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_747_Библиотеки_им_академика_М_И_Перельмана
.pdf
414 Long esophageal myotomy and excision of diverticula
https://t.me/med1917
OPERATION
Incision
The esophagus is approached through a left thoracic
1
incision. The pleura is opened at the superior border of
the eighth rib, and a small posterior segment of the rib is
removed. Anesthesia via a double-lumen endotracheal tube
allows exclusion and retraction of the left lung during the
operation.
2
Eighth rib
1
The mediastinum is opened 1 cm anterior to the aorta,
2
from the aortic arch to the diaphragm. At the distal
extent the pleura is incised as an inverted T to provide free
access to the hiatus. The inferior pulmonary ligament is
divided up to the inferior pulmonary vein.
The esophagus is mobilized proximally and at the level of
the hiatus, below the diverticulum. Penrose drains are passed
around it to facilitate traction and dissection.
The esophageal body is freed completely from its fascial
https://t.me/med1917
3
and vascular attachments up to the inferior border of the
aortic arch.
Progressive dissection of the diverticulum is then undertaken, with care given to ensure that the right pleura is protected.
If the hiatus is small and without a hernia, free access to the
peritoneal cavity is obtained through a peripheral diaphragmatic incision 2–3 cm from its insertion at the chest wall. This
allows complete and easy dissection of the fundus, gastrosplenic vessels, and hiatal structures. The phrenoesophageal
ligament and the peritoneum are opened, and the whole gastroesophageal junction is delivered into the chest through the
hiatus. The gastroesophageal fat pad is removed.
Operation 415
3
4
When the esophagus and proximal stomach have been
4
fully mobilized, the diverticulum and the distal esophagus are rotated toward the left chest. Usually a layer of fibromuscular tissue invests the diverticulum. The mucosa of the
diverticulum is freed progressively toward its neck, and the
muscular defect surrounding the neck is thus clearly identified.
If the diverticulum is not directed toward the right chest, it
may have to be included in the planned myotomy and then
suspended rather than removed.
416 Long esophageal myotomy and excision of diverticula
Left vagus
Large endo-esophageal bougie
https://t.me/med1917
On completion of the dissection, a large
5a–c
esophagus and stomach. This stent serves to distend the
esophageal lumen and prevent undue narrowing at the point
of excision of the diverticulum.
With the bougie safely in place, resection of the diverticu-
lum is now undertaken, using one of two methods.
mercury bougie (No. 50) is placed into the
Right vagus
Left vagus
5a
The first technique is a manual one for resection of the
6
diverticulum. Traction sutures are placed on the proximal and distal borders of the neck, and the diverticulum is
resected by opening a straight line of mucosa.
6
5b
5c
The esophagotomy is closed longitudinally, as for any
https://t.me/med1917
7
esophageal anastomosis, with an interrupted single layer
of inverting sutures. Both ends are closed with internal knots.
The last three or four sutures are tied externally.
Operation 417
7
The second technique is to use a 5- to 6-cm stapler to
8
close the neck of the diverticulum. This is again accomplished with a large bougie protecting the esophageal lumen.
A small cuff of mucosa is left distal to the stapling line, and a
second row of sutures reapproximates the muscle over the
staple line, anchoring it to the cut rim of the mucosa.
8
When the rotation traction is eased, the site of the diver-
9
ticulectomy resumes its normal position facing the right
chest. A long myotomy is performed on the left posterolateral
esophagus. The mercury bougie remains in place and serves
as support for the mucosa. The use of magnifying spectacles
helps in identifying the esophageal structures and encourages
stringent hemostasis. A No. 15 scalpel blade is used, and the
longitudinal muscle is opened along the whole length of the
planned myotomy. The myotomy is then completed through
the circular muscle layer, with care taken to avoid perforating
the mucosa. The lower esophageal sphincter area may be recognized as the muscle is usually thinner here.
9
418 Long esophageal myotomy and excision of diverticula
https://t.me/med1917
The myotomy is extended for 1 cm onto the gastric
10
seen as a richly vascularized layer.
wall muscle, and the gastric submucosa can then be
10
11
Right
vagus
Left vagus
Lateral dissection of the muscle from the mucosa is
11
cle outward while the surgeon holds the mucosa against the
bougie with a dissector swab. This exposes a cellular tissue
plane between the layers that affords easy dissection.
