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
258
Fig. 9.4.2 Gastropexy. Position of the operating team and equipment.
As in conventional gastric surgery, the surgeon stands to the right of the
patient. The assistant holding the laparoscope stands opposite the sur-
geon to the left of the patient; another assistant stands next to the surgeon on the patient’s right. The monitor is placed behind the patient’s left
shoulder so that the entire operating team looks beyond the operative
site to the monitor. This permits a coordinated approach using one moni-
tor. The operating room nurse and the instrument table are at the
patient’s feet. The electrocautery unit and aspirator/irrigator set can be
placed wherever is best.
9.4 Gastropexy in Paraesophageal Hiatus Hernia Repair
Monitor
Assistant
Surgeon
Instrument table
Assistant
holding
laparoscope
OR nurse
T4
T3
T1
T2
Fig. 9.4.3 Gastropexy. Trocar placement.
T1 10/12-mm laparoscope/camera trocar placed at the inferior mar-
gin of the umbilicus.
T2 and T3 The three instrument or working trocars form a semicircle with
the laparoscope/camera trocar. The right and left 10/12-mm trocars are for the surgeon who manipulates instruments with both
hands. These trocars are placed at the respective lateral margin
of the rectus abdominis.
T4 The right 10/12-mm instrument trocar is placed in the upper ab-
domen inferior to the costal arch at about the lateral margin of
the rectus abdominis. A blunt swab or retractor inserted through
this trocar is used to elevate the left hepatic lobe.
Complications
259
− Intestinal injuries from placement of the Veress needle or
trocars.
− Iatrogenic injury to the stomach and/or esophagus resulting
from the use of traumatic graspers.
− Injury to the spleen.
− Unsuccessful replacement of the stomach, especially in the
case of an upside-down stomach.
− Cutting through of sutures used for the hiatal repair.
Corrective action: Where a major complication occurs or the
operation cannot be safely continued laparoscopically, conversion to an open procedure is indicated. Only minor complications such as seromuscular tears of the stomach or inadvertently cutting the hiatal sutures may be managed laparoscopically, if the surgeon is sufficiently accomplished in
laparoscopic techniques.
Postoperative Complications
− Postoperative bleeding.
− Undetected injury to the hollow viscera.
− Esophageal stenosis or strictures resulting from excessive
narrowing of the esophageal hiatus.
− Subphrenic abscess.
Corrective action: Laparotomy and cure of complication.
Step-by-Step Procedure
1. Insert the trocars under laparoscopic visualization.
2. Explore the peritoneal cavity, establish the diagnosis, and determine the operative strategy.
3. Using a sponge held by a grasper, reduce the herniated paraesophageal part of the stomach into the abdomen.
4. Suture the fundus to the inferior aspect of the diaphragm by
placing interrupted sutures laparoscopically.
5. Place interrupted sutures over felt pledgets to repair the
esophageal hiatus around the esophagus.
6. Verify the caliber of the resulting diaphragmatic esophageal hiatus by inserting a swab or compress held by a grasper, between esophagus and hiatal repair.
7. If the entire stomach has herniated into the chest through a
grossly enlarged esophageal hiatus, reduce the pneumoperitoneum sufficiently to perform additional gastropexy of the
anterior wall of the stomach to the parietal peritoneum and
rectus muscle by placing interrupted sutures laparoscopically.
Operative Technique
T4
T3
1
T4
2
3
4
Fig. 9.4.4 Gastropexy. Replacing the stomach below the diaphragm.
Insert the trocars and introduce a compress held by a grasper to elevate
the left hepatic lobe. Exploration reveals a patulous esophageal hiatus
with partial volvulus of the stomach and cephalad displacement of the
fundus into the chest. Adhesions are generally absent so that the part of
the stomach that has herniated into the chest is easily replaced into the
abdomen (see Fig. 9.4.3 for key to instrument numbers).
Fig. 9.4.5 Gastropexy. Inspecting the esophageal hiatus.
Replacing the stomach into the abdomen reveals the grossly enlarged diaphragmatic esophageal hiatus with thickened margins. The hiatus can be
inspected with a 30-degree laparoscope. One can easily see if the gastroesophageal junction is fixed in the proper position (see Fig. 9.4.3 for key
to instrument numbers).
1 Thickened margins of the esophageal hiatus
2 Patulous esophageal hiatus
3 Diaphragm
4 Esophagus
260
9.4 Gastropexy in Paraesophageal Hiatus Hernia Repair
T4
T3
T4
T2
T3
Fig. 9.4.6 Gastropexy. Suturing the fundus to the diaphragm. After re-
ducing the fundus into the abdomen, it is sutured to the inferior aspect of
the diaphragm by interrupted seromuscular gastric to muscular diaphrag-
matic sutures. Use nonabsorbable sutures (size 2−0; metric 2.5). Make
sure that each suture captures enough tissue on both sides (see Fig. 9.4.3
for key to instrument numbers).
