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_788_Библиотеки_им_академика_М_И_Перельмана.pdf
238
9. Operations on the G.-E. Junction
9.1 Nissen Fundoplication
A. Pier , F . Götz
Goals and Methods
Incompetent lower esophageal sphincters are often primarily
treated nonoperatively with the goal of eliminating gastroe-
sophageal reflux and its consequences.
Operative management of gastroesophageal reflux may include
a laparoscopic approach for a variety of antireflux procedures.
One such option is the Nissen fundoplication.
Indications
Indications for surgical intervention include:
− Functionally and endoscopically confirmed diagnosis refractory to long-term non-operative treatment (i. e., over a
period of about six months).
− Gastroesophageal reflux stages III and IV (Table 9.1.1).
Peptic stricture may be treated by:
− Endoscopic dilatation and long-term omeprazole therapy
(10−20 mg).
− Laparoscopic selective proximal vagotomy with Nissen fundoplication.
Alternative.
− In the presence of a scarred peptic stricture refractory to endoscopic dilatation, a conventional open procedure may be
performed. After the surgeon has enlarged the hiatus, intraluminal dilatation may be monitored with the hand surrounding the lower esophagus to protect the wall from forceful instrumentation. If the dilatation is successful, selective
vagotomy and Nissen fundoplication will complete the open
approach.
Table 9.1.1 Endoscopic classification of gastroesophageal reflux according to Savary and Miller.
Stage I Isolated or multiple confluent mucosal changes charac-
terized by erythema, exudate, and superficial erosions.
Stage II Confluent exudative areas of erosion which do not cover
the entire circumference of the esophagus.
Stage III Tissue changes covering the entire circumference of the
esophagus in the absence of stenosis.
Stage IV Chronic changes such as ulcer or stricture.
Published studies cite a morbidity of 2−3% with the laparoscopic Nissen procedure; varying mortality rates are cited
(Rothen, Bühler et al. 1994).
Special Preparations
− Esophagogastroscopy with biopsy to confirm the diagnosis
and exclude the possibility of cancer.
− Indwelling urinary catheter.
− Nasogastric tube.
Anesthesia
General anesthesia.
Patient Positioning
(Fig. 9.1.1).
Anatomy
Contraindications
− Anesthetic risks, see chapter 2.5.
− Coagulation disorders that do not respond to treatment.
− Previous upper abdominal operations (relative contraindication).
Surgical Risks and Patient Information
The patient must be made aware of the present state of intermediate experience with laparoscopic fundoplication and that
intraoperative complications can force the surgeon to convert to
an open procedure.
The specif ic risks of this technique are the same as those of the
conventional open procedure.
(Figs. 9.1.4 to 9.1.7).
Complications
Intraoperative Complications
Injuries to the Esophagus, Cardia, or Body of the Stomach
Corrective action: If you suspect a perforation has occurred, inject a dilute methylene blue solution to identify any leaks. Perform an open procedure to close the defect with interrupted sutures through all tissue layers (Fig. 9.1.16), and cover it with a
fundoplication or an omental patch. Always place a drain.
Injuries to the Spleen
Corrective action: Perform laparotomy, and attempt to control
bleeding using electrocoagulation and fibrin glue. When these
measures are in doubt, splenectomy is indicated.
Monitor
2
nd
assistant
Aspirator/irrigator set
Insufflator
1
st
assistant
Electroautery unit
Surgeon
Instrument table
OR nurse or
technician
Fig. 9.1.2 Nissen fundoplica-
tion. Position of the operating
team and equipment.
The aspirator/irrigator set is
on the patient’s left, the electrocautery unit and insufflator
on the patient’s right.
Complications
Fig. 9.1.1 Nissen fundoplication. Positioning the patient.
Position the patient supine in a reverse Trendelenburg position with one
arm extended and the legs spread apart.
239
Injuries to the Liver
Corrective action: Control bleeding with bipolar electrocautery.
