Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_738_Библиотеки_им_академика_М_И_Перельмана.pdf
452 Atlas of Gastrointestinal Surgery: Esophagus
Hiatus
Heart
Esophagus
mobilized
extensively
Aorta
Mediastinal pleura
opened
1
The esophagus is mobilized
extensively up to and even under the aortic arch
(1). The hiatus is stretched, and the fundus of the stomach mobilized and delivered into
the chest. This maneuver may require division of branches of the left gastric vessels along the
lesser curvature and the vasa brevia along the greater curvature.
Esophageal Spasm: Long Esophagomyotomy and Belsey Repair 453
Once the esophagus has been mobilized
sufficiently, a long esophagomyotomy
is performed. A right angle clamp is
used to lift and separate the muscle layer from the mucosa,
dividing it with electrocautery
on low voltage. This plane is
easily developed. The muscular
layer should be dissected free
from the mucosal tube for approximately 50% of the circumference
of the esophagus (2).
Fundus brought
into chest
Lung
Esophagomyotomy
2
Hypertrophied
muscular layer
dissected off
mucosa
Since the esophagomyotomy extends down onto the stomach for at least 1 cm, the lower esophageal sphincter is
destroyed. The hiatus and lower esophageal sphincter are reconstructed with a modified Belsey procedure. Interrupted
sutures of No. 2 silk are placed through both crura of the diaphragm, but not tied. A modified Belsey Mark IV procedure is performed that uses two, instead of three sutures in each of the two rows. The first row is initiated with a 2-0 silk
suture placed in the fundus of the stomach 2 cm below the gastroesophageal junction, and then longitudinally through the
esophagus 2 cm above the gastroesophageal junction. The mattress stitch is completed by passing
the suture back down through the esophagus and through the fundus of the stomach (3).
Mucosa
Esophagomyotomy
First row
placed
Crural
sutures
3
454 Atlas of Gastrointestinal Surgery: Esophagus
First row tied
4
A similar mattress suture is placed on the other side of the
esophagomyotomy and then secured (4). A second layer of two
sutures is then placed. The 2-0 suture is first passed through the
diaphragm (from the thoracic to the abdominal side) and then through the
fundus of the stomach 2 cm below the first row of sutures. The stitch then passes longitudinally through the esophagus 2 cm above the first row. The mattress stitch is completed by passing the suture back down
through the esophagus, the fundus of the stomach, and the diaphragm (from the abdominal to the thoracic side). A similar suture is placed on the other side of the esophagomyotomy. Placement of the suture through the diaphragm is aided
by retraction of the abdominal contents with a large spoon (5). The two previously placed sutures of the second row are
then secured by reducing the fundus of the stomach into the abdomen and tying the sutures.
5
Second row placed
through diaphragm
before being tied
Esophageal Spasm: Long Esophagomyotomy and Belsey Repair 455
Alternatively, the esophageal and gastric portions of the second row of sutures can be secured, and then the ends
passed through the diaphragm with large Ferguson needles (6). The stomach is reduced and the sutures are tied. Either
technique is acceptable, but we prefer tying the sutures of the second row placed in the stomach and esophagus before
passing the ends through the diaphragm.
Alternative: Sutures tied, then passed through diaphragm
6
Aorta
Esophagomyotomy
456 Atlas of Gastrointestinal Surgery: Esophagus
Once the second row of sutures has been secured, the crural stitches are tied.
Only enough space should be left to admit a fingertip between the esophagus
and crural stitches. Alternatively, a 46 French Maloney dilator can be passed
adjacent to the nasogastric tube, and then the crural sutures secured. The operative procedure divides all of the circular muscles of the esophageal wall for the
entire length of the esophagus affected by spasm, thus eliminating the spasm. In
the process, the lower esophageal sphincter is destroyed and has to be
reconstructed via a Belsey repair (7, 8). A chest tube is inserted
and the thoracotomy incision closed.
