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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Section II • Esophagus, Stomach, and Duodenum
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Step4
Introducing the catheter system
e inner dilator is removed and a regular 24Fr urinary balloon catheter is placed through the
remaining peel-away sheath into the stomach. e peel-away sheath is removed. Aer the balloon
of the catheter is inated, the stomach is pulled against the abdominal wall and the sutures are
subcutaneously tied under traction and progressive reduction of the pneumoperitoneum. e
catheter is then put under gentle traction for 24hours (. Fig. 30.9). Alternatively, a purse string
suture can be placed laparoscopically and a Stamm gastrostomy performed laparoscopically as
done with an open Stamm gastrostomy.
See above conventional gastrostomy section for postoperative investigations and complications.
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. Fig.30.9
Tricks of the Senior Surgeon
Exchange the 24Fr urinary catheter for a special gastrostomy button device 14days postop-
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eratively (
To avoid dietary deciencies, patients should be under the supervision of a nutritional spe-
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cialist.
In case of contraindications for general anesthesia, the procedure can also be performed
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under local or regional anesthesia.
. Fig. 30.10).
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. Fig.30.10
Fundoplication for GERD: Laparoscopic Approach
Nathaniel J. Soper
Laparoscopic antireflux surgery (LARS) has assumed a major role in the treatment of gastroesophageal reflux disease (GERD). e advancement in laparoscopic techniques and instrumentation over the past two decades has led to an increase in the number of antireflux operations.
Although the operation is fundamentally similar to open antireflux procedures, clear benefits to
the laparoscopic approach have been described.
In 1955, Rudolf Nissen reported the ecacy of a 360° gastric wrap through an upper abdominal incision to control reflux symptoms. It was not until 1991 that the rst laparoscopic Nissen
fundoplication was reported. From that point, acceptance on the part of patients and physicians to
proceed with surgical treatment began to grow. Although the minimally invasive approach follows
the same surgical principles as the open operation, LARS reduces postoperative pain, shortens the
hospital stay and recovery period, and achieves a functional outcome that is similar to, or better
than, that of the open operation.
Indications
Absolute Contraindications
Relative Contraindications
Indications and Contraindications
GERD symptoms (heartburn, regurgitation, dysphagia, chest pain) not controlled by medi-
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cal therapy
Volume reflux (regurgitation)
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Paraesophageal hernia (PEH) with GERD
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Inability to take acid reduction medication (allergic reaction, poor compliance, cost)
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Preference for surgery (young age, lifestyle choice)
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Inability to tolerate general anesthesia or laparoscopy
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Previous upper abdominal surgery
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Morbid obesity
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Short esophagus
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Preoperative Investigations/Preparation for the Procedure
History: Presence or absence of typical/atypical GERD symptoms, and acid reduction medication
use; warning symptoms of gastrointestinal bleeding or dysphagia
Upper endoscopy with biopsies: Evaluation for esophagitis, gastritis, Barrett’s metaplasia/dysplasia, hiatal hernia, and strictures
Esophageal manometry for evaluation of esophageal motility disorder: Measurement of esophageal body peristalsis and lower esophageal sphincter (LES) position/length/pressure, separation
of LES from diaphragm
24-h pH testing: Following the cessation of proton-pump inhibitors for longer than 7days
Laparoscopic Nissen Fundoplication
Used in greater than 90 % of patients with GERD. It can be argued that total (360°) fundoplication
is generally not performed in patients with severe esophageal dysmotility.
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_31, © Springer-Verlag Berlin Heidelberg 2016
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31
9
Step1
Section II • Esophagus, Stomach, and Duodenum
Procedure
Operating room and patient setup
e patient is placed supine with the legs abducted on straight leg boards (no exion of the hips
or knees). An orogastric tube is placed.
e operating room personnel and equipment are arranged with the surgeon between the
patient’s legs, the assistant surgeon on the patient’s right, and the camera holder to the le.
Video monitors are placed at either side of the head of the table and should be viewed easily
by all members of the operating team.
Irrigation, suction, and electrocautery connections come at the head of the table on the patient’s right side. Special instruments include endoscopic Babcock graspers, cautery scissors,
curved dissectors, clip applier, atraumatic liver retractor, 5-mm needle holders, and ultrasonic
coagulating shears (. Fig. 31.1).
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Step2
. Fig.31.1
Port placement
Port arrangement should allow easy access to the hiatus and permit comfortable suturing by placing the optics between the surgeon’s hands. Access to the abdominal cavity is achieved by either
a closed or an open technique cranial to the umbilicus.
e initial port is placed in the le midrectus muscle approximately 12 to 15 cm below the
xiphoid process. Four additional ports are placed under direct vision of the laparoscope. Ports are
typically placed in the following locations to optimize visualization and tissue manipulation and
to facilitate suturing: right subcostal, 15 cm from the xiphoid process; a point midway between the
first two ports in the right midrectus region; in the le subcostal region 10 cm from the xiphoid;
and in the right paramedian location at the same horizontal level as the le subcostal trocar (usually 5 cm caudal to the xiphoid process).
e gastroesophageal junction is usually deep to the xiphoid, and from a point 15 cm distant,
only half of the laparoscopic instrument must be introduced to reach the hiatus. is distance
establishes the fulcrum at the midpoint of the instrument and maximizes its range of motion
during tissue manipulation.