Minor injuries to the capsule can be treated with fibrin glue.
Where this is unsuccessful, use deep sutures to close the
parenchyma (open operation).
Postoperative Complications
Dysphagia
This complication occurs in 7−10% of all patients. Generally, it
subsides after a few months. Persistent dysphagia can be the
sign of an excessively tight wrap (Fig. 9.1.17).
Corrective action: Revision laparoscopy to relax and redo the
fundoplication. If any difficulties are encountered, conventional
laparotomy is indicated.
240
9.1 Nissen Fundoplication
T4
T5
T3
T2
T1
Fig. 9.1.3 Nissen fundoplication. Trocar placement.
After inserting the laparoscope/camera trocar (T1) into the abdominal
cavity about two finger breadths above the umbilicus, place the instrument trocars according to the laparoscopic findings. We recommend
placing trocar T3 as shown in the illustration to expose the left hepatic
lobe. Splint the esophagus with a large nasogastric tube.
T1 Laparoscope/camera trocar (30-degree laparoscope)
T2 Grasper (Babcock)/probe
T3 Laparoscopic retractor/swab
T4 Grasper
T5 Laparoscopic retractor
Open trocar placement is an alternative.
Fig. 9.1.4 Nissen fundoplication. Muscular structure of the antrum, pylorus, and proximal duodenum representing the distal sphincter assembly
of the stomach.
Two muscle layers cover the pylorus, a superficial longitudinal layer and a
deep transverse layer.
a
Fig. 9.1.5a, b Nissen fundoplication. Muscular structure of the lower
esophageal sphincter.
a In the open position, the lower esophageal sphincter is shortened with
the musculature relaxed.
b If the segment is closed, it is elongated and the musculature is con-
tracted.
b
1
2
3
Fig. 9.1.6 Nissen fundoplication. Phrenoesophageal membrane.
1 Pleura
2 Phrenoesophageal membrane
3 Superior diaphragmatic fascia
4 Inferior diaphragmatic fascia
5 Parietal peritoneum
4
5
Fig. 9.1.7 Nissen fundoplication.Variations in anatomy.
The phrenoesophageal membrane (see Fig. 9.1.6) is only loosely connected to the superior diaphragmatic fascia (illustrated here with interrupted lines) and is missing below the diaphragm. On the right, it can ad-
join the right gastric artery.
Persistent Reflux
Persistent reflux can occur due to insufficiency of the fundopli-
cation (Fig. 9.1.18).
Corrective action: Revision laparoscopy to relax and redo the
fundoplication. If any difficulties are encountered, conventional
laparotomy is indicated.
“Telescoping”
“Telescoping” may occur; see Fig. 9.1.19).
Corrective action: Revision laparoscopy to reduce the stomach
and rework the fundoplication. If any difficulties are en-
countered, conventional laparotomy is indicated.
Denervation Syndrome
This complication occurs in about 3% of all patients, generally
heralded by transitory diarrhea and repeated episodes of
abdominal bloating.
Corrective action: Treatment with motility agents and placement of a nasogastric tube is necessary.
Alternative Procedures
− Hill posterior gastropexy procedure.
− Belsey Mark IV repair.
Postoperative Care
The nasogastric tube should remain in place for the first few
days postoperatively. Radiographic follow-up with Gastrografin
to verify patency is indicated immediately before the first post-
operative oral feeding. This also applies to patients with dysphagia (excessively tight wrap) and those with sensation of
fullness (denervation syndrome).
Revision Surgery
The most reliable criterion is endoscopically confirme d regres-
sion of mucosal changes associated with reflux esophagitis.
241
Revision Surgery
Any revision operation should be performed as a laparotomy.
The procedure may be quite involved.
Step-by-Step Procedure
I Technical preparations
1. Adjust the electrocautery unit to a medium setting.
2. Connect the aspirator/irrigator set.
3. Prepare an endoluminal endoscope.
4. Start the recording unit.
II Establishing the pneumoperitoneum
1. Select pressure levels according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Prepare all equipment required for operation.
