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_794_Библиотеки_им_академика_М_И_Перельмана.pdf
1
2
3
4
5
6
7
8
32
Step1
Section II • Esophagus, Stomach, and Duodenum
Ligamentum teres (round ligament) plasty
-
Complicated reux disease (esophagitisIV)
-
Fundoplication+dilation (of orid esophagitis)
-
Fundoplication+parietal cell vagotomy (in gastric hyperacidity)+if necessary dilation
-
(of orid esophagitis)
Fundoplication+parietal cell vagotomy+stricturoplasty (of scarred strictures)
-
Limited resection of the gastroesophageal junction
-
Mobilization of the distal esophagus and fundus
e distal esophagus is completely dissected and encircled with a vessel loop being careful to avoid
injury to the vagus nerves. e gastric fundus is completely mobilized by division of the short
gastric vessels in order to form a loose, “oppy” fundoplication.
If ligamentum teres plasty is planned, there is no need for fundic mobilization. Special attention has to be paid to thoroughly preserving the ligament at laparotomy.
In the presence of a hiatal hernia, a posterior hiatoplasty is performed using nonabsorbable
suture material (
. Fig. 32.1).
10
11
12
13
14
15
16
17
18
19
20
. Fig.32.1
21
22
23
Chapter • Operation for GERD: Conventional Approach
Total (“Nissen”) Fundoplication
Step2
Passage of the fundus
e mobilized fundus is passed behind the esophagus to the right side so far that it can be easily
sewn to the remaining front wall of the wrapped fund is in front of the esophagus (
. Fig.32.2
. Fig. 32.2).
Step3
Formation of the wrap
e two cu folds are xed with three, maximally four, nonabsorbable sutures. At least, one or
more sutures should include the esophageal wall to prevent proximal or distal "slippage" of the
fundoplication wrap (
. Fig. 32.3).
. Fig.32.3
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
32
10
Step4
Anchoring of the wrap
Finally the fundic cu is again tested. Two ngers should easily pass under the loose wrap around
the distal esophagus (“oppy Nissen”).
One or two additional sutures can x the le cu of the anterior gastric wall to the right crus
in order to prevent slippage (
. Fig. 32.4).
11
12
13
14
15
16
17
18
19
20
Step1
Step2
. Fig.32.4
Ligamentum Teres (Round Ligament) Plasty
See above.
Dissection of the round ligament
e round ligament is carefully dissected from the abdominal wall and from the liver, respectively.
e free end of the ligament is transposed posteriorly around the esophagus coming from the
right side (
. Fig. 32.5).
21
22
23
. Fig.32.5
Chapter • Operation for GERD: Conventional Approach
Step3
Fixation to the anterior gastric wall
e round ligament is then attached to the anterior gastric wall under relative tension using three
or four nonabsorbable sutures. Fixation to the anterior aspect of the gastric corpus is performed
(
. Fig. 32.6).
. Fig.32.6
Standard Postoperative Investigations
See ▶ Chap. 31 “Operation for GERD: Laparoscopic Approach.”
Postoperative Complications
z Short term
Esophageal perforation
-
Dysphagia
-
z Long term
Dysphagia
-
Gas bloat
-
Recurrent disease
-
Tricks of the Senior Surgeon
Perform Nissen fundoplication around a large 45 to 60 Fr bougie to facilitate formation of a
-
loose “oppy,” fundic wrap.
Use of a self-retaining retractor system will facilitate exposure of the esophagogastric junction.
-
Dissection of the short gastrics is not mandatory but will ensure a loose fundoplication, thus
-
preventing postoperative dysphagia.
Do not dissect the round ligament at laparotomy.
-
Consider partial posterior fundoplication (Toupét technique) especially in patients with poor
-
esophageal motility – the only dierence is that in step4 (as described above) suture both
fundus cu folds to the right and left esophageal aspect respectively, thus forming a poste-
rior 270°cu instead of a 360°cu. Anchor the posterior wall of the cu to the right and left
crus with two sutures each.