With current 5-mm equipment and optics, we generally use only one 10- to 12-cm port, for the
surgeon’s right hand, to allow insertion of an SH needle through the valve mechanism (.
Fig. 31.2
).
Chapter • Fundoplication for GERD: Laparoscopic Approach
Step2 (continued)
. Fig.31.2
Step3
Exposure
Exposure of the esophageal hiatus is facilitated by gravity and maintained by an assistant. Positioning the patient in the reverse Trendelenburg position displaces the bowel and stomach from the
diaphragm and brings the patient’s torso closer to the surgeon.
A skilled camera holder and the use of an angled laparoscope (30° or 45°) are important.
e assistant introduces a self-retaining liver retractor through the right lateral subcostal port,
and a Babcock grasper is introduced through the right midrectus port to pull the stomach and
epiphrenic fat pad inferiorly and allow division of the gastrohepatic ligament using the ultrasonic
shears. Division of the gastrohepatic ligament is done with preservation of the anterior vagus nerve
and its hepatic branch. Note, the anterior vagus nerve is le on the anterior surface of the esophagus.
e le triangular ligament is not divided but is le to aid in retracting the liver anteriorly.
Next, both the crura and the anterior vagus nerve are identified aer opening the phrenoesophageal membrane (
. Fig. 31.3).
. Fig.31.3
Section II • Esophagus, Stomach, and Duodenum
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Step4
Dissection
If a hiatal hernia is present, the stomach is repositioned into the abdominal cavity with gentle
traction aer cutting all adhesions to the hernia sac.
e right crus is retracted laterally, and the right side of the esophagus is carefully dissected
to visualize the aortoesophageal groove and posterior vagus nerve.
e le crus is similarly dissected from the esophagus and fundus to its point of origin from
the right crural leaflet. A “window” is created between the crura and the posterior esophageal wall
under direct vision from the angled laparoscope (. Fig. 31.4a).
e fundus and proximal stomach is then fully mobilized by dividing the proximal gastrosplenic ligament. e short gastric vessels are placed on traction and a window is created into the
lesser sac. e short gastric vessels are then divided by serial application of the ultrasonic shears
or by clipping and dividing them (.
gastric junction, and proximal stomach, all posterior retroperitoneal adhesions are divided being
careful to preserve the posterior vagus nerve.
Fig. 31.4b
). To fully mobilize the distal esophagus, esophago-
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. Fig.31.4
Chapter • Fundoplication for GERD: Laparoscopic Approach
Step5
Closure of the hiatal defect
Aer the mobilization of esophagus and proximal stomach, a Babcock clamp is passed right to
le in front of both crura and behind the esophagus. e Babcock clamp grasps the fundus near
the insertion of the short gastric vessels and pulls the fundus le to right around the esophagus.
Following the “shoe-shine” maneuver, the fundus should lie in place (
springs back around the esophagus, the wrap will be under tension.
e hiatal defect is closed with several interrupted 0-Ethibond sutures (
esophageal exposure of the crura is gained either by using the mobilized fundus to retract the
esophagus anteriorly and to the le or by placing a Penrose drain around the distal esophagus
for retraction. is allows visualization of the retroesophageal space. Approximation of the right
and le crura is usually performed posterior to the esophagus, although anterior closure may be
appropriate in select cases. e crura are reapporoximated until they just touch the surface of the
empty esophagus. A dilator is not in place during crural closure, as this limits exposure of the
tissue posterior to the esophagus.
. Fig. 31.5a). If the fundus
. Fig. 31.5b). Retro-
. Fig.31.5
Section II • Esophagus, Stomach, and Duodenum
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Step6
Fundoplication
e esophagus is serially dilated, and a 50- to 60-French Maloney dilator is le in place during
the creation of the wrap. e dilator calibrates the wrap and prevents excessive narrowing of the
esophagus during the actual fundoplication. Dilation must be performed cautiously if the patient
has esophageal stricture or severe inflammation.
e surgeon should watch the bougie pass smoothly through the gastroesophageal junction.
If the bougie appears to be hung up at the gastroesophageal junction, the surgeon can sometimes
improve the angulation by retracting the stomach anteriorly or caudally.
With the dilator in the esophagus, the fundus is positioned, and a “short, floppy” Nissen fundoplication is constructed using three interrupted, braided0- or 2-0polyester sutures. Usually 3
seromuscular bites of fundus to the le of the esophagus, the anterior esophageal wall away from
the anterior vagus nerve, and the fundus to the right are all incorporated in the 360° fundoplication. e esophageal wall should be incorporated in at least one of the sutures to inhibit slippage
of the wrap inferiorly onto the body of the stomach or into the thoracic cavity. e surgeon should
take generous tissue bites and appose the gastric wall without strangulating tissue. Ideally, the
wrap should be 2 cm or less in length. Note, the anterior vagus nerve is included in the wrap, but
usually not the posterior vagus nerve whenever possible.