3. Make a skin incision about two finger breadths above the
umbilicus for the Veress needle and laparoscope/camera trocar.
4. Insert the Veress needle.
5. Perform safety tests: injection, aspiration, “slurp,” manometer,
and rotation tests.
6. Perform insufflation procedure.
Caution: Insufflate infants at 1 liter/min maximum.
III Laparoacopy
1. Place large nasogastric tube.
2. Insert laparoscope/camera trocar with tapered stylet about
two finger breadths above the umbilicus directly through the
linea alba.
3. Insert the instrument trocars in the left and right upper abdo-
men under laparoscopic visualization.
4. Explore the peritoneal cavity visually.
5. Expose the cardia and gastric fundus.
6. Incise the part of the lesser omentum superior to the hepatic
vagus branches, parallel to the right abdominal border of the
esophagus (see Fig. 9.1.8). Make a longitudinal incision along
the left border of the esophagus.
7. Clear the phrenoesophageal membrane off the GE junction
with a dissection swab or grasper.
8. Place an elastic loop around the abdominal esophagus.
9. Transect the gastrophrenic ligament to mobilize the fundus.
10. Expose the crural pillars of the esophageal hiatus with a
grasper and swab.
11. Place three or four interrupted sutures to reduce the
esophageal hiatus.
12. Pull the mobilized fundus behind the esophagus, in front of
the repaired hiatus.
13. Wrap the fundus around the esophagus and secure the wrap
with one to four interrupted sutures.
14. Verify proper tightness of the wrap with a dissection swab.
15. Place a drain (surgeon’s choice).
16. Remove the trocars under laparoscopic visualization.
Caution: Residual bleeding from the trocar incisions may occur.
242
9.1 Nissen Fundoplication
Specific Technique
T5
T5
T4
T3
Fig. 9.1.8 Nissen fundoplication. Incision of the peritoneal fold.
Incise the peritoneal covering where the esophagus joins the cardia, and
continue the circular dissection to expose the esophagus.
T2 Scissors
T3 Retracting the anterior wall of the stomach
T4 Lifting the peritoneum
T5 Laparoscopic retractor to elevate the left hepatic lobe
T4
T2
T2
Fig. 9.1.9 Nissen fundoplication. Elastic loop passed around the abdominal esophagus.
After exposing the entire circumference of the abdominal segment of the
esophagus, the elastic loop is insinuated between the esophagus and the
abdominal aorta. Both ends of the elastic loop can be grasped and
tightened intraabdominally or retracted through the appropriate trocar.
Divide the gastrophrenic ligament at the fundus with a broad cut coursing
laterally. Coagulate vascular structures with bipolar electrocautery or ligate them with clips. The complete fundic mobilization is important to
allow construction of a tension-free fundoplication.
T2 Grasper grips elastic loop
T4 Scissors
T5 Laparoscopic retractor for elevating the left hepatic lobe
Revision Surgery
243
T5
T2
T3
Fig. 9.1.10 Nissen fundoplication. Exposing the arches of the esophageal
hiatus. Right medial crus.
Dissect the left and right sides of the esophageal diaphragmatic hiatus
while retracting the esophagus laterally and inferiorly with the elastic loop
(port T2).
T3 Grasper
T5 Laparoscopic retractor for elevating the left hepatic lobe
T2
T3
Fig. 9.1.11 Nissen fundoplication. Narrowing of the esophageal diaphragmatic hiatus (optional).
The hiatus is narrowed as in conventional open operation. Retract the
esophagus laterally (port T2) and reduce the patency of the hiatus by
placing three or four interrupted sutures posteriorly (absorbable suture
material 2 × 0, metric 3, no. 27 curved needle). With a second needle
holder inserted through trocar T4, you can tie an intracorporeal surgeon’s
knot.