Approximately 50% of the esophageal circumference is freed
from the muscle. Once the myotomy is completed, hemostasis is obtained and the mucosa of the myotomized zone is
checked to make sure that it has not been breached. The
transverse sections show the points of dissection between layers, the placement of sutures to evert the dissected muscle,
and the position of the sutures in relation to the right and left
vagi.
esophageal cavity, and 50–100 mL of air is introduced into
the esophagus while it is kept under saline. Any leak will be
shown by bubbles of escaping air.
carried out with scissors. The assistant pulls the mus-
The bougie is removed, a nasogastric tube is placed in the
A two-thirds fundic wrap of the Belsey type is next
https://t.me/med1917
12
plication on each side of the myotomized zone and at two levels. The two layers of the muscle are transfixed from outside
to inside to evert the muscle while anchoring the seromuscular layer of the fundus to the esophageal wall. This is accomplished to prevent any closure of the myotomy at the
gastroesophageal junction.
mer insertion of the phrenoesophageal ligament. The two
sutures of the second layer are placed in a similar fashion, 2–3
cm more proximal, from the esophagus to the fundus and
then through the diaphragm to tie both sutures on the thoracic side of the hiatus.
carried out. Two 2/0 silk sutures anchor the fundo-
The first two sutures are completed at the level of the for-
Further reading 419
12
13
POSTOPERATIVE CARE
The nasogastric tube is left in place until normal bowel activity has resumed. Once gastric drainage is discontinued, an
esophagogram is obtained using water-soluble contrast
medium. If the mucosal configuration is considered adequate, liquid barium is added to complete the immediate
postoperative evaluation.
The chest tube is removed when normal pulmonary reexpansion is obtained with less than 100 mL of drainage over
a 24-hour period.
A liquid diet is resumed once the myotomy and diverticulectomy sites have been shown to be intact. The patient progresses to a semiliquid diet for the following 10 days. Normal
alimentation is then resumed.
Complete functional reassessment is obtained 2 years after
With this partial fundoplication, the distal 4–5 cm of
13
tension under the diaphragm. It affords good antireflux protection while allowing proper food transit at the gastroesophageal junction.
the operation and at regular intervals thereafter.
Documentation of emptying capacity and reflux damage over
time in these patients is particularly important.
the myotomized esophagus is reduced without any
FURTHER READING
Allen TH, Claggett OT. Changing concepts in the surgical treatment of
pulsion diverticula of the lower esophagus. Journal of Thoracic and
Cardiovascular Surgery 1965; 50: 455–62.
Benacci JC, Deschamps C, Trastek V, Allen MS, Daly RC, Pairolero PC.
Epiphrenic diverticulum: results of surgical treatment. Annals of
Thoracic Surgery 1993; 55(5): 1109–13.
Cross FS. Esophageal diverticula related neuromuscular problems. Annals
of Otology, Rhinology and Laryngology 1968; 77: 914–26.
Cross FS, Johnson GF, Gerein AN. Esophageal diverticula. Archives of
Surgery 1961; 83: 525–33.
This page intentionally left blank
https://t.me/med1917
40
https://t.me/med1917
Thoracoscopic management of esophageal
diverticulum
GLYN G. JAMIESON MS, MD, FRACS, FRCS, FACS
Dorothy Mortlock Professor and Chairman, Department of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia,
Australia
ROBERT LUDEMANN MD, PHD
Research Fellow, University of Adelaide, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
JOHN HUNTER MD
Professor and Chairman, Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
INTRODUCTION
The principles and justification for surgery in patients with
diverticula of the esophagus are detailed in Chapter 40, and
will not be repeated here.
When planning for a minimal access approach to a diverticulum, there are two possible approaches. First, in mid
esophageal or lower esophageal diverticula, the approach can
be through either a right or left thoracoscopy. If the diverticulum is in the mid esophagus or proximal lower esophagus,
our preference is for a right-sided thoracoscopy. If the diverticulum is epiphrenic, our preference is either a left-sided
thoracoscopy or latterly, via laparoscopy. The second
approach via laparoscopy can be used for most lower third
diverticula, as it is usually feasible to mobilize the lower third
of the esophagus via a laparoscopic approach through the
esophageal hiatus.
