incentive spirometry for improving breathing capacity, treating anemias,
and improving exercise tolerance [19]. Another modiable risk factor that could
increase the risk for postoperative complications is the patient’s nutritional status. It is well known that many patients suffer from severe dysphagia, nausea,
and vomiting from secondary gastroparesis before reoperative antireux surgery.
Depending on the urgency of the procedure as well as the procedure selection,
the surgical team should decide whether to defer the surgery to minimize postoperative risk.
19 Revisional Foregut andBariatric Surgery
231
Fig. 19.1 Operating room layout. Typical setup for bariatric and foregut robotic cases. The vision
cart is typically opposite to the patient cart and scrub tech with instruments at the foot of the bed
Operating Room Setup
A large operating room is preferable when performing robotic surgery. Larger operating rooms allow the robot components to be stored in the room and allow the operating room personnel to more freely around the room. The room should also facilitate
docking of the system depending on the type of surgery to be performed. Preferably,
the room will be a dedicated room with an integration system to allow for at panel
monitors mounted from the ceiling, CO2 gas is piped directly into the room for insufation, and ceiling-mounted equipment booms can house insufators, electrosurgical units, laparoscopic camera equipment, and lights sources. The operating table is
placed directly under the room lights. Anesthesia equipment is located at the head of
the operating table. The advent of the new da Vinci Xi offers some advantages with
respect to the da Vinci Si providing streamlined setup and port placement.
• An overview of the operating room layout is shown in Fig.19.1.
Patient Positioning
The patient is placed in a supine position with the arms kept open and properly
padded. The patient is then secured to the bed around the legs using a safety
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M. Nessen and C. A. Galvani
strap. Pneumatic compression devices are placed on the lower legs prior to
induction of anesthesia. Following successful endotracheal intubation, an orogastric tube is placed to decompress the stomach. Preoperative antibiotics are
given prior to making an incision. An upper body warming device is then placed
above the nipples. Once the patient is positioned, a face protection donut is used
to protect the patient’s face and endotracheal tube from inadvertent damage or
dislodgement during movement of the robotic endoscope. Once this is established, the abdomen and lower chest are prepped widely with iodine and then
sterile drapes.
Troubleshooting
• The Integrated Table Motion feature of the da Vinci Xi allows for the OR table to
pair with the system. The surgeon can reposition the table during the case to get
optimal exposure and access to the target anatomy, increase autonomy, or provide immediate patient repositioning.
Access/Port Placement/Liver Retraction
The port placement described is specic to the da Vinci Xi System. Entry into
the abdominal cavity is obtained using an optical technique in the periumbilical
area, just to the left of the midline, using an 8 mm robotic optical trocar.
However, if history of open surgery, the entry to the abdominal cavity will
migrate to the left upper quadrant, right upper quadrant, and sometimes periumbilical using a Hassan technique (upper midline incision, hernia repair, etc.). If
optical technique is used, a 5mm 0/30 degree laparoscope is used for access and
port placement. The rst port is placed in the left mid-abdomen two ngerbreadths lateral to the umbilicus and one palm-width inferior to the left costal
margin. This port is used for the robotic camera (arm #2). Insufation is started
to 15mmHg. Three 8-mm trocars are then placed at the same level of the camera
port: 8-mm port on the right midclavicular line (arm #1), one on the left midclavicular line (arm #3), and one in the left anterior axillary line (arm #4). A 5-mm
subxiphoid incision is used for the placement of the Nathanson liver retractor.
Finally, an assistant port (8 mm) is inserted in between arms #2 and #3
(Fig.19.2). At this point, the robotic surgical cart is approximated into position
and the arms are attached to the four specic trocars. The da Vinci Xi Surgical
System can be docked from the patient’s right or left side.
Troubleshooting
• If the liver retractor cannot be placed at the beginning of the case due to adhesions, we still dock the robot to expedite the adhesiolysis. Once this is completed, the left lobe of the liver can be retracted using an internal liver retractor
such as a liver sling (Fig.19.3). This could be done with barbed sutures between
the diaphragm and the abdominal wall.
19 Revisional Foregut andBariatric Surgery
Fig. 19.2 Port placement.
1. 12mm right
midclavicular line. 2.
8mm (camera port) left
and cephalad to umbilicus.
3. 8mm left midclavicular.