T3 Needle holder
T5
T3
T4
T2
Fig. 9.1.12 a, b Nissen fundoplication. Pulling the mobilized fundus be-
tween the esophagus and diaphragm posteriorly.
a By retracting the esophagus toward the anterior abdominal wall it be-
comes possible to push the anterior wall of the fundus posterior to the
esophagus with a swab. An angled grasper (T3) inserted beneath the
esophagus helps. Be careful to avoid rotating the stomach. Pull the
fundus behind the esophagus with an atraumatic grasper inserted
through port T4. Wherever possible, grasp the posterior wall of the
fundus to counteract rotation of the stomach.
b The insert shows the line of the incision in the gastrophrenic ligament
(dashed line). Ligate vascular structures with clips.
T2 Grasper (holding elastic loop)
T3 Angled swab holder
T4 Babcock grasper (for pulling the fundus through beneath the esophagus)
T5 Laparoscopic retractor (for elevating the left hepatic lobe)
244
9.1 Nissen Fundoplication
T4
T4
T3
T5
Fig. 9.1.13 Nissen fundoplication. Placing interrupted sutures.
Wrap the fundus around the esophagus and secure the wrap with three to
four interrupted sutures. Here you can use an extracorporeal slip knot secured with a locking knot. An intraabdominal surgeon’s knot is preferable
if you are sufficiently experienced in laparoscopic knot tying. Use non-ab-
sorbable suture material, metric 2, 3 × 0, with a length of 90 cm.
Oppose the fundic folds to each other with two Babcock graspers to re-
lieve tension on the interrupted sutures while they are placed.
T2 Babcock grasper
T3 Needle holder
T4 Laparoscopic retractor (for elevating the left hepatic lobe)
T5 Babcock grasper
T2
T3
Fig. 9.1.14 Nissen fundoplication. Verifying proper tightness of the
wrap.
Proper tightness has been obtained when one can easily insert a dissection swab into the wrap with a nasogastric tube in place in the esophagogastric junction after having tied the knots.
Now suture the inferior border of the wrap to the wall of the stomach (absorbable suture material, metric 2/3 × 0.
T3 Grasper
T4 Retractor
Fig. 9.1.15 Partial fundoplication.
In an anterior esophageal puncture or a deficient lower esophageal
sphincter, one can cover a suture repair through all esophageal tissue layers with a partial fundoplication.
Fig. 9.1.16 Nissen fundoplication.
Repair the esophageal defect with interrupted sutures through all tissue
layers, and cover it with a full fundoplication.
Bibliography
245
Fig. 9.1.17 Nissen fundoplication. Stenotic obstruction caused by fundic
wrap.
Stenotic obstruction with typical gas bloat symptoms.
Fig. 9.1.19 Nissen fundoplication. Herniated fundus.
Where the wrap has not been sufficiently anchored to the wall of the
stomach, the superiorly herniated fundus may result in reflux or obstruction.
Fig. 9.1.18 Nissen fundoplication. “Slipped Nissen” due to failure of sutures.
Where the entire wrap fails and persistent refractory reflux results, a
thoracoscopic take-down and partial fundoplication should be considered.
Bibliography
Bushnin FL, Wenstein CL, Parker TH, Woodward ER. Nissen fundoplication
for reflux peptic esophagitis. Ann. Surg. 1977; 185:672.
Dallemagne B, Weerts J, Jehaes C et al. Laparoscopic Nissen fundoplication:
preliminary reports. Surg. Laparosc. Endosc. 1991; 1:138.
DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastro-
esophageal reflux disease. Evaluation of primary repair in 100 consecutive
patients. Ann. Surg. 1986; 204:19.
Donahue PE, Samelson S, Nyhus LM, Bombeck CT. The floppy Nissen fundo-
plication. Arch. Surg. 1985; 120:1440.
Ellis HF, Garabedian M, Gibb PS. Fundoplication for gastroesphageal reflux.
Medications, surgical techniques, and manometric results. Arch. Surg.
1973; 107:186.