OPERATION
Mid to lower third diverticulum of the
esophagus via right thoracoscopy
POSITION OF PATIENT
The patient is intubated with a double-lumen endotracheal
tube. If the diverticulum is large (the usual situation requiring operation) the aspiration risk in these patients is substantial, and care should be taken during induction. The patient is
then placed either in the full left lateral decubitus position, or
our preference is for the patient to be placed in the fully prone
position. The advantage of the fully prone position is that the
lung falls forward, so with minimal insufflation gas pressure
there is usually no need to deflate the right lung.
422 Thoracoscopic management of esophageal diverticulum
https://t.me/med1917
TROCHAR PLACEMENT
A small amount of gas at 5mmHg pressure is then intro-
1
duced into the right hemithorax. This can be done using
a Veress needle, or our preference is to introduce a 10 mm
round-ended rod blindly through a 1 cm cut, and then introduce a 10–11 mm trochar over the rod. Two other trochars
(10–11mm) are placed under direct vision in the sites shown,
with site A being for the camera. As stated above, it is not usually necessary to deflate the right lung, although if it obscures
the view it can be collapsed.
1
ESOPHAGEAL EXPOSURE
Identification of the esophagus is facilitated by intro-
2
ducing a flexible endoscope, with the endoscope
transilluminating the esophageal body. The pleura over the
esophagus is picked up and longitudinally incised for the
whole length of the esophagus up to the azygos vein, using
endoscissors. Sharp and blunt dissection is then used to
mobilize the distal esophagus. Particular care needs to be
exercised in the region of the diverticulum, since it can be
associated with peridiverticular inflammation in this area.
Certainly this is not always the case, but if present, it makes
dissection of the diverticulum more difficult.
2
The esophagus itself is not usually difficult to dissect
from its bed, although the most difficult maneuver is get-
3
ting around the esophagus with a curved instrument in order
to place a tape around the esophagus. The tape is brought out
through one of the ports, the blunt-ended rod reinserted, the
port removed, and the tape picked up outside the patient, and
then the port is reinserted over the rod, leaving the tape outside the port. Next, the diverticulum is dissected out in its
entirety. It may be necessary to rotate the esophagus so that
the neck of the diverticulum can be clearly displayed.
3
DIVERTICULECTOMY
https://t.me/med1917
Both intraluminal (through the endoscope) and extra-
4
luminal views (through the thoracoscope) help to provide a complete demonstration of the anatomy of the diverticulum. Sometimes it can prove helpful to use an additional
port if those already in place do not give optimal entry, particularly for the stapling instrument. An Endo GIA stapler
with a roticulating head is then introduced. The endoscope is
removed and a 52 French bougie is passed down the esophagus. The neck of the diverticulum is then stapled across, the
diverticulum is removed, and the longitudinal muscle of the
esophagus is approximated across the staple line using either
a 5-0 monofilament or braided suture.
Operation 423
4
5
MYOTOMY
A myotomy is performed at a different site from the
5
staple line in the esophagus, preferably at a site 90–180
degrees from the site. The myotomy is undertaken using a
combination of endoshears and the hook diathermy. It is
helpful to use a curved instrument such as a Mixter clamp,
which helps to separate the mucosa from the muscle, and by
spreading the jaws of the instrument the muscle is put under
tension for division with the diathermy hook. The proximal
extent of the myotomy should be at least equal to the proximal extent of the neck of the diverticulum. The distal extent is
directed by manometric findings, but in any case is taken well
below the diverticulum. The diverticulectomy and myotomy
sites are then checked for leaks, sites are submerged in saline,
and the esophagus is gently filled with air via the endoscope,
the bougie having been removed. If a leak is found, it is usually a very small perforation, and is closed using a 5/0 prolene
suture with intracorporeal suturing. We believe it is important to loosely close the myotomy using several interrupted
sutures in the longitudinal muscle layer of the esophagus.
This is done to prevent future herniation of the mucosa.
CLOSURE
The skin wounds are closed in standard fashion and a chest
drainage tube is brought out through one of the trochar sites.
POSTOPERATIVE CARE
Most patients are immediately extubated and the chest tube is
placed on underwater seal drainage. A barium swallow is
obtained on the first postoperative day and if satisfactory, the
patient is allowed a liquid diet. The chest tube is usually
removed on the first postoperative day and the patient may be
discharged on the second or third postoperative day with
instructions to slowly introduce soft foods until reviewed 14
days later.
Соседние файлы в папке Библиотека им академика М.И. Перельмана