4. 8mm left anterior
axillary line. A. Assist port
inferior and between 2 and
3 (or 1 and 2). LR. Liver
retractor subxiphoid
Fig. 19.3 Liver retraction
using barbed suture
233
Adhesiolysis, Crural Dissection, andCircumferential Dissection
oftheEsophagus
Depending on whether the previous procedure was done open or laparoscopic, the
adhesions could form around the midline incision, and most frequently between the
liver and the stomach. The main goal is to clear the anterior stomach/fundoplication/
GE junction if possible.
Early docking of the robot is key to facilitate exposure and visualization
while taking down adhesions. Adhesions are usually taken down with a combination of blunt maneuvers and robotic scissors. The advantages of the articulated monopolar scissors in this stage are related to extended reach and
234
M. Nessen and C. A. Galvani
precision taking down adhesions in tight spaces to separate the liver from the
diaphragm, from the stomach and many times to separate the right crura/stomach from the inferior vena cava (IVC) or the stomach from the splenic area. The
next step is the release of the fundoplication from hiatal structures. If the fundoplication is observed herniated through a tight opening at the hiatus, taking
down the previous crural repair is advised to prevent gastric injuries. Dense
adhesions are usually found between the posterior fundoplication and the previous crural repair. This could also be complicated by the presence of a previously implanted mesh or more nonabsorbable frequently pledgets. Once both
crura are cleared, and a posterior esophageal window is observed, a Penrose
drain is placed around the lower esophagus and circumferential dissection of
the esophagus is started. The lower esophagus is then retracted by arm #4. This
is a key step of this lengthy procedure. Depending on the previous surgery
(e.g., paraesophageal hernia repair), extensive lysis of adhesions and mediastinal dissection will be required.
Careful separation of the mediastinal pleura, aorta, and pericardium from the
esophagus can be challenging. The extensive use of scissors in this situation can
potentially increase bleeding of the operative eld. Transhiatal dissection of the
esophagus is continued in a cephalad direction. The goal of the dissection is to
get to a virgin area within the mediastinum likely proximal to the previous surgery. The articulated vessel sealer/synchroseal device and the force bipolar are
used during this step and are key in this tight space (Fig.19.4). Mobilization of
the esophagus can typically be accomplished using blunt dissection of relatively
thin alveolar tissue by exercising traction and countertraction maneuvers always
dissecting away from the esophagus. The progression of the dissection is as follows: right side of the esophagus, posterior, left side of the esophagus and
anterior.
Fig. 19.4 Anterior
mediastinal dissection.
Sweeping blunt
movements with Arms #1
and #3 used to dissected
mediastinum
19 Revisional Foregut andBariatric Surgery
235
Troubleshooting
• The “scope ip” feature of the Xi system allows to perform a better esophageal
mobilization due to the direct visualization of the mediastinal structures.
• The mediastinal dissection is facilitated by self-driving of the scope and the
extensive use of the fourth arm.
• Pleural injury or tear is not an uncommon complication due to the previous dissection. Although intraoperative capnothorax may develop after the opening of
the mediastinal pleura, its consequences for the patient are negligible since CO2
is quickly reabsorbed and the lung is rarely involved. It is extremely important
for the operating surgeon to communicate with the anesthesiologist if pleural
injury ensues. Adequate monitoring of end-tidal carbon dioxide levels (EtCO2)
and airway pressures will facilitate early diagnosis. Positive end-expiratory pressure (PEEP) application is an effective way of managing pneumothorax secondary to the passage of gas into the pleural space. In our experience, decreasing the
intra-abdominal pressure (10 mmHg) has helped stop CO2 diffusion into the
pleural cavity. We prefer not sealing pleural injury to prevent tension
pneumothorax.
Fundoplication Takedown
This step of the procedure entails taking down the prior wrap and bringing the fundus of the stomach to its original position in the left upper quadrant. This is primarily done with robotic scissors. Identifying the previously the gastro-gastro or
gastroesophageal stitches in the anterior esophagus facilitates this step. We prefer to
start with the right side of the fundoplication and carefully dissecting the right half
of the wrap off the lower esophagus. (Fig.19.5) After this is accomplished, the dissection continues outer side of the wrap. Then the dissection moves to the left side
by dissecting of the wrap from the left side of the esophagus. Any remaining hernia
Fig. 19.5 Takedown of fundoplication. Both right and left side portion of the prior fundoplication
must be freed
236
M. Nessen and C. A. Galvani
sac should be removed. Upper endoscopy usually conrms that the fundoplication
was completely undone. Endoscopy will also conrm the indemnity of the esophagus before the crural repair. The surgeon should also conrm the viability of the
fundus of the stomach if a redo-fundoplication is planned.