Feifel G. Chirurgische Therapie der Refluxkrankheit. In Kremer K, Lierse W,
Platzer W, Schreiber HW, Weller S. Chirurgische Operationslehre, Vol. 3,
p. 317. Stuttgart: Thieme; 1987.
Geagea T. Laparoscopic Nissen-Rosetti fundoplication. Surg. Endosc. 1994;
8:1080.
Grönninger J, Rothmund M. Anatomische Rekonstruktionen. In Blum AL,
Siewert JR. Refluxtherapie. Berlin: Springer; 1981.
Hallerbäck B, Glise H, Johansson B, Rådmark T. Laparoscopic Rosetti fundo-
plication. Surg. Endosc. 1994; 8:1417.
Höhle KD, Kümmerle F. Eine neue Methode zur Behandlung von Hiatusher-
nien durch Fundopexie und Hiatuseinengung. Langenbecks Arch. Chir.
Forum, 1972; Suppl. 169:255.
Lepsien G. Laparoskopische Therapie der Refluxösophagitis: Fundoplikation.
Nissen-Rosetti. Verdauungskrankheiten 1993; 11:141.
McKernan JB, Laws HL. Laparoscopic Nissen fundoplication for the treatment
of gastroesophageal reflux disease. The American Surgeon 1994; 60:87.
Nissen R, Pfeiffer R. Zwerchfellhernien. Bern: Huber; 1968.
Nissen R, Rosetti M. Chirurgie der Kardia. Ciba Symp. 1963; 11:123.
Nissen R, Rosetti M. Die Behandlung von Hiatushernien und Refluxö-
sophagitis mit Gastropexie und Fundoplicatio, 2nd edn., Stuttgart:
Thieme; 1981.
Nissen R, Rosetti M, Siewert R. Fundoplicatio und Gastropexie bei Reflux-
krankheit und Hiatushernie, 2nd edn., p. 45. Stuttgart: Thieme; 1981.
Thor KBA, Silander S. A long-term randomized prospective trial of the Nissen
procedure versus a modif ied Toupet technique. Ann. Surg. 1989; 210:719.
Watson A, Jenkinson LR, Ball CS, Bartlow AP et al. A more physiological alter-
native total fundoplication for the surgical correction of resistant gastro-
oesophageal reflux. Brit. J. Surg. 1991; 78:1088.
246
9.2 Fundoplication and Partial Fundoplication Techniques
K.-H. Fuchs
Aims and Methods (Fig. 9.2.1)
The majority of patients with gastroesophageal reflux disease
can be successfully treated by medication. Around 20 to 25% of
reflux patients develope a progressive form of the disease. Only
the latter group of patients are candidates for surgical therapy.
Most of these patients develope complications of their continuous pathological reflux into the esophagus with esophagitis, ulcers, strictures and, in about 10−15% of these patients eventually, Barrett’s esophagus or columnar lined epithelium in the
distal esophagus. It is important for the surgeon to keep in mind
that the disease is a multifactorial process with several
pathophysiological components in the background. The most
important functional defect in reflux disease is the incompetence of the lower esophageal sphincter or the high pressure
zone in the distal esophagus. A second important factor is impaired esophageal peristalsis leading to an insufficient
esophageal clearance. A third group of defects are gastric disorders, such as gastric hypersecretion, delayed gastric emptying, antroduodenal motility disorders, and gastric dilatation.
The principal aim of any fundoplication technique is the mechanical augmentation of the lower esophageal sphincter or the
high pressure zone in the distal esophagus. The role of the
operation is the correction of the functional defect, the healing
and prevention of further complications. The methods of total
and partial fundoplication can be performed by open and laparoscopic techniques.
Esophageal pump
insufficiency
Incompetence
of LES
Duodenogastric
reflux
Gastric
hyperacidity
Aims of Surgical Technique
1. Restore the anatomical situation by reducing the hiatal
hernia.
2. Close crura in the caudal and posterior part to restore the
normal hiatal width.