T4
T2
Fig. 9.4.7 Gastropexy. Suturing the fundus to the diaphragm. Tie extracorporeal laparoscopic knots with conventional knot-tying techniques,
using a laparoscopic knot pusher to introduce the knots into the abdominal cavity. Verify proper seating and tightness of the sutures between the
fundus and inferior aspect of the diaphragm by applying tension to the
anterior wall of the stomach with a swab. Depending on the length of the
fundus, between five and seven interrupted sutures are required. After
completion of the gastropexy, the fundus of the stomach should be securely fixed to the diaphragm over a wide area (see Fig. 9.4.3 for key to in-
strument numbers).
T4
Fig. 9.4.8 Gastropexy. Repair of the esophageal hiatus.
The esophageal hiatus must be narrowed toeliminate a possible hernia recurrence. Since simple interrupted sutures may tear through the mostly
muscular left and right crural pillars of the diaphragm, the nonabsorbable
sutures are placedover felt or Teflon pledgets. The suturemust encompass
sufficient crural muscular tissue (see Fig. 9.4.3 for key to instrument num-
bers).
T2
T2
T4
T2
T3
Complications
T4
261
T2
Fig. 9.4.10 Gastropexy. The operative site after suture placement.
View of the fundic and cardia regions after completed gastropexy and re-
pair of the crus. The illustration shows the fundus of the stomach fixed to
the diaphragm over a wide area and closure of the hiatus hernia with interrupted laparoscopic sutures (see Fig. 9.4.3 for key to instrument num-
bers).
컅 Fig. 9.4.9 Gastropexy. Repair of the esophageal hiatus.
After passing the suture through both limbs of the diaphragmatic crus,
place a second felt pledget at the exit of the suture. An extracorporeal
knot is then introduced into the abdominal cavity with a knot pusher. The
pledgets relieve the tension on the crural limbs and reduce tension on the
tissue. After tying the first suture, the hiatus will narrow down. However, a
second suture is required to repair the hiatus satisfactorily.
Place the pledgets so that they lie between the knot and the crural musculature as the knot is tightened. After the second knot is tightened, the
crural limbs are drawn far enough into apposition so that a swab will just
barely pass through the remaining opening. To avoid the risk of stenosis,
do not place additional sutures on the crural limbs (see Fig. 9.4.3 for key
to instrument numbers).
Fig. 9.4.11 Gastropexy. Alternative technique.
An extremely large hernia resulting from displacement of the entire
stomach into the chest can make it difficult to repair the crus with interrupted sutures. An alternative technique for this situation involves bridging the hernia opening with nonabsorbable mesh and fixing it to the
thickened margins of the right crus with staples. Use relatively soft mesh
material to reduce the risk of injuring the esophagus (see Fig. 9.4.3 for key
to instrument numbers).
Bibliography
Ackermann E, Bally H, Harder F. Die paraösophageale Hiatushernie − Risiken
und Operationsindikation. Helv. Chir. Acta 1989; 56:159.
Ackermann C, Bally H, Rothenbühler JM, Harder F. Die Operation bei para-
ösophagealer Hiatushernie: Technik und Ergebnisse. Schweiz. Med. Wochenschr. 1989; 119:723.
Ellis jr. FH, Crozier RE, Shea JA. Paraesophageal hiatus hernia. Arch. Surg.
1986; 121:416.
Kuster GGR, Gilroy S. Laparoscopic technique for repair of paraesophageal
hiatal hernias. J. of Laparoendosc. Surg. 1993; 331.
Rossetti M. Hiatushernien und andere Erkrankungen des Zwerchfells. In:
Allgöwer M, Harder F, Hollender LF, Peiper HJ, Siewert JR. Chirurgische
Gastroenterologie, p. 353. Berlin: Springer; 1981.
262
9.5 Cardiomyo tom y and F undoplasty for Achalasia
H. Feussner
Goals and Methods
The goal in treating achalasia is to weaken the lower esophageal
sphincter mechanism to improve passage from the esophagus
into stomach. The strategy is to achieve an optimal compromise
between improving transit and avoiding gastroesophageal reflux. Pneumatic dilation is indicated for the initial treatment of
achalasia. In the presence of recurrent dysphagia, in very young
patients, and in patients in whom pseudoachalasia cannot be
safely excluded, operative cardiomyotomy is indicated. Many
authors also recommend additional fundoplasty (Thal/Dor) to:
a) cover the exposed mucosa in the area of the myotomy;
b) keep the defect created by the myotomy open to prevent sec-
ondary scarring;
c) achieve a definite anti-reflux effect.
Indication
Cardiomyotomy is indicated if dysphagia recurs especially after
a second pneumatic dilation. Operative treatment is preferred
in young patients and if secondary achalasia is suspected.
