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422 Atlas of Gastrointestinal Surgery: Esophagus
Since a bilateral vagotomy is performed in resecting the distal
esophagus, either a pyloroplasty or a pyloromyotomy is required. A
pyloromyotomy is often preferred, to minimize entrance into the
gastrointestinal lumen. For this method, the seromuscular layers of
the distal stomach, pylorus, and proximal duodenum are divided carefully with the electrocautery on low voltage, being certain not to open the mucosal layer (16). A fine right angle
clamp is used not only to gently lift the circular muscular layers off the mucosa, but also to gently spread them; this allows
the mucosal layer to bulge out (17). Once the pyloromyotomy is completed, it is covered with a piece of omentum and the
sutures marked with metal clips so that, if dysphagia due to pyloric
stenosis develops postoperatively, this site can be found radiographically and used to guide endoscopic dilatation (18).
Pyloromyotomy
16
Mucosal
layer intact
17
Omentum
18
Short Segment Colon Interposition for Benign Esophageal Stricture 423
If the mucosa is inadvertently opened, it should be converted to a pyloroplasty by opening the mucosal layer the length of the seromuscular defect. If
a Heineke-Mikulicz pyloroplasty is performed, the pylorus is opened in a
horizontal fashion and closed vertically (19). The Gambee stitch is used,
passing through and through the stomach, then back up through gastric
mucosa only. The suture is then passed through mucosa only into the
duodenal lumen on the duodenal side, and then back full thickness
through the duodenum. This suture ensures good approximation of the
19
stomach and duodenum, without narrowing of the pyloric channel.
Similarly, a piece of omentum with metal clips is sutured over the site.
The short segment of colon replaces the strictured distal esophagus
and effectively prevents subsequent gastroesophageal reflux up into the
mid-esophagus. With the cologastric anastomosis in the posterior position, this
shorter distance places the vascular pedicle away from potential tension if the
stomach becomes dilated (20, 21).
Heineke-Mikuliz
pyloroplasty
20
Colon
anastomosed
to
posterior
stomach
21
424 Atlas of Gastrointestinal Surgery: Esophagus
Alternatively, this anastomosis can be done anteriorly (22, 23), particularly if it is
Esophagus
Diaphragm
Stomach
Colon
Colon
difficult to do posteriorly.
The transverse and descending colon are easily re-approximated anterior to the
pedicle supplying the colon interposition, either by a two-layer hand-sewn tech-
nique or using stapling devices. Occasionally, the hiatus will be somewhat larger
than the colon conduit, so that tacking it circumferentially to the colon interpo-
sition with interrupted sutures of 4-0 silk is required to prevent herniation
of abdominal content through it. The abdominal and thoracic retractors are
removed, and the diaphragm re-approximated with 0 synthetic non-
absorbable suture in a horizontal mattress fashion. This step is usually
best done from the thoracic side. A single chest tube is left in place.
The thoracoabdominal incision is closed in layers.
Esophagus
22
Omentum
Colon
Diaphragm
Stomach
Omentum
Vascular
pedicle to
colon
segment
23
Colocolostomy
Repair of Paraesophageal Hernia
Operative Indications
Paraesophageal hernias are relatively uncommon and are generally seen in the older patient. A true paraesophageal hernia,
Type I, is defined without a sliding component where the gastroesophageal junction remains in the abdomen, and a large
peritoneal hernia sac develops around the esophagus, usually anteriorly and/or to the left (1). The hiatus is usually very
enlarged. The hernia sac in the anterior mediastinum generally contains the fundus of the stomach. More commonly, in the
Type II hernia, the esophagogastric junction and the upper stomach herniate as one unit into the chest (2). Rarely, if the
hiatal opening and sac become very large, most of the stomach will flip anteriorly into the mediastinum in a Type III hernia (3). With an upside down stomach, virtually all of the stomach can be in the chest (3).