3. Augment the mechanical aspect of the lower esophageal
sphincter (increase pressure and length).
4. Attach the wrap and the abdominal segment of the lower
esophageal sphincter in the abdominal environment.
A number of different complete and partial fundoplication
techniques have been developed (Fig. 9.2.2). The optimal choice
of antireflux procedures is a matter of controversial discussion.
The best sphincter augmentation can be achieved with a full
360° wrap of the Nissen fundoplication. This should be the
standard procedure for reflux patients. However, if preopera-
tive manometry or clinical symptoms show an impaired
esophageal peristalsis with an insufficient esophageal clearance, it is advisable to use a partial fundoplication technique
rather than a full Nissen fundoplication. The Nissen fundoplication can lead to postoperative persistent dysphagia in these
cases. Therefore, the partial fundoplication techniques are a
compromise between the necessary sphincter augmentation to
prevent reflux on one hand and, on the other hand, a weaker
mechanical augmentation which allows postoperative symptom-free swallowing with an insufficient peristalsis (Fig. 9.2.3).
As a consequence, manometry should be performed preopera-
Delayed gastric emptying
Fig. 9.2.1 Overview on pathophysiological components of gastroesophageal reflux disease.
tively to assess esophageal body function and peristaltic sufficiency.
A combination of an antireflux procedure with highly selective
vagotomy in patients with abnormal gastric acidity is currently
considered to be controversial. Therefore it cannot generally be
recommended.
HILL
TOUPET
Indications
WATSON
BELSEY
247
anterior 180°
Fig. 9.2.2 Overview of different antireflux operations. There is a number
of variations of partial fundoplication. The Nissen fundoplication has been
modified also and basically 3 different types have been used
− the original Nissen version with a fundoplication, a rather symmetric
plication of the fundus around the distal esophagus,
Special Anatomical Aspects for Surgical
Intervention
The phrenoesophageal membrane can insert at different points
along the distal esophagus. This can be important for the individual expression of the sites of the hiatal hernia in patients.
The phrenoesophageal membrane usually is only loosely con-
nected with the fascia diaphragmatica superior and can have
connections to the left gastric artery. The short gastric vessels
connect the fundus with the spleen. In addition the posterior
gastric artery can limit the mobility of the fundus (Fig. 9.2.4).
A schematic overview of the different types of hiatal hernia that
often are associated with gastroesophageal reflux disease is
shown in Fig. 9.2.5. Most common is an axial hiatal hernia in reflux patients in up to 80%. A combined hiatal hernia can develop
if the total proximal part of the stomach with the fundus and the
cardia is moving up into the lower mediastinum, usually due to
a wide enlarged hiatal opening. True paraesophageal hernias,
usually, are not related to reflux disease. Rarely do patients with
paraesophageal hernias suffer from pathological reflux. In these
patients the distal esophagus and the sphincter are at their cor-
(Figs. 9.2.4 and 9.2.5)
NISSEN
− the Nissen-Rossetti fundoplication using the anterior gastric wall for
the retroesophageal pull-through to fix the wrap anteriorly to the
esophagus in an asymmetric way,
− the very short and floppy Nissen-DeMeester fundoplication with only
one U-stitch.
rect anatomical position at the thoracoabdominal junction. In
antireflux surgery, it is important to reduce or dissect the
hernia, restore the normal hiatus by a posterior hiatoplasty or
crural closure.
Indications
Antireflux surgery is indicated when:
1. Symptoms cannot be completely controlled by nonoperative
treatment.
2. Complications of the disease such as esophagitis, ulcer stric-
tures or Barrett’s esophagus are present or recurrent.
3. The disease and its progress is well documented and also the
functional defect is assessed by functional studies.
In addition, surgery must be considered, especially in young
patients, even if symptoms and esophagitis can be controlled by
conservative medication, when the individual perspective in
this patient together with the functional assessment shows a
necessity for life-long medication and therefore drug dependency.