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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_738_Библиотеки_им_академика_М_И_Перельмана.pdf
442 Atlas of Gastrointestinal Surgery: Esophagus
Operative Technique
The patient is placed in the lateral thoracotomy position with the left chest
up. The left pleural cavity is entered through the sixth or seventh interspace.
The mediastinal pleura is opened, and the markedly dilated and hypertrophied
esophagus is easily identified. It is mobilized out of the mediastinum with both
sharp and blunt dissection. The esophagus is looped with a Penrose drain (2).
The hiatus is enlarged so that the fundus of the stomach may be delivered up
into the chest. To do this, it is necessary to divide the branches of the left
gastric vessels along the lesser curvature of the stomach and the vasa brevia
along the greater curvature. The distal esophagus, cardia, and fundus are dissected out of the retroperitoneum.
Once the esophagus and stomach have been appropriately mobilized, the
fat pad is dissected free from the gastroesophageal junction. The vagus nerves are
identified and carefully preserved, and both are swept posteriorly (inset). An
esophagomyotomy is performed that extends up onto the esophagus for approximately 10 cm and onto the stomach for approximately 1 cm.
Left
2
Fat pad
dissected
Left vagus n.
Right
vagus n.
vagus n.
Fundus brought
into chest
Vagus nerves
swept posteriorly
Esophagus looped with
Penrose drain
Mediastinal
pleura opened
Achalasia: Heller Esoophagomyotomy and Belsey Repair 443
This is best done by separating the muscular layer of the esophagus from the mucosa with a right angle clamp and then dividing the
muscle with the electrocautery on low voltage (3). The muscular
layer of the esophagus is easily separated from the mucosal tube,
and should be freed for at least 50% of the circumference of
the esophagus (4). However, in a small number of cases where
repetitive dilatation or toxin injection have taken place preoperatively, there may be scarring between the muscle and mucosal layers. The integrity of the esophageal mucosa can be checked by
inserting a flexible esophagoscope, submerging the area under saline,
and insufflating the esophagus while holding distal pressure on the
lumen. Any leaks should be repaired with 4-0 absorbable
suture prior to the fundoplication.
Once the esophagomyotomy has been performed and
Fundus
3
Esophagomyotomy
Muscular layer of esophagus dissected off
4
esophageal mucosa
the distal esophageal sphincter destroyed, a new sphincter is created by a modified Belsey Mark IV procedure.
Crural sutures of No. 2 silk are placed, but not tied. In the
presence of the esophagomyotomy, it is only possible to place
two sutures in each of the two rows of stitches used in the Belsey
repair. Thus the first row passes from the fundus of the stomach, 2 cm from
the gastroesophageal junction, up through the esophagus, again 2 cm from the gastroesophageal junction. The mattress
suture is completed by bringing the stitch back down through esophagus and through the fundus (5). One such suture is
placed on either side of the esophagomyotomy and then secured (6).
First row
placed
Crural
sutures
First row
tied
5
6
444 Atlas of Gastrointestinal Surgery: Esophagus
The second row of two stitches is
Second row placed
through diaaphragm
7
then placed. The stitch passes from the fundus of the stomach, through the esophagus,
back down through esophagus and fundus, each
being placed 2 cm from the first row of sutures.
These are secured, and the two ends then rethreaded
on large Ferguson needles and passed through the
diaphragm, from the abdominal to the thoracic side
(7). The fundus is then reduced below the
diaphragm, and the sutures are secured.
The previously placed crural sutures
are tied (8) with a 46 French
Maloney dilator in place. Since the
esophagus is aperistaltic, a Nissen
Second
row tied
fundoplication should not be used to
create a new lower esophageal sphincter,
for it may lead to partial obstruction.
Crural sutures
tied
8
Second
and
first
rows of
Belesy
repair
Achalasia: Heller Esoophagomyotomy and Belsey Repair 445
By wrapping the esophagus for only two-thirds of its circum-
ference, with a Belsey Mark IV operation, a lower
esophageal sphincter pressure is created that does not result in
functional obstruction (9, 10, 11). A chest tube is inserted,
and the thoracotomy incision closed.
9
Vagus nerves posterior to esophagus
Esophagomyotomy
270º wrap
Stomach
10
11
Achalasia: Laparoscopic Heller
Esophagomyotomy and Toupet Repair
Operative Indications
The indications for a laparoscopic Heller esophagomyotomy and Toupet (270˚) fundoplication are identical to those outlined for the esophagomyotomy and Belsey repair for achalasia in the previous section. Currently, the Toupet fundoplication is
probably used more frequently to create a new lower esophageal sphincter than is the Belsey Mark IV operation.
Operative Technique
The patient is positioned supine, and the port locations are identical to those for a
laparoscopic Nissen fundoplication. The abdomen is insufflated via a small incision and
Veress needle puncture just above or below the umbilicus. During insufflation, the patient
is placed in the reverse Trendelenburg’s position. Once fully insufflated, a measurement
is made from the xiphoid (or, more properly, where the costal margins meet near the
xiphoid) 16 cm down and 3 to 4 cm to the left of the midline. This affords the best
visibility of the angle of His and the space behind the gastroesophageal junction from
the patient’s left. Auxiliary ports are placed under direct vision through the scope.
