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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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454 Open antireflux operations through a left thoracic approach
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The fundoplasty line is
14c
“u” stitch apposes the middle of the
fundic tissue to the distal extremity of
the staple line. Separate inverting
resorbable sutures are used to close
the fundoplasty line on both sides of
the middle suture.
made symmetrical, and a
Bougie
14c
The remaining fundus
14d
lized greater curvature are then
brought up to completely cover the
gastroplasty suture line. The new fundus is applied symmetrically to cover
the gastroplasty and is held in place
by two sutures positioned on each
side of the proximal gastroplasty.
and the extensively mobi-
14d
A standard total fundoplication is created,
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14e
vature side, away from the gastroplasty line; this makes
the transverse fundoplasty part of the total fundoplication wrapping the gastroplasty.
with the sutures anchored on the lesser cur-
Operation 455
14f
Transected
staple line
Bougie in
neoesophagus
Suture
14e
The 3 cm total fundoplication is reduced under
14f
sutures are passed from the apex of the gastroplasty to the
apex of the fundoplication and then through the
diaphragm.
the diaphragm, and three or four anchoring
456 Open antireflux operations through a left thoracic approach
https://t.me/med1917
Elongation gastroplasty with partial
fundoplication (Pearson)
When a lengthening procedure is required with a
15
plasty, the same technique can be used to create the elongation of the esophagus. The 240 degrees wrap around the
gastroplasty uses exactly the same method as for the Belsey
partial fundoplication as a wrap around the gastro-
mark IV repair, using both vagi as the anterior and posterior
limits of the fundic wrap. The transsection line of the gastroplasty is completely covered by the partial fundic wrap. The
primary indicator for this type of repair is an acquired shortening of the esophagus as occurs with massive paraesophageal
hernias, especially if poor propulsion or poor contraction
strength has been documented in the esophagus.
16
15
Standard partial or total fundoplication or elonga-
16
reduced into the abdomen in the same way as illustrated in
the Belsey repair. The heavy silk sutures reapproximating the
left and right crura are then tied.
tion gastroplasties with their fundoplication are
With the repair reduced and anchoring completed,
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17
esophageal wall and the last crural suture.
an index finger should pass easily between the
Postoperative care 457
Pericardium
Esophagus
Anchoring
suture
Dilator
Crural suture
17
18
Surgical closure
The peripheral diaphragm, when opened, is closed with 2-0
interrupted silk sutures. A number 28 chest tube is installed
in a posterolateral position to allow proper re-expansion and
drainage. The chest wall is closed in the usual manner.
POSTOPERATIVE CARE
Pain relief
Most patients undergoing repair by means of a thoracotomy
for a simple hiatus hernia or for the complications of gastro-
The final result should be a tension-free repair and a
18
esophageal reflux receive an epidural analgesia catheter
before the operation starts. Impressive comfort is afforded by
the technique supplemented by nonsteroidal anti-inflammatory medication or morphine derivatives.
closed hiatus.
Respiratory care
Optimal care is obtained by early ambulation and active
physiotherapy favoring full diaphragmatic excursion. The
chest tube installed after the repair is left in place until
drainage decreases to less than 200 ml in a 24-hour period.
The epidural is discontinued after the chest tube is
removed.
458 Open antireflux operations through a left thoracic approach
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Gastric drainage
A double-lumen nasogastric tube is installed and verified for
its position in the gastric cavity at the end of the repair. This
type of tubing favors the use of continuous low-grade suction
without mucosal occlusion of the drainage ports. Early return
of active peristalsis and the absence of significant gastric
retention prevents undue distension and pressure on the
repair. The repair is verified radiologically once the nasogastric tube has been removed.
Infection and thromboembolic prophylaxis
When the esophagus or esophagogastric junction is opened,
prophylactic antibiotics (a third generation cyclosporin with
metronidazole) are provided before the operation starts and
are given for the initial 24 hours after the operation.
Subcutaneous heparin (5000 IU) is administered every 8
hours until the patient leaves the hospital. Discharge is usually within 5–6 days.
OUTCOME
The Belsey mark IV operation provides a good early control
of reflux symptoms for 95% of the patients treated. When followed up for over 20 years the failure rate increases by 1% per
year.
The elongation gastroplasty proposed by Collis in 1957,
and subsequently modified by Orringer in 1976 and
Henderson in 1977 to include a total fundoplication, provides excellent results for over 90% of patients treated. The
uncut Collis–Nissen repair has shown favorable results in
94% of patients.