Type I Type II Type III
1 2 3
426 Atlas of Gastrointestinal Surgery: Esophagus
Most paraesophageal hernias have a sliding component, with the gastroesophageal junction actually residing in the
chest. Because gastroesophageal reflux is not a frequent symptom in these patients, they may be asymptomatic or have
mild nonspecific symptoms of belching, early satiety, or a sense of fullness in the chest. Currently, it is thought that if
patients are asymptomatic repair is not necessary. However, if significant symptoms are present a substantial risk of incarceration, bleeding, and/or perforation is believed to exist. Gastric stasis can lead to ulceration and gastritis in the herniated portion of the stomach. The most serious complication is incarceration and strangulation, which presents as a catastrophic event with an exceedingly high mortality.
Operative Technique
The patient can be explored through either the chest or the abdomen. The latter
approach is usually favored because of lower morbidity from the incision. An upper midline incision is made and both costal margins are retracted using retractors suspended from
a frame fixed to the operating room table. In addition to the stomach, the spleen and
colon are components that can be found herniated into the mediastinum, Type IV. The
stomach can almost always easily be reduced by gentle downward traction (4).
Exposure is often aided if the triangular ligament is taken down, retracting the left lobe
of the liver to the right.
Reduce
stomach into
abdomen
4
Removing the large peritoneal sac, which invariably
accompanies the paraesophageal hernia, from the mediastinum is not essential. However, if it is removed it helps
Repair of Paraesophageal Hernia 427
Enlarged
hiatus
facilitate identification of proper tissue planes when the
repair is performed (5). One has to be careful while
excising the sac posteriorly that the posterior (right) vagal
trunk is not injured. In the process of excising the sac, the
esophagus is completely mobilized, and both vagal nerves
are identified and kept adjacent to the esophagus.
Vasa brevia
divided
Posterior
crural
closure
Anterior and
posterior
vagus nn.
Peritoneal
(hernia)
sac
5
After the hernia has been reduced, the sac excised, and
6
the abdominal esophagus and fundus completely mobilized,
the large hiatal opening is closed. It is preferable to close the
hiatus from posterior to anterior, thereby displacing the esophagus anteriorly (6). As with the previously described
diaphragm repairs, the crural sutures of No. 2 silk or
polypropylene are placed first, prior to tying them. The crur-
7
Anterior
crural
sutures
al leaves should be approximated with a 46 French Maloney
dilator in place, making the hiatus snug. Some favor anterior
crural sutures (7), thereby avoiding the marked anterior displacement of the esophagus. In addition, some surgeons feel
that the closure fo the hiatus should be reinforced with a synthetic or biologic mesh.
428 Atlas of Gastrointestinal Surgery: Esophagus
During mobilization of the cardia, the gastrohepatic ligament is divid-
8
Closed
crura
Fundoplication
ed, along with branches of the left gastric vessels. In addition, sev-
eral vasa brevia are divided so that a fundoplication can be per-
formed. Because of the herniation of the stomach, the vasa
brevia are elongated and easily divided. A fundoplication is
performed by wrapping the very mobile fundic portion of
the stomach around the esophagus posteriorly and sutur-
ing it to adjacent fundus and esophagus with a series of
four 2-0 silk sutures (8). Many of these hernias actual-
ly have a sliding component. Even if a sliding compo-
nent is not present, the gastroesophageal junction is
completely mobilized and its posterior attachments are
taken down during the dissection. A fundoplication is
important because it adds bulk to the fundic portion of
the stomach, which makes a recurrence of the hernia less
likely. The abdomen is closed without drains.
Alternatively, the stomach can be simply tacked to the
anterior abdominal wall and held in place with a gastrostomy tube
after the hernia is reduced and the crura closed, without doing a formal fundoplication. This procedure can be considered in the older patient or when a quicker operation is desired because of
comorbid patient factors, or when extensive adhesions are encountered precluding mobilization of the fundus for wrapping.