Initially, the abdomen is explored for other pathology. Then, the lateral segment of the left lobe of the liver is retract-
ed with a fixed laparoscopic retraction device to expose the anterior upper stomach.
As with the Nissen fundoplication, the vasa brevia are divided using an appropriate energy source (1) beginning at
the mid-greater curvature of the stomach and carried to the superior pole of the spleen, exposing the angle of His and the
left crus (2). This provides an opening to the retroesophageal space from the left of the esophagus.
Esophagus
Achalasia: Laparoscopic Heller Esophagomyotomy and Toupet Repair 447
Vasa brevia divided
Spleen
Stomach
Esophagus
retracted
medially
Anterior vagus n.
Aorta
1
Left crus
Posterior
stomach
2
448 Atlas of Gastrointestinal Surgery: Esophagus
The right side of the esophagus and the retroesophageal space are dissected as for the laparoscopic Nissen fundoplication, and a small Penrose drain is placed around the gastroesophageal junction for retraction and exposure. The space
between the anterior esophagus and the arch of the crura of the diaphragm is carefully dissected and opened, creating a
space cephalad into the anterior mediastinum. During this dissection, the anterior vagus nerve is identified and protected.
This dissection mobilizes the esophagus, creates a length of intra-abdominal esophagus, and exposes the anterior esophagus for the myotomy.
The myotomy can be carried out with cold scissors, cautery scissors, a hook cautery, or other specialized tool. The
hook cautery allows fine dissection and lifting of individual fibers. The hook is used to dissect the fibers and to lift them
up, away from the tissue below, while energy is applied. This lifting avoids injury to the esophagus. The challenge of this
dissection is separation of the outer longitudinal fibers, and division of the inner circular fibers, while not injuring the mucosa
(3). Once the proper layer is identified, the dissection becomes clear, as there is normally an easily dissected plane
between the mucosa layer and the muscle. The mucosa responds by bulging out once it is released from the muscle. This
dissection is carried well down onto the stomach, 2 cm below the crossing veins that mark the junction between the esophagus and the stomach. The total length of the myotomy should be at least 7 cm (4).
Anterior vagus n.
Outer longitudinal
and inner circular
fibers of esophageal
muscle
Mucosa
3
4
Complete myotomy
extends 2 cm into
stomach
As with the Nissen fundoplication, the
crura are approximated by suturing posterior to
Achalasia: Laparoscopic Heller Esophagomyotomy and Toupet Repair 449
Mucosa
the gastroesophageal junction using Teflon
pledgets, as described for the laparoscopic
Nissen fundoplication.
Then, the 270˚ posterior wrap is constructed
by pulling the posterior fundus of the stomach around
behind the esophagus with an atraumatic grasper. The
fundus is then sutured laparoscopically to the crus on the
right, using pledgets (5). Similarly, the anterior fundus of the
stomach is sutured to the left crus using pledgets (6).
Posterior
fundus
sutured to
right crus
5
Anterior vagus n.
Mucosa
Anterior
fundus
sutured to
left crus
6
450 Atlas of Gastrointestinal Surgery: Esophagus
Once these are secured, each side of the fundus of the stomach is sutured to the divided edge of the esophageal muscle layers
(7). In combination, these sutures anchor the 270˚ wrap and keep the myotomized edges of the muscle separated.
The abdomen is then surveyed laparoscopically to ensure that there is no unexpected bleeding or injury. Then, an
endoscope is passed orally to examine the construction from within the esophagus (8). If the myotomy is adequate, the
scope will pass easily from the esophagus into the stomach. To ensure that there is no defect in the mucosa, some irrigation fluid is dripped onto the anterior esophagus while the scope insufflates air. The scope is then withdrawn, and the
port sites closed.
Fundus
sutured
to edge of
myotomy
7
Completed Toupet
fundoplication
270˚ wrap
8
Esophageal Spasm: Long
Esophagomyotomy and Belsey Repair
Operative Indications
Diffuse esophageal spasm is a disorder characterized by chest pain, secondary to marked uncoordinated contractions of the
thoracic esophagus. Esophageal manometrics demonstrate uncoordinated, nonprogressive, high-amplitude contractions in the
esophagus. This disorder may initially be confused with coronary artery disease and angina pectoris. Some of these patients
undergo extensive cardiac testing, and only when it is normal does the diagnostic workup lead to the esophagus. It is not
clear what triggers the spasm in many of these patients, but in up to half of them, emotional stress is associated. Dysphagia,
gastroesophageal reflux, and a hiatal hernia are usually absent. Interestingly, patients may initially receive some benefit from
the administration of nitroglycerin and calcium channel blockers, further delaying recognition of the entity. If the management of this disorder with smooth muscle relaxants is unsuccessful, surgical intervention is indicated.
Operative Technique
The patient is placed in the lateral thoracotomy position with the left chest up.
The left pleural cavity is entered through the sixth or seventh interspace. The
mediastinal pleura is opened and the esophagus identified. The esophagus is
often markedly thickened and hypertrophied and is easily palpated in the mediastinum. Preoperative manometrics can map out the section of esophagus that
is involved with the uncoordinated high-amplitude contractions. Generally, it is
the distal two-thirds of the esophagus, so an esophagomyotomy that extends
up to the aortic arch encompasses all of the involved esophagus. The myotomy should also extend down onto the stomach.