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268
9.6 Ligamentum Teres Sling of the Gastroesophageal Junction and Hiatus Hernia Repair
Complications
Intraoperative Complications
− Arterial and/or venous bleeding from placement of the
Veress needle or the laparoscope/camera trocar.
− Intestinal injuries from placement of the Veress needle or
trocars.
− Injury to the stomach and/or esophagus resulting from the
use of traumatic graspers.
− Injury to the spleen.
− Unsuccessful repositioning of the stomach or recreation of
the angle of His.
− Cutting through the sutures used for the hiatal repair.
Corrective action: If a severe complication occurs or the
operation cannot be safely completed as described, conversion to an open procedure is indicated. Only minor complications such as seromuscular tears of the stomach or inadver-
T4
T3
T2
tently cutting the hiatal sutures may be managed laparoscopically, if the surgeon is sufficiently accomplished in laparoscopic techniques.
Postoperative Complications
T1
Fig. 9.6.3 Ligamentum teres repair. Trocar placement.
T1 10/12-mm laparoscope/camera trocar placed at the inferior
margin of the umbilicus.
T2 and T3 The instrument or working trocars form a semicircle with
the laparoscope/camera trocar. The right and left 10/12mm trocars in the mid-abdomen are for the surgeon who
manipulates instruments with both hands. These trocars are
placed at the respective lateral margins of the rectus
abdominis muscles.
T4 The right 10/12-mm instrument trocar is placed in the upper
abdomen inferior to the costal arch at about the lateral margin of the rectus abdominis. A swab or retractor inserted
through this trocar is used to elevate the left hepatic lobe.
Trocar Placement
(Fig. 9.6.3).
− Postoperative bleeding.
− Undetected injury to the esophagus or stomach.
− 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. Mobilize the ligamentum teres above the liver.
4. Ligate and divide the ligamentum teres at the umbilicus.
5. Verify that the ligamentum teres is long enough.
6. Open the lesser omentum; mobilize and undermine the intraabdominal segment of the esophagus.
7. Pull the ligamentum teres through behind the esophagus.
8. Suture the ligamentum teres to the lesser curvature of the
anterior gastric wall.
9. Perform additional gastropexy and repair the esophageal hiatus around the esophagus if necessary.
Operative Technique
Complications
269
Fig. 9.6.4 Ligamentum teres repair. Suprahepatic mobilization of the ligamentum teres.
To preserve the vascular supply of the ligamentum teres on the hepatic
side, open a suprahepatic window in the falciform ligament of the liver
using hooked-electrode electrocautery. Next, dissect the ligamentum
teres from the anterior abdominal wall as far as the umbilicus.
Fig. 9.6.6 Ligamentum teres repair. Checking the length
of the ligamentum teres.
Once the ligamentum teres has been divided at the umbilicus, the surgeon checks the length by pulling the ligament toward the esophageal hiatus. For its length to be
sufficient, the ligamentum teres should extend as far as
the left crus of the diaphragm.
Fig. 9.6.5 Ligamentum teres repair. Ligation and transection of the ligamentum teres at the umbilicus.
Once the ligamentum teres has been sufficiently mobilized, two PDS clips
are placed close to the umbilicus to prevent bleeding, after which the ligamentum teres is transected at the umbilicus (view from above).
270
9.6 Ligamentum Teres Sling of the Gastroesophageal Junction and Hiatus Hernia Repair
Fig. 9.6.7 Ligamentum teres repair. Opening the lesser omentum.
Next the surgeon begins the mobilization of the intraabdominal segments of the esophagus. To do this, the lesser omentum is opened with
electrocautery. A wide-lumen nasogastric tube placed preoperatively
makes it easy to palpate the position and course of the esophagus.
Fig. 9.6.8 Ligamentum teres repair. Mobilizing and undermining the intraabdominal section of the esophagus.
The abdominal section of the esophagus can be mobilized by blunt dissection sufficiently to permit insertion of a curved instrument behind it.
The esophagus must only be mobilized to the extent necessary to achieve
sufficient reduction of the hiatus hernia and to permit pulling the ligamentum teres through behind the esophagus.
Fig. 9.6.9 Ligamentum teres repair. Pulling the ligamentum teres
through behind the esophagus.
Once the esophagus has been sufficiently mobilized and undermined, a
laparoscopic suture is fed behind the esophagus from left to right using a
curved needle. This needle with the suture is passed through the tip of the
mobilized ligamentum teres. The ligament is then drawn through behind
the esophagus by pulling the suture to the left.