Preoperative diagnostic procedures include endoscopy and
esophageal manometry.
Cardiomyotomy is ideally suited for laparoscopy; as an open
procedure, it is only justified in special instances.
Contraindications
Aside from the general contraindications to laparoscopic operations, anesthetic risks, coagulation disorders that do not re-
spond to treatment, and extensive previous operations in the
upper abdomen, no specific contraindications to the laparo-
scopic procedure are known.
Surgical Risks and Patient Information
An orogastric tube is advanced through the gastroesophageal
junction intraoperatively. This may be done under laparoscopic
visualization and control.
It may also be advisable to prepare a gastroscope and light
source for intraoperative esophageal endoscopy (see Fig. 9.5.7)
to localize the gastroesophageal junction by transillumination
and examine for possible esophageal mucosal perforation.
Anesthesia
General anesthesia.
Patient Positioning and Position of the
Operating Team
See Fig. 9.5.1.
Complications
Intraoperative Complications
Mucosal injuries can be repaired with fine absorbable sutures.
Intracorporeal knot-tying techniques are preferred because of
the delicate tissue involved. Always check for intraluminal
patency and complete repair by injecting a dilute methylene
blue solution.
Injuries to the diaphragm are repaired with nonabsorbable sutures.
Postoperative Complications
Persistent Gastroesophageal Reflux
Usually, this is treated with medication (proton pump blockers).
Since esophageal clearance is always significantly impaired in
achalasia, operative intervention to treat gastroesophageal reflux by a complete fundoplication is not an option.
As with the open procedure, there is the possibility of postoperative gastroesophageal reflux. The surgeon should mention
the risk of perforation and the possibility of recurrent dysphagia.
Injuries to the diaphragm and postoperative bleeding have been
known to occur.
The morbidity rate for the laparoscopic method is less than 5%.
Definite data on mortality are not yet available.
Special Preparations
As in the open procedure, the diagnosis should be confirmed by
esophageal manometry. The patient should receive no solid
food for one to two days prior to the operation. Have the patient
drink plenty of liquid to flush the esophagus. Prior to administering anesthesia, the esophagus must be aspirated with a wide
orogastric tube.
Persistent Dysphagia
This may be treated with pneumatic dilation, or, alternatively,
with local injection of botulinus toxin. Depending on the findings at manometry, repeat myotomy may be required.
Postoperative Treatment
Once transit from the esophagus to the stomach and postoperative wound healing are satisfactory, the patient may receive
solid food on postoperative day one or two.
Fig. 9.5.1 Cardiomyotomy and fundoplasty for achalasia.
The patient is placed supine in a reverse Trendelenburg position with the
right arm extended.
The surgeon stands to the right of the patient, and the assistant to the
left.
The laparoscopy cart with the monitor is positioned at the level of the
patient’s left shoulder.
Alternatively, the surgeon may stand or sit between the patient’s legs. The
first assistant stands on the patient’s left side, and the second assistant on
the right.
Monitor
Complications
263
Assistant
Surgeon
Fig. 9.5.2 Cardiomyotomy and fundoplasty for achalasia. Placement and
function of the trocars.
After the pneumoperitoneum is established, a 10/12-mm trocar is placed
in a left lateral position superior to the umbilicus. After the laparoscope/
camera is inserted, the remaining trocars can be placed under laparoscopic visualization. A 10/12-mm trocar (T2) is inserted inferior to the left
costal arch approximately to the level of the midclavicular line. Ports T3
and T4 (5 and 10 mm trocars) are placed inferior to the right costal arch
and slightly left of the midline superior to port T1. The laparoscope/
camera is now transferred to trocar T4. A retractor to lift the left hepatic
lobe is advanced through port T2. Ports T4 and T2 are available for instrumentation.
Instrument table
Assistant
holding
laparoscope
OR nurse
T4
T3
T1
T2
264
a b
9.5 Cardiomyotomy and Fundoplasty for Achalasia
5
6
5
Fig. 9.5.3a, b Step-by-step procedure.
5
6
5
6
Step-by-Step Procedure (Fig. 9.5.3 a, b)
1. Establish the pneumoperitoneum.
2. Place the trocars.
3. Incise or, if necessary, resect the fatty tissue overlying the wall
of the junction between the esophagus and stomach. Incise
the musculature in the wall of the stomach down to mucosa for
a distance of approximately 1−2 cm below the gastroesophageal junction.
4. Extend the myotomy proximally to a point some 4 cm superior
to the inferior esophageal sphincter assembly.
5. Grasp a fold of the anterior wall of the fundus and suture it to
the left edge of the defect created by the myotomy.
6. Suture a separate gastric fundus fold to the right edge of the
defect created by the myotomy.