FURTHER READING
Allison P. Reflux esophagitis, sliding hiatal hernia and anatomy of repair.
Surgery Gynecology and Obstetrics 1951; 92: 419–31.
Chen LQ, Nastus D, Hu C-Y, Chughtai TS, Taillefer R, Ferraro P,
Duranceau A. Results of the Collis–Nissen gastroplasty in patients
with Barrett’s esophagus. Annals of Thoracic Surgery 1999; 68:
1014–21.
Collis JL. Gastroplasty. Thorax 1961; 116: 197–206.
Ferraro P, Duranceau A. Elongation gastroplasty with total
fundoplication (Collis–Nissen operation). Operative Techniques in
General Surgery 2000; 2: 24–37.
Hiebert CA. Surgical management of esophageal reflux and hiatal
hernia. Annals of Thoracic Surgery 1991; 52: 159–60.
Pera M, Deschamps C, Taillefer R, et al. The uncut Collis–Nissen
gastroplasty: early functional results. Annals of Thoracic Surgery
1995; 60: 915–21.
Stipa S, Belsey R. La Chirurgia dell’esofago. Indicazioni e techniche
Piccin Editore, Padova.
Skinner DB, Belsey R. Management of esophageal disease. Philadelphia:
WB Saunders, 1988: 576–99.
43
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The uncut Collis-Nissen procedure
VICTOR F. TRASTEK MD
Professor of Surgery, Consultant Division of General Thoracic Surgery, and Chair, Board of Governors Mayo Clinic Arizona, Scottsdale,
Arizona, USA
FRANCIS C. NICHOLS MD
Assistant Professor of Surgery and Consultant Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester,
Minnesota, USA
HISTORY
The repair of diaphragmatic hiatal hernia began with reduction of the hernia and reapproximation of the crura. Over
time it was appreciated that solely this approach failed to
relieve the associated symptoms of gastroesophageal reflux
disease (GERD). Increased knowledge of the pathophysiology
of GERD led to the development of a surgically created antireflux valve. These procedures included the Nissen fundoplication, the Belsey partial fundoplication, and the Hill repair.
In 1957, Collis described an esophageal lengthening procedure utilizing gastric tissue to create a connecting tube (neoesophagus) between the lower end of the esophagus and the
proximal stomach. In 1974, Bingham modified the cut gastrotomy portion of the Collis gastroplasty by utilizing an
uncut staple line followed by a 360-degree stomach wrap over
the connecting tube (uncut Collis–Nissen procedure). Piehler
and colleagues from our institution in 1984 reported results
of this procedure showing better relief of symptoms associated with GERD.
PRINCIPLES AND JUSTIFICATION
Lower gastroesophageal sphincter incompetence permits free
reflux of gastroduodenal contents into the esophagus. The
recognized esophageal consequences of this reflux are directly
related to the effects of the secretions on the esophagus and to
the esophageal mucosa’s response to chemical injury. These
consequences include desquamation, erosion, ulceration,
inflammation, pain, bleeding, motility disturbances,
esophageal shortening, stricture formation, and Barrett’s disease (columnar epithelial lining of the lower esophagus).
Complications vary from patient to patient, and the patho-
logical processes are often reversed by eliminating the exposure of the esophageal mucosa to the corrosive secretions.
Surgical control of the complications of gastroesophageal
reflux depends upon restoring gastroesophageal competence.
While many different surgical approaches have been utilized
to accomplish competence, all have three basic goals in
common. First is adequate mobilization of the esophagus
resulting in an adequate length of both the esophagus and
gastroesophageal junction resting comfortably in the
abdomen. Second is proper closure of the esophageal hiatus.
Third is restoration of the lower esophageal high-pressure
zone. Over the past 15 years, laparoscopic fundoplication has
become the most common surgical approach. Recognized
benefits of the laparoscopic approach include less morbidity,
decreased pain, shorter length of hospital stay, and earlier
return to normal daily activities. Nevertheless, laparoscopic
fundoplication may not be feasible in certain clinical situations. While not absolute contraindications, some of these
situations include: obesity, previous upper abdominal surgery, giant paraesophageal hernia, and failed previous fundoplication. For nearly 30 years, the authors and our colleagues
have advocated the uncut Collis–Nissen procedure when an
open surgical approach is required. This technique is a modification of Nissen’s 360-degree fundoplication and Collis’s
technique for lengthening the esophagus, to provide a
tension-free wrap.