Second and
first
rows of
Belsey
repair
Esophagus
7
Stomach
8
Open Resection of Esophageal Leiomyoma
Operative Indications
Leiomyomas arise from the muscular layer of the esophageal wall (1). The mucosa is not involved and remains intact over
the benign tumor, resulting in the characteristic smooth appearance on barium swallow. The defect seen radiographically
is smooth and usually protrudes in a semicircular fashion into the esophageal lumen. These lesions are easily differentiated from the more common malignant mucosal lesions. If these
leimyomas are large, they may be seen on a plain chest x-ray
or a computed tomography (CT) scan. If the tumors are
large enough to result in dysphagia, the characteristic
appearance on barium swallow makes the diagnosis
Muscular layer of
esophageal wall
almost a certainty. If endoscopy is carried out, one can
see an intact mucosa over the lesion protruding into the
esophageal lumen. One should not perform a biopsy of
the mucosa overlying the lesion, because an opening into
the esophageal lumen at the time of surgical resection will
result. If the radiographic appearance is pathognomonic
and symptoms are minimal or absent, some surgeons have
advocated following the patient and not removing the
tumor surgically unless symptoms increase. Most, however, think these lesions should be excised when they are
found to prevent or alleviate symptoms and to do so while
they are smaller and more manageable. Esophageal resection is
rarely indicated.
Leiomyoma
Mucosa of esophagus
Diaphragm
1
458 Atlas of Gastrointestinal Surgery: Esophagus
Operative Technique
Flexible esophagoscopy should be performed after induction of anesthesia to
localize the tumor and again, after resection, to check for mucosal leaks. The
patient is positioned in the lateral thoracotomy position. Most esophageal
leiomyomas can be approached via the right chest, but those approaching the
esophagogastric junction should be resected from the left side; the illustrations depict the latter. The thoracic cavity is entered through the sixth intercostal space.
The mediastinal pleura is opened, and the esophagus identified and dissected free. The lesion is easily palpated in the esophageal wall. It has a firm, rubbery
consistency and is easily differentiated from
a malignant neoplasm. Occasionally,
the flexible esophagoscope can be
used to help localize it. Once
the esophagus has been mobilized and encircled with a
Penrose drain, the outer longitudinal muscle layer is
opened with the scalpel (2).
The incision in the esophageal
wall is deepened until the whitish,
rubbery, benign smooth muscle neoplasm is identified. It can be gently
Heart
Esophageal
muscle opened
over leiomyoma
grasped with a Babcock clamp or Ring
forceps.
Mediastinal
2
pleura opened
Leiomyoma dissected
from esophageal wall
Open Resection of Esophageal Leiomyoma 459
3
4
Muscular layer
closed
By using both blunt and sharp dissection, the leiomyoma is generally easily removed from the esophageal wall (3) without entering the esophageal lumen. If the esophagoscope is still in place, the integrity of the esophageal wall is checked
by insufflating air into the lumen. Once the tumor has been removed, the esophageal muscular layer is closed with a series
of interrupted 3-0 silks. A chest tube is inserted and the thoracotomy incision closed.
Video-Assisted Thoracic Surgical
Resection of Esophageal Leiomyoma
Operative Indications
The indications for removal of a leiomyoma using the video-assisted thoracic surgical (VATS) technique are similar to those
described previously for the open technique. General principles of VATS should also be considered, however, in that contraindications for this method include the inability to tolerate one-lung ventilation and prior major thoracic surgery in that
pleural space.
Operative Technique
After induction of general anesthesia, a double lumen endotracheal tube is inserted and verified in the correct position by
bronchoscopy and auscultation. Most tumors can be approached via the right pleural space, except for distal tumors that
should be removed via the left; illustrated is the approach from the right. After flexible esophagoscopy, the scope is left
in position. The patient is placed in the left lateral decubitus position. At least three 1-cm ports are created in the fourth,
fifth and sixth intercostal spaces (1). If traction on the esophagus is required, an additional 5-mm port is placed in the
third intercostal space, and a Penrose drain placed circumferentially around the esophagus and brought out via this port.
The thoracoscope is inserted via the middle port.
Video-Assisted Thoracic Surgical Resection of Esophageal Leiomyoma 461
NG tube
in esophagus
Leiomyoma
1