Operation for Paraesophageal Hernia
Jean-Marie Michel, Lucas Krähenbühl
In 1889, Postempski rst reported the repair of a wound of the diaphragm. Ackerlund described
dierent types of paraesophageal hernia in 1926, and the rst hiatal hernia repair (fundoplication)
was reported by Nissen in 1955. Since then, Nissen fundoplication has gained wide acceptance
and is now recognized as the operation of choice for antireux surgery and, although technically
challenging, the laparoscopic approach has become the “gold standard” of paraesophageal hernia
repair.
e goal of a paraesophageal hernia repair is to bring the stomach (with other organs such as
colon, omentum, spleen) and the lower esophagus back into the abdominal cavity, to excise the
hernia sac, to approximate crura, to perform a fundoplication in order to prevent gastroesophageal
reux, and nally to perform a gastropexy in order to prevent gastric volvulus.
Indications and Contraindications for Laparoscopy
Indications
Contraindications
Contraindications
Symptomatic or asymptomatic typeII, typeIII, and typeIV hiatal hernia
TypeII: Pure paraesophageal hernias; the gastroesophageal junction remains in its normal
-
anatomical position but a portion of the fundus and proximal stomach herniates through
the diaphragmatic hiatus adjacent to the esophagus.
TypeIII: e gastroesophageal junction and the fundus herniating through the hiatus. e
-
fundus lies above the gastroesophageal junction.
TypeIV: ese hernias are characterized by the presence of a structure other than the stom-
-
ach, like the omentum, colon, small bowel, or spleen, within the hernia sac.
z Absolute
Intrathoracic gastric perforation with typeII, typeIII, or typeIV hiatal hernia
-
z Relative
Gastric incarceration
-
Partially xed paraesophageal hernia
-
Short esophagus
-
Indications and Contraindications for Laparotomy
Intrathoracic gastric perforation with typeII, typeIII, or typeIV hiatal hernia due to the
-
peritonitis/mediastinatis no plastic reparation in the acute phase.
z Relative
None
-
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_33, © Springer-Verlag Berlin Heidelberg 2016
1
10 to 12 cm
2
3
4
5
6
7
Section II • Esophagus, Stomach, and Duodenum
Preoperative Investigations/Preparation for the Procedure
History: Long-term history of gastroesophageal reux disease (GERD), symptoms of upper gastrointestinal occlusion
Upright radiograph of the thorax: Search for a retrocardiac air-uid level
Contrast radiographic studies (barium swallow): Preoperative localization of the gastroesoph-
ageal junction, assessment of the type of hernia
Esophageal manometry: To exclude a motility disorder of the esophagus
Upper endoscopy: To conrm ndings of GERD and/or exclusion of gastric ulcer disease
24-h pH monitoring and stationary manometry: To document GERD and esophageal dysmotility. In typeII hernias, 70 % of patients have pathologic pH-metry, with up to 100 % of patients
with typeIII hernias.
Actively treat dehydration
Empty the stomach: Nasogastric tube or immediate preoperative endoscopy
One-shot prophylactic antibiotic with second-generation cephalosporine
8
9
33
11
12
13
14
15
16
17
18
Procedure
e patient is placed in a modied lithotomy position. e table is placed in a steep reverse Trendelenburg position (French position), with the surgeon standing between the patient’s legs, the
rst assistant on the patient’s le, and the camera assistant on the patient’s right.
Port Placement
A 10-mm port is placed 5 to 8 cm cranial to the umbilicus in the midline (open Hasson technique). A carbon dioxide pneumoperitoneum is established (12 mmHg). A 30°laparoscope is
mandatory. Aer exploratory laparoscopy, the next four trocar sleeves are placed under direct
vision. A subxiphoid 5-mm port for liver retraction; two working ports: one 5-mm one in the
right upper quadrant (UQ), another 10-mm one in the le UQ; and a 5-mm le subcostal
port (
. Fig. 33.1).