Fig. 9.6.10 Ligamentum teres repair. Suturing the ligamentum teres to
the lesser curvature of the anterior gastric wall.
After pulling the ligamentum teres through behind the esophagus, the
surgeon draws it toward the lesser curvature of the anterior gastric wall,
applying sufficient tension to completely reduce the hiatus hernia and restore the angle of His. The ligamentum teres is then fixed to the lesser curvature of the anterior gastric wall with several interrupted sutures. Usually
five to 6 sutures will be required. Intracorporeal knots may be used, or extracorporeal knots introduced with a knot pusher.
Fig. 9.6.11 Ligamentum teres repair. Additional gastropexy and repair of
the esophageal hiatus.
After securely fixing the ligamentum teres to the lesser curvature of the
anterior gastric wall, the surgeon can repair a widened esophageal hiatus
by placing interrupted sutures over felt pledgets (see p. 260). The angle of
His can be recreated by fixing the gastric fundus to the inferior surface of
the diaphragm as in a gastropexy.
271
9.7 Laparoscopically Guided Gastric Banding for Morbid Obesity
U. Kunath
Goals and Methods
Nonoperative treatment, which includes caloric restriction in
combination with psychotherapy, is the method of choice for
weight reduction in the presence of morbid obesity. After a
careful assessment of risks and alternatives, surgical treatment
of obesity can be offered if the nonoperative treatment is not
successful.
Weight loss can be achieved by:
− inducing a malabsorption syndrome by reducing the length
of the small bowel (Kremen 1954 and Payne 1963);
− reducing the size of the stomach and delaying its emptying
by means of a gastric bypass (Mason 1967) or a transverse or
vertical partial transection of the stomach to form a small
proximal and a large distal segment (Alden 1977).
Disadvantages of the artificially induced malabsorption syn-
drome include diarrhea, blind loop syndrome, and malabsorption of vitamins and minerals.
Disadvantages of the gastric bypass procedure include the risk
of a peptic ulcer at the anastomosis and exclusion of the re-
sidual stomach from diagnostic means such as endoscopy. Both
the residual pouch and the artificial stenosis can enlarge over
time.
Silicone gastric banding is a simpler way to reduce the size of
the stomach and delay its emptying. Developed by Kuzmak in
1983, this procedure minimizes alterations to the abdominal
anatomy and physiology, and can be tailored to the individual
patient. A unique advantage is that it is reversible.
Following laparotomy, a proximal gastric pouch with a volume
of approximately 25 cc is created. This is connected to the distal
stomach via an artificially created stenosis approximately
10 mm in diameter. This stenosis is produced by applying a silicone band with an inner cuff. The cuff can be filled with Ringer’s
lactate solution through a catheter connected to an implanted
subcutaneous port.
The disadvantage of this method includes laparotomy with the
risks it involves for obese patients (pneumonia, wound infection, dehiscence, and deep venous thrombosis).
For these reasons, this operation has been performed as a laparoscopic procedure since 1993.
Indications
Indications for this procedure include:
− Patient insight into the pathologic condition that is the cause
of and has resulted in his or her obesity.
− Several nonoperative attempts at weight reduction.
− Sequelae of obesity such as arthritis of weight-bearing joints,
dyspnea during exercise, arterial hypertension, and diabetes
mellitus.
− Overweight condition is due to compulsive eating and a
morbid appetite that does not primarily involve sweets.
− Discipline and the will to cooperate on the part of the patient
after the operative procedure.
The procedure is indicated for patients with a body mass index
of 35 kg/m
2
and higher.
272
9.7 Laparoscopically Guided Gastric Banding for Morbid Obesity
Fig. 9.7.1 Laparoscopically guided gastric banding.
The pneumoperitoneum is established with the
patient in the semiseated position. Insert the
safety trocar (15 mm) and the 30-degree laparoscope/camera. Place the 10-mm trocar at position 2 under laparoscopic visualization. Now
transfer the laparoscope/camera to trocar 2 and
insert the remaining trocars under laparoscopic
visualization.
Common problems are placing trocars too far
inferior to the costal arch or too close together.
Contraindications
− Patients below age 18 or above age 65.
− Esophagitis or gastritis and/or gastric, esophageal, or
duodenal ulcer.
− Drug or alcohol addiction.