The uncut Collis–Nissen gastroplasty uses a stapling device
applied to the stomach to create a 3 cm neoesophagus around
which a 360-degree Nissen fundoplication is performed. This
restores gastroesophageal competence and provides excellent
protection from esophageal reflux. By minimization of the
length of the uncut Collis maneuver (3 cm) and the fundoplication (2 cm), a reasonably low rate of dysphagia is possible
without sacrificing control of reflux.
460 The uncut Collis-Nissen procedure
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PREOPERATIVE ASSESSMENT AND
PREPARATION
Preoperative evaluation includes a thorough history, barium
upper gastrointestinal swallow, and upper gastrointestinal
endoscopy. Esophageal motility and 24-hour pH studies are
obtained selectively. Both of these studies are performed in
most patients with GERD, particularly in those with complicated or atypical reflux histories. Alternatively, both of these
studies are not routinely performed in patients with symptomatic large paraesophageal hernia.
OPERATION
Incision
A left thoracotomy is performed, and the pleural space is
1
entered through the periosteal bed of the nonresected
eighth rib. After a posterolateral thoracotomy, the chest
cavity and lung should be thoroughly explored.
ANESTHESIA
Placement of a thoracic epidural assists in initial management
of postoperative pain. Utilization of a double-lumen endotracheal tube collapses the ipsilateral lung leading to a less
obtrusive operative field. The patient is placed in the right
lateral decubitus position.
1
Operation 461
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Exposure
The inferior pulmonary vein is divided, and
2a–c
packed away out of the operative field. The esophagus, gastroesophageal junction, stomach, and hernia sac (if present)
should be freed from the mediastinum extending from the
inferior pulmonary vein to the hiatus. The mediastinal pleura
along the pericardium is divided and dissected down through
the associated plane to the parietal pleura of the opposite
chest cavity. A second incision is made parallel to the aorta
through the mediastinal pleura and carried down, which frees
the hernia sac and esophagus from the parietal pleura down
to the hiatus. The intrathoracic protrusion of proximal stomach and gastroesophageal junction is usually apparent. The
esophagus (including the vagal nerves) is then surrounded
with a Penrose drain.
the lung is collapsed, retracted cephalad, and
Pericardium
Hernia
Aorta
2a
2b
Pericardium
Penrose
drain
Aorta Esophagus
2c
462 The uncut Collis-Nissen procedure
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Dissection of the esophageal hiatus
The posterior or right crus is identified during
3a–d
entered, and the liver edge identified. Anteriorly, the phrenoesophageal ligament should be freed from the anterior or left
crus using cautery to increase the portion of sac available for
division. The sac is then entered and the phrenoesophageal
ligament and sac are resected medially by placing the fingers
the exposure of the hiatus, the lesser sac is
of the left hand astride the attachments between the gastroesophageal junction and the crura of the diaphragm, dividing
the hepatic branches of the vagus nerve, and joining up with
the posterior division of the sac made previously. The anterior sac is then divided laterally, stopping at the level of the
short gastric vessels. This completely frees the sac circumferentially from all hiatal attachments except the short gastric
vessels.
3a
3b
3c 3d
Division of the short gastric vessels
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A small Richardson retractor is placed in the caudad
position and a lung clamp is placed on the stomach in the
4
cephalad direction just below the gastroesophageal junction,
and the short gastric vessels are exposed, ligated with 2/0 silk,
and divided. If the hernia is large, this task is relatively easy as
the short gastric vessels are elongated. If the hernia sac is very
small, however, this portion of the operation may need to be
completed through a separate radial incision in the
diaphragm. The short gastric vessels are divided until the
right gastroepiploic arcade is visible. This completes the
exposure and mobilization of the esophagus, gastroesophageal junction, and fundus, from the inferior pulmonary vein to midstomach on the greater curve side.
Operation 463
4
Placement of crural sutures for closure of the
hiatus
The stomach and gastroesophageal junction are reduced
5
to ensure that they will easily go below the hiatus. The
need for a lengthening procedure is rare, except in the case of
reoperations. At this stage the hiatal crural sutures should be
placed and tagged, because they will allow the hiatus to be
closed as the last step of the procedure. Figure-of-eight
sutures of 1 polypropylene (Prolene) are placed through the
right and left crura, taking up the right crus to the insertion of
the pericardium but using only half of the left crus. This
allows space for the esophagus and gastroesophageal junction
when the sutures are tied. Care must be taken that the sutures
are not driven within the pericardium and that they do not
become twisted during placement.
5
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