5 mm ports
12 mm
optical
port
12 mm
working
port
about
from
xiphoid
19
20
21
22
23
. Fig.33.1
Chapter • Operation for Paraesophageal Hernia
Exposure
To allow free access to the enlarged esophageal hiatus, the le lobe of the liver has to be elevated
with a liver retractor to expose the esophago-gastric junction (
. Fig. 33.2).
Step1
. Fig.33.2
Reduction of herniated stomach
e herniated stomach and the greater omentum are reduced into the abdominal cavity with two
Babcock graspers. A nasogastric tube is then introduced to decompress the stomach.
is maneuver is a dangerous step of the procedure with risks of stomach perforation, particularly in case of mechanical obstruction of the stomach (volvulus) with incarceration and gastric
wall ischemia.
e spleen, colon, and omentum should also be reduced if they have herniated into the thorax
(. Fig. 33.3).
. Fig.33.3
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
9
33
Step2
Exposure of the hiatal hernia
Open the gastrohepatic ligament aer reduction of the hernia content and expose the right crus
of the diaphragm. e hepatic trunk of the vagus nerve and aberrant le hepatic artery should be
preserved if possible. e hiatus and the hernia sac are now visible (
. Fig. 33.4).
11
12
13
14
15
16
17
18
19
20
21
Step3
. Fig.33.4
Circular incision of the hernia sac
Start the procedure on the right side and dissect the hernia sac o the right crural edge using the
harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). Complete the dissection inferiorly and
obtain a good exposure of the junction between the right and the le crura, then cranially with the
incision of the phrenoesophageal membrane, nally to the le over the le crus. e dissection
over the inferoposterior edge of the le crus is dicult at this moment and is best achieved when
the hernia sac is completely reduced from the mediastinum.
22
23
Chapter • Operation for Paraesophageal Hernia
Step4
Blunt dissection of the hernia sac
e hernia sac now should be bluntly removed from the mediastinum with complete exposure of
the right and le crura (see STEP3) (
During this step anterior and posterior vagal nerves have to be identied and protected; this
can be dicult to perform if there is associated inammation.
It is not unusual for the le and/or right pleura to be opened within the mediastinum during
blunt dissection, but most of the time pleural drainage is not mandatory.
Complete the dissection of the inferoposterior edge of the le crus. Pay particular attention
to nding the plane between the esophagus and the body of the le crus, which may sometimes
be extraordinarily dicult. It is not necessary to excise the hernia sac.
. Fig. 33.5).
Step5
. Fig.33.5
Intra-abdominal reduction of the gastroesophageal junction
e distal esophagus is now completely freed and a Penrose drain is placed around the gastroesophageal junction to permit a better retraction in the abdominal cavity.
It is reported that as many as 15 % of giant typeIII paraesophageal hernias will present with a
shortened esophagus and have an irreducible gastroesophageal junction. Adequate mobilization
of the esophagus then should be performed as high as possible into the mediastinum. If the reduction remains impossible aer this maneuver, the patient will most benet from a Collis-Nissen
gastroplasty, which can be done via a laparoscopic and/or a thoracoscopic approach.
Section II • Esophagus, Stomach, and Duodenum
1
2
3
4
5
6
7
8
9
33
Step6
Closure of the hiatal defect (posterior cruroplasty)
e hiatal defect is closed with ve to six nonabsorbable 2-0Ethibond mattress sutures placed
posteriorly and anteriorly from the esophagus to return the gastroesophageal junction into the
abdomen (.
around the esophagus.
e axis of the hiatal hernia has an inferosuperior direction with an angle of about 10°clockwise in the perpendicular plane, and an inferosuperior direction with an angle of about 70°clockwise in the sagittal plane. us closure of the hiatal defect must follow the schema represented
in
. Fig. 33.6b.
Fig. 33.6a
). e sutures are placed from caudad to cephalad so the hiatus is snug
11
12
13
14
15
16
17
18
19
20
21
22
23
. Fig.33.6