7. Verify hemostasis, irrigate the wound, and place a suction drain
if necessary.
Fig. 9.5.6 Cardiomyotomy and fundoplasty for achalasia. 컄
Once the submucosa has been exposed, the surgeon can undermine the
musculature with the dissector and then carefully divide the muscle fibers
under traction one by one with the scissors. Bleeding from veins in the
submucosa will almost always stop spontaneously. Avoid electrocautery
because of the danger of perforation.
Fig. 9.5.7 Cardiomyotomy and fundoplasty for achalasia.
The myotomy is extended proximally for a distance of 4−5 cm over the
distal esophagus. All muscle fibers should be completely transected since
even small muscle strands may cause the dysphagia to persist.
When in doubt, verify that the myotomy is complete by means of transillumination. To do this, a gastroscope is advanced into the junction of the
esophagus and cardia. Any residual muscle fibers will appear as dark
strands over the transilluminated mucosa, and can be divided. 컄컄
Operative Technique
Complications
265
Fig. 9.5.4 Cardiomyotomy and fundoplasty for achalasia.
The left hepatic lobe is lifted with a retractor. The surgeon grasps the pre-
cardial cushion of fat with a laparoscopic grasper advanced through port
T2. Using scissors advanced through port T1, the fat cushion can now be
incised (or resected if necessary) lateral to the anterior vagal trunk to expose the wall of the distal esophagus and the junction of the esophagus
and cardia.
Fig. 9.5.5 Cardiomyotomy and fundoplasty for achalasia.
The incision in the musculature begins approximately one thumb breadth
below the inferior esophageal sphincter, which can usually be localized
slightly superior to the easily identifiable superficial vessels of the
stomach. Careful control of bleeding is required in every phase of the dissection. Even minor vessels should be ligated because diffuse bleeding
that forces the surgeon to use electrocautery increases the chances of
perforation. The muscle fibers must be carefully spread apart and then
transected in small fascicles to avoid perforating the mucosa. The border
between the musculature and mucosa can always be readily identified at
the junction of the stomach and cardia if one proceeds carefully.
Fig. 9.5.6 Fig. 9.5.7
266
9.5 Cardiomyotomy and Fundoplasty for Achalasia
Fig. 9.5.8 Cardiomyotomy and fundoplasty for achalasia.
The fundoplasty is formed by grasping the anterior wall of the fundus
lateral to the junction of the esophagus and cardia with the laparoscopic
grasper and pulling it over the defect created by the myotomy. There will
usually be sufficient tissue to create a tension free fundoplasty; the fundus
will only require mobilization from the short vessels in exceptional cases.
Fig. 9.5.9 a−c Cardiomyotomy and fundoplasty for achalasia.
First the left edge of the myotomy is sutured to the fold of the fundus
beginning at the inferior end of the myotomy. Then the right side is sutured to the tip of the fundus (also beginning inferiorly) so that the defect
created by the myotomy is completely covered.
Fig. 9.5.9b Fig. 9.5.9c
267
9.6 Ligamentum Teres Sling of the Gastroesophageal Junction and
Hiatus Hernia Repair
F. Köc kerling
Goals and Methods
The Narbona-Arnau ligamentum teres procedure is an alternative to the Nissen-Rossetti fundoplication in the surgical management of insufficiency of the gastroesophageal junction.
Indications
The indications for laparoscopic ligamentum teres repair are
the same as those for a Nissen-Rossetti fundoplication.
Contraindications
The contraindications are also identical to those of the Nissen-
Rossetti fundoplication.
Fig. 9.6.1 Ligamentum teres repair. Patient positioning.
The patient is placed supine with the left arm tucked to his or her side and
the right arm extended to facilitate intravenous access. After establishing
the pneumoperitoneum and inserting the laparoscope/camera trocar,
move the patient into a 20−30° reverse Trendelenburg position so that
the greater omentum, transverse colon, and small bowel fall into the
lower abdomen.
Surgical Risks and Patient Information
See page 257.
Special Preparations
See page 257.
Anesthesia
General anesthesia.
Patient Positioning
See Fig. 9.6.1.
Position of the Operating
Assistant
Team
(Fig. 9.6.2).
Monitor
Fig. 9.6.2 Ligamentum teres repair. Position of the operating team and
equipment.
The surgeon stands to the right of the patient. The assistant holding the
laparoscope stands opposite the surgeon to the left of the patient;
another assistant stands next to the surgeon on the patient’s right. The
monitor is placed behind the patient’s left shoulder so that the entire
operating team looks beyond the operative site to the monitor. This permits a coordinated approach using one monitor. The operating room
nurse and the instrument table are at the patient’s feet. The electro-
cautery unit and aspirator/irrigator set can be placed wherever is best.
Surgeon
Instrument table
Assistant
holding
laparoscope
OR nurse