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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_747_Библиотеки_им_академика_М_И_Перельмана
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444 Open antireflux operations through a left thoracic approach
https://t.me/med1917
The sutures, when tied, provide
7a,b
the tissues and create a first 1.5–2.0 cm fold
between the esophagus and stomach.
a delicate reapproximation of
7a
7b
Operation 445
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The second row of three sutures uses the
8a,b
needles at both extremities. The anterior and posterior
vagi still mark the limits of the 240 degrees fundoplication. The three stitches are placed deep into the muscularis of the esophageal wall, without penetrating the
lumen. Each suture is then anchored into the seromuscular layers of the fundus using the same precautions.
same 2-0 silk material, with atraumatic
8a
8b
446 Open antireflux operations through a left thoracic approach
https://t.me/med1917
The second row of sutures reap-
9
proximates once more the fundus
against the esophageal wall and the
sutures are tied, completing the effects
of the fundoplication. The partial wrap
is ready to be reduced in an abdominal
position.
9
Operation 447
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The two needles at the extremities of
10a,b
through the diaphragmatic hiatus, peritoneal side
first, to emerge through the pleura on the thoracic
side of the muscle. The first suture is positioned
immediately behind the pericardial reflexion,
through the fibrous portion of the diaphragm. The
second suture is also placed in the tendinous portion
of the diaphragm at its junction with the muscle of
the hiatus, while the third suture traverses the tendinous part, juxtaposed to the last suture reapproximating both crura behind the esophagus.
each silk suture are now placed
10a
10b
448 Open antireflux operations through a left thoracic approach
https://t.me/med1917
The reconstructed esophagogastric junction is
11
reduced under the diaphragm by pushing on
the cardia while delicately tugging on the transdiaphragmatic sutures. Snug apposition of the fundus
on the undersurface of the diaphragm is insured. The
repair must be completed without any tension.
Any stress on the repair should alert the surgeon to the
requirement of a lengthening procedure, as illustrated in
Figure 12.
The uncut elongation gastroplasty with total
fundoplication
The entire esophagogastric junction lies within the chest. A
number 50 tapered bougie is positioned in the esophagus and
stomach. The bougie is held snug against the wall of the lesser
curvature, and the gastroplasty is created using a linear stapler. Three techniques are available to create an elongation
gastroplasty in association with a total fundoplication.
11
The uncut elongation gastroplasty is made by applying a 3 cm linear stapler with
https://t.me/med1917
12a
bougie held against the lesser curvature. Pushing through the pin of the stapling device results
in small anterior and posterior gastric perforations, which are closed with separate monofilament resorbable sutures.
4.8 mm staples to appose the anterior and posterior walls of the fundus around the
Fundus
Operation 449
12a
Anterior and posterior
vagi are dissected free
of lesser curvature
The fundus, extensively mobilized, is manipulated to bring the anterior and
12b
while the intraesophageal bougie remains in place. The fundoplication is completed with
the vagi safely retracted away from the gastroplasty.
posterior walls together to surround the entire length of the uncut gastroplasty
Dissected vagi freed
and pushed away from
gastroplasty
12b
450 Open antireflux operations through a left thoracic approach
https://t.me/med1917
2-0 silk sutures are used
12c
a line immediately anterior to the
staple line. Fixation of the sutures
on the neoesophagus is optional.
The entire length of the gastroplasty is then covered by the
wrapped fundus. The bougie is
removed, and a nasogastric tube is
positioned under direct guidance.
to tie the free fundus to
3 anchoring sutures
passed through esophagus,
top of fundoplication and
through diaphragm
Bougie within
neoesophagus
Suture
Staple
12c
A second row of silk sutures
12d
and the repair is reduced under the
diaphragm. Using a double needle, three 2-0
prolene sutures are positioned on the apex of
the gastroplasty tube, passed through the
apex of the fundoplication, and tied. Both
needles are then passed separately through
the diaphragm from below to above, and the
sutures are tied on the pleural side of the
diaphragm. The repair is reduced and fixed
under the diaphragm.
buries the first series of sutures,
12d
The cut elongation gastroplasty with total fundoplication (Orringer–Henderson)
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The anterior and posterior proximal lesser curvatures are free. Both vagi have been dissected
13a
vature, the GIA stapling device is applied, creating a 5 cm gastroplasty around the bougie.
away from the gastroplasty tube. With the endoluminal bougie held against the lesser cur-
Operation 451
13a
The gastric tissue has
13b
the staple lines. Both suture lines are
scrutinized for hemostasis and
suture integrity. The fundus remains
attached by its base to the gastric
body.
been transected between
5 cm.
13b
452 Open antireflux operations through a left thoracic approach
s
y
Gas
S
e
T
e
3
.
n
https://t.me/med1917
The tip of the fundus
13c
elongation gastroplasty to create
a total fundoplication. The
fundic wrap is sutured anterior
to the gastroplasty suture line
and to the wrap itself, completing a 360 degrees fundoplication
that covers both suture lines.
is brought around the
13c
cm
utur
ransected
staple lin
Bougie i
neoesophagus
troplast
The elongation gastro-
13d
fundoplication is reduced under the
diaphragm. The anchoring sutures
are passed from the apex of the gastroplasty through the apex of the
fundoplication and through the
diaphragm to be tied above the
diaphragm. The crural sutures are
then tied behind the esophagus,
leaving enough space to pass an
index finger between the last suture
and the esophageal wall.
plasty covered by the
13d
Fundoplication
The cut elongation gastroplasty with transverse fundoplasty and total
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fundoplication (Jeyasingham)
A second type of cut gastroplasty may be useful to repair a shortened esophagus. The GIA
14a
stomach walls around the number 50 bougie held against the lesser curvature of the stomach.
stapler with 4.8 mm staples is applied to appose and divides the anterior and posterior
Operation 453
14b
Row of
linear staples
14a
The fundus on the side of the
14b
results in a closed 3 cm elongation gastroplasty and a wide-open gastrotomy. The
fundus is positioned for transverse closure
to provide a widened fundus for the subsequent fundoplication.
stapler is transected open. This
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