− Long-term treatment with steroids, salicylates, or other
medications that have a negative effect on the gastric mucosa.
− Chronic, non-remediable infections of the skin, subcutaneous tissues, or bronchopulmonary and urogenital systems.
Surgical Risks and Patient Information
The patient and surgeon should discuss and fill out a detailed
questionnaire regarding the patient’s lifestyle, eating habits,
and comorbidities. Documenting the patient’s condition by preoperative photographs is recommended. The patient must con-
sent to the procedure in writing.
The surgeon should mention the risk (less than 1%) of intraoperativeperforationof the posterior gastric wall or esophagus, as well
as the risk of injury to the spleen or liver (less than 1%).
Postoperative risks include dilation of the small proximal gastric
pouch with left lateral ballooning and stasis of food matters (2−
3%). The risk of deep venous thrombosis is especially high in
obese patients. This risk should be countered by administration
of low-molecular-weightheparin in the immediate preoperative
phase and postoperatively until the patient is full active again.
During the operation rythmic compression-decompression
boots for the lower extremities are a must.
Late complications include penetration by the band of the gastric
wall (less than 1%).
The patient’s eating habits must be modified following hospital
discharge. The patient can only eat small servings, must chew
thoroughly, and must stop eating when he or she feels satiated.
Regular outpatient follow-up examinations should be performed every two months. The patient should carry information
about the operation to assist other physicians.
Special Preparations
− Verify the absence of cardiopulmonary comorbidities.
− Stabilize hypertension and diabetes mellitus if present.
− Initiate prophylactic treatment for deep venous thrombosis,
including compression wrapping of the legs intra- and postoperatively as well as mini-heparin regimen.
Anesthesia
− General anesthesia.
− Placement of a nasogastric tube. The stomach must be
decompressed.
Patient Positioning
The patient is placed in a semi-seated position. The legs are
maintained by special supports so that the surgeon can stand
between the patient’s legs. The arms are elevated and restrained
(Fig. 9.7.1).
Complications
273
Trocar Placement
The trocars should be arranged close to the costal arches. Four
10-mm and one 15-mm trocars will be required (Fig. 9.7.1).
Instrumentation
The basic instrumentation for laparoscopic surgery is required.
This includes one liver retractor, one Babcock grasper, one Roticulator Endograsp (long shaft), one long hooked-electrode electrocautery, one pair of endoscopic scissors, one endoscopic
needle holder and endoscopic forceps, one endoscopic swab
grasper, one 10-cm laparoscopic gastric silicone band with port
and calibration tube and closing device. Not obligatory is a
gastrostenometer for tension measuring.
Complications
Intraoperative Complications
Injury to the Left Hepatic Lobe
The left hepatic lobe is often fatty and distended and can be in-
jured by insertion of the Veress needle.
Prevention: Placing the Veress needle at position 1 instead of
position 2 is recommended. Open trocar placement may not be
possible in obese patients.
Bleeding
Bleeding from any of the numerous small vessels along the
lesser curvature can obscure the tissue of the lesser omentum
and impair further dissection.
Corrective action: Clip larger vessels. Bleeding from smaller vessels can be controlled by applying compresses saturated with a
dilute epinephrine solution(1:1000).
Perforation of the Stomach or Esophagus
This complication can be avoided by careful dissection; the
Roticulator Endograsp should be advanced under laparoscopic
visualization, and the surgeon should avoid sudden twisting
maneuvers. If there is any doubt, use a methylene blue solution
in the esophagus and stomach to check for perforation.
Corrective action: Perforation can force the surgeon to convert to
laparotomy. Placement of the implant is not indicated in a con-
taminated operative site.
Injury to the Spleen
Injury to the spleen with hooked-electrode electrocautery is
possible.
Corrective action: Usually, this injury can be treated with fibrin
glue and/or collagen fleece.
Postoperative Complications
Late Postoperative Complications
Vomiting and Reflux Esophagitis
This is due to pouch dilation, migration, and stasis above the artificial stenosis.
Corrective action: Initial treatment should be nonoperative.
Decompress the pouch for three to five days through a nasogastric tube. Then have the patient eat small servings under supervision.
Persistent Vomiting
Corrective action: Perform repeat laparoscopy, and remove the
sutures in the gastric wall cuff. Remove the band if necessary,
cutting it at the appropriate location.
Band Erodes through the Gastric Wall
This occurs in less than 1% of all cases.