Aer three sutures to secure the fundoplication, additional sutures may be placed from the
wrap to the crura for stabilization, although we currently do not perform this step. e esophageal
dilator is withdrawn by the anesthesiologist. At this point the Nissen fundoplication is complete
(
. Fig. 31.6).
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. Fig.31.6
Laparoscopic Partial Fundoplication
Procedure of choice for GERD patients with preoperative dysphagia and markedly abnor-
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mal proximal esophageal motility in order to prevent excessive postoperative dysphagia or
gas bloating symptoms (
. Table 31.1).
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Chapter • Fundoplication for GERD: Laparoscopic Approach
. Table31.1 Partial Fundoplication Techniques
Thal 90° anterior wrap
Watson 120° anterolateral wrap
Dor 150–200° anterior wrap
Toupet 270° posterior wrap
Belsey Mark IV 270° transthoracic anterolateral wrap
Indications and Contraindications
Primary esophageal motility disorders
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Achalasia (aer myotomy)
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Scleroderma
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Secondary esophageal motility disorders
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Severely disordered motility secondary to chronic reflux/Barrett’s esophagus
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Inability to tolerate complete fundoplication
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Dysphagia
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Gas bloating
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Chronic nausea
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Aerophagia
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Revision of obstructing 360° wrap
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Step1
Laparoscopic Toupet Fundoplication
Procedure
Initial operating room/patient setup, port placement, exposure, dissection, and closure of hiatal
defect identical to the procedure outlined in “Laparoscopic Nissen Fundoplication.”
Fundoplication
Fixation of the fundus to the right crus
Aer the leading edge of the fundus is pulled posterior and to the right of the esophagus, the
fundus is sutured to the right crus and to the right side of the esophagus over a length of 2 to 3 cm
being careful to avoid both vagus nerves in the fundoplication (
. Fig. 31.7a and 31.7b).
. Fig.31.7
Section II • Esophagus, Stomach, and Duodenum
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Step2
Fixation of the fundus to the esophagus and the right crus
e anterior fundus is sutured to the right side of the esophagus over a length of 2 cm (. Fig. 31.8a).
e 270° fundoplication is secured to the right crus with separate gastrocrural sutures
(. Fig. 31.8b).
. Fig.31.8
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Standard Postoperative Investigations
Patients who report unusual abdominal or chest discomfort, GERD-related symptoms, or dysphagia should undergo testing (endoscopic, radiological, and/or physiological evaluation).
Postoperative Complications
Dysphagia
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Recurrent GERD symptoms and/or esophagitis
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Wrap disruption/migration or acute paraesophageal hernia
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Gas bloat syndrome
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Tricks of the Senior Surgeon
Securing the patient to the table using a beanbag will allow steep reverse Trendelenburg posi-
tioning for gravity displacement of the bowel and maximum exposure of the gastroesophageal
junction.
Dividing the short gastric vessels will freely mobilize the fundus.
Adequacy of fundic mobilization is checked before suturing the fundoplication by releasing the
fundus and watching whether the fundus rests in place or recoils under tension.
Care should be taken not to excessively angulate the esophagus when performing posterior
hiatoplasty.
A short, “floppy” wrap 2 cm or less in length is ideal.
A 360° wrap is too tight if a 5-mm Babcock clamp does not easily pass under the wrap.
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Operation for GERD: Conventional Approach
Karim A. Gawad, Alexandra M. König
In 1956, Rudolph Nissen introduced the antireux eect of wrapping the gastric fundus around
the distal esophagus. e “open Nissen fundoplication” and its modications have since been
used to treat moderate-to-severe gastroesophageal reux disease (GERD) in situations in which
medical therapy has failed. Laparoscopic antireux procedures have, since the rst reports in 1991,
become the method of choice in dealing with surgical options for symptoms of GERD. As has
been the case for several other laparoscopic procedures, questions have arisen about the limitations of these procedures in comparison with the traditional open techniques. An open approach
may be preferable in patients who have undergone previous open upper abdominal surgery or in
cases of recurrent or re-recurrent GERD when revisional laparoscopy may not seem sucient to
denitely treat the disease.
Indications and Contraindications
Indications
Contraindications
Signicant gastroesophageal reux
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“When a laparoscopic approach is not indicated”
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Recurrent disease following previous open or laparoscopic surgery; a laparoscopic revision
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of a prior fundoplication should only be done by experienced laparoscopic surgeons
Status postconventional upper abdominal surgery with massive adhesions
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Failure of conservative treatment
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Anatomical reasons such as diculties in retracting the le lobe of the liver or an excess of
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intraperitoneal fat
Physiological derangements secondary to a pneumoperitoneum
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General contraindications for surgery under general anesthesia
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Preoperative Investigations/Preparation for the Procedure
See ▶ Chap. 31 “Operation for GERD: Laparoscopic Approach.”
Procedures
Access
Transverse upper abdominal incision, if required, with additional upper midline incision; alternatively, le subcostal or upper midline incision
Division of the triangular ligament to expose the esophagogastric junction
Choice of Procedure
Simple reux disease (esophagitis up to III):
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Fundoplication
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P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_32, © Springer-Verlag Berlin Heidelberg 2016