Resection of Zenker’s Diverticulum
Operative Indications
Zenker’s diverticulum is a herniation of esophageal mucosa that occurs posteriorly below the inferior pharyngeal constrictor muscles and just above the cricopharyngeus (1). Discoordination of the cricopharyngeus, or upper esophageal sphincter, is thought to be responsible for the high pressure that is generated above the sphincter, and thus the herniation of
mucosa (inset). Zenker’s diverticulum can be seen in any age group but is more common in the older patient. It generally
presents with dysphagia, and an associated sensation of gurgling or bubbling in the neck. Occasionally, undigested food
that was ingested days earlier will be regurgitated.
Thyroid
Esophagus
Thyroid cartilage
Pharynx
Trachea
Diverticulum (esophageal mucosa)
C7
1
Cricopharyngeus m.
Inferior pharyngeal constrictor m.
Diverticulum
430 Atlas of Gastrointestinal Surgery: Esophagus
Particularly in the elderly, recurrent bouts of aspiration or awakening at night with coughing spells is common. When a
patient with a Zenker’s diverticulum swallows, the liquid or solid bolus takes the path of least resistance. Since the cricopharyngeus muscle is not coordinated with a swallow, food preferentially enters the diverticulum, compressing the esophagus,
and leading to dysphagia. Virtually all patients with symptomatic Zenker’s diverticulum should be treated surgically. There
is no medical management.
Operative Technique
It is advised that the patient be on a clear liquid diet for several days prior to surgery.
The patient is placed supine on the operating room table with the head rotated to the
right. The diverticulum arises from the midline posteriorly but is often deviated somewhat to the left side of the neck. Thus, approaching these lesions from the left neck is
preferred. An incision is made along the anterior border of the left sternocleidomastoid
muscle, usually at the midportion of the neck. The platysma is divided, and the sternocleidomastoid muscle retracted laterally. The trachea and the thyroid gland are retracted medially by the assistant using only
fingers. Retractors should not be placed on the trachea for fear of injury to the recurrent laryngeal nerve, which resides in the
groove between the trachea and esophagus. The omohyoid muscle can be retracted but, depending on its size and orientation, is usually in the way and is best divided. The esophagus is easily identified. At this point, the anesthesiologist gently
passes the tip of a 46 French Maloney dilator, which invariably
enters the diverticulum, making identification of the tip of
the diverticulum easy. The diverticulum is grasped with a
small Babcock clamp and mobilized by sharp and blunt
dissection (2).
Recurrent
laryngeal n.
2
Esophagus
Diverticulum
Omohyoid m.
divided
Sternocleidomastoid m.
Using sharp and blunt dissection, the diverticulum is easily mobilized until it is
attached to the esophagus only by its neck (3). If the diverticulum is not treated gently, bleeding and hematomas quickly result. When the diverticulum has
been completely mobilized, the anesthesiologist can reposition the
Resection of Zenker’s Diverticulum 431
Maloney dilator into the esophagus proper beyond the opening of the
diverticulum and into the stomach; this is facilitated by pinching
3
Diverticulum
the neck of the diverticulum between the surgeon’s fingers.
The diverticulum can then be excised and
closed with a layer of interrupted 4-0 synthetic absorbable suture material. Alternatively, it
can be divided with a thoracoabdominal
(TA) stapler (4). In dividing the diverticulum,
one has to be careful to divide it flush with the
Cricopharyngeus m.
Inferior
pharyngeal
constrictor m.
esophagus and to not pull normal esophageal mucosa into
the stapler, thus narrowing the esophageal lumen. This is avoided
with the Maloney dilator in place. In addition, it is advised to open up the tip of the diverticulum prior to firing the stapler to ensure that all solid food debris has been removed so it is not caught in the staple line.
Once the diverticulum has been resected, the dilator is removed, and the staple line is covered posteriorly by reapproximating the inferior constrictor muscles with a layer of interrupted 3-0 synthetic absorbable suture material (5).
4
TA
stapler
Muscular defect
closed
5