Corrective action: Remove the band.
Ulceration of the Gastric Mucosa at the Artifical Stenosis
Corrective action: Remove the band.
Infection at the Implanted Portal
Corrective action: Remove portal and band.
Step-by-Step Procedure (Fig. 9.7.2 a, b)
1. Make a 4−5-cm transverse skin incision approximately 7−
8 cm inferior to the left costal arch in the midclavicular line.
Establish the pneumoperitoneum with a Veress needle, con-
trolling gas pressure.
2. Insert a 15-mm safety trocar through the left rectus abdominis muscle. Place the remaining trocars under laparoscopic
visualization (using a 30-degree laparoscope/camera). Transfer the laparoscope/camera to trocar 2.
3. Introduce the liver retractor and Babcock grasper.
4. Introduce the calibration tube orally. Verify proper position in
the stomach under endoscopic visualization, inflate the cali-
bration balloon, and place it below the gastroesophageal
junction.
5. Open a 2-cm window in the lesser omentum along the lesser
curvature at a point inferior to the calibration balloon using
the hooked-electrode electrocautery or ultracision.
6. Advance the Roticulator Endograsp posteriorly around the
stomach.
7. Introduce the gastric band through the 15-mm trocar and
place it around the stomach.
8. Close the band over the distal end of the calibration tube
slightly inferior to the calibration balloon (checking the pressure with the gastrostenometer).
9. Form a cuff around the band by using the gastric wall of the
greater curvature to invaginate the band below sutures
placed above and below and tied on the band.
10. Connect the catheter of the band to the port fixed to the
anterior rectus sheath subcutaneously, with four sutures.
Vomiting
This occurs if edema of the artificial stenosis occurs. This symptom will subside spontaneously within two to four days. For this
reason, the cuff of the band is not filled with Ringer’s lactate in-
traoperatively, but only four to six weeks later on an outpatient
basis.
274
9.7 Laparoscopically Guided Gastric Banding for Morbid Obesity
4
9
4
6
5
a b
Fig. 9.7.2a, b Step-by-Step procedure.
Operative Technique
10
4
8
7
10
a b
Fig. 9.7.3 a−d Laparoscopically guided gastric banding.
With the liver retractor, the left hepatic lobe is elevated superiorly and to
the right. The calibration balloon (inferior to the cardia) is inflated with
20 cc. The Babcock grasper holds the stomach and lesser omentum. The
incision begins on the side of the lesser curvature distal to the calibration
balloon.
Fig. 9.7.3c, d 컄
c d
Complications
275
Fig. 9.7.3c, d
a b
Fig. 9.7.4 a−d Laparoscopically guided gastric banding.
Using the hooked-electrode electrocautery, locate an avascular area and
open a 1−2-cm window in the lesser omentum along the lesser curvature.
The posterior gastric wall can be pulled anteriorly with the Babcock
grasper. Under laparoscopic visualization, advance the Roticulator Endograsp posteriorly around the stomach to the border of the greater curvature at the apex of the gastric fundus. Open the gastrophrenic ligament
along the fundus with cautery over the tip of the Roticulator Endograsp.
Fig. 9.7.4c, d 컄
276
c d
Fig. 9.7.4c The retrogastric tunnel is open. Fig. 9.7.4d The catheter of the gastric band is guided behind the
9.7 Laparoscopically Guided Gastric Banding for Morbid Obesity
stomach.
Fig. 9.7.5 Laparoscopically guided gastric banding.
Close the silicone band with a tension device. The D-ring of the device engages behind the taper of the band catheter, and the eye on the end of
the band is slipped onto the hook of the device. Tightening the device
closes the band like a belt.
Fig. 9.7.6 Laparoscopically guided gastric banding.
Grasp the catheter end of the silicone band with the Roticulator Endograsp and pull the band through behind the stomach. Thread the catheter
in through an eye on the band, and close the band like a belt with the tension device.
Complications
a
277
b
Fig. 9.7.7a, b Laparoscopically guided gastric banding.
Place two or three interrupted sutures at the greater curvature to form a
cuff of gastric wall around the band to prevent it from migrating and dislocating. Connect the catheter to the port fixed to the anterior rectus
sheath with four interrupted sutures. Prior to implantation, the entire
port/catheter system is filled with saline solution and all air is bled out of
it. The cuff on the silicone band initially remains empty to avoid early
edema as mentioned under postoperative complications.