Crural Repair
The esophagus is retracted anteriorly and to the left by arm #4, and the vessel
sealer is replaced with a suture cut needle driver. Closure of the diaphragmatic
defect is started at the junction of the right and left crus to decrease tension on
every stitch and is carried out anteriorly. The closure is performed using running
nonabsorbable barbed suture (2-0). We routinely place multiple running loose
bites tightened sequentially (“pulley system”) advancing toward the esophagus
(Fig.19.6).
A 54-56Fr taper tip bougie is passed down the esophagus to tailor the closure and
avoid postoperative dysphagia. However, the bougie is not left in place during the
closure since it will compromise exposure and could also result on injury to the
esophagus.
Troubleshooting
• It is paramount for the surgeon to monitor the advancement of the bougie by the
anesthesia team to prevent esophageal perforations.
• If excessive tension is observed during the crural repair, additional tactics should
be used to decrease radial forces, such as decreasing the pneumoperitoneum
pressure to 8–10 mmHg and loosening the liver retraction. Even though less
frequent relaxing incisions are a suitable alternative.
Fig. 19.6 Posterior crural
repair with barbed suture.
The “pulley system” used
to sequentially tighten
posterior crura to reduce
tension
19 Revisional Foregut andBariatric Surgery
237
• If undue tearing of the right crus is observed, consideration to a relaxing incision
of the should be given. In this case, the goal is to rst perform a right relaxing
incision, and if this approach were not sufcient to guarantee a tensionless repair,
a left relaxing incision should be performed.
Mesh Reinforcement
The crural defect must be closed prior to mesh placement. Bridging of the diaphragmatic defect is not recommended. A ruler is introduced in order to tailor the mesh to the
patient. Furthermore, a “U-shaped” or “reverse C”-shaped bioabsorbable mesh is cut to
size to reinforce the closure of the diaphragmatic defect (Fig.19.7). Our preference is
a “reverse C” mesh for both posterior and anterior coverage. The mesh is placed onlay
and secured in place to the edge of the right and left crura and at the bottom of the repair
with nonabsorbable interrupted stitches. It is our practice to place the hiatal xation
stitches at 1, 4, 8, and 11 o’clock around the circumference of the hiatus. Mesh reinforcement is considered useful to prevent early recurrences (6–12months).
The ideal mesh characteristics are
• Slow absorbable
• Low prole, easy to use (introduce, position, xate)
• Decrease risk for erosion
• Does not preclude reoperation
It is our practice to routinely use mesh in the following situations:
• Large hiatal hernias (>5cm)
• Closure under tension
– Observed tearing of the R crus
Fig. 19.7 Mesh
placement. Mesh
congured in “reverse C”
orientation to ensure
anterior and posterior
coverage
238
M. Nessen and C. A. Galvani
• Redo operations
• Relaxing incisions
• Patients with obesity with large hiatal hernias
Antireflux Procedure
• Redo-Fundoplication
When a redo-fundoplication is indicated, our preferred procedure is a Toupet
fundoplication gauged over a bougie. A “shoeshine” maneuver is performed to
make sure the right and left sides of the fundoplication are symmetric (Fig.19.8).
The right and left graspers then bring toward the anterior esophagus. The bougie
is inserted after the stomach is passed behind the esophagus. At this time, arm #
4 holds the right side of the wrap in place while swapping to arm #1 for placement of the rst stitch of the fundoplication. A total of three 2-0 silk stitches are
used to x the wrap to the right side of the esophagus; the most proximal stitch
was used to secure the wrap to the esophagus and the right crura. This followed
by three 2-0 silk stitches between the wrap and the left side of the esophagus;
the most proximal stitch is used to secure the wrap to the esophagus and the left
crura (Fig.19.9). At the completion of the procedure, the bougie is carefully
removed.
Upper endoscopy is routinely performed at the completion of the case to check
the indemnity of the esophagus, stomach, and the adequacy and patency of the fundoplication (Fig.19.10).
Fig. 19.8 Creation of
posterior Toupen
fundoplication.
“Shoeshine” technique
employed to ensure
symmetry
19 Revisional Foregut andBariatric Surgery
Fig. 19.9 Completed
Toupen fundoplication.
Silk sutures used to x
fundus to the crura and
esophagus
Fig. 19.10 Upper
endoscopy after
completion of wrap. After
completion of the wrap,
upper endoscopy is used to
visualize the “omega”
shape wrap in retroexion
239