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induration/brosis, fat necrosis, and radiation induced malignancy [35]. The degree
of the severity of radiation changes varies from patient to patient. Although not
standard, some plastic surgeons will plan for the breast cancer side to be 20% larger
than the non-breast cancer side to account for soft tissue retraction in the setting of
radiation. The senior author does not use this approach as it is often difcult to
determine this intra-operatively and again the degree of soft tissue retraction varies
greatly between patients.
P. Rudnicki et al.
7.3 Revisions
Revision surgery can be performed if complications arise or if patient is dissatised
with results. In a systematic review, post-operative complications were similar
among patients undergoing breast conserving therapy compared to oncoplastic surgery [4]. Complications include, but not limited to, wound dehiscence and poor
wound healing, nipple necrosis, unfavorable scarring, fat necrosis, seroma formation, infection, and hematomas. Most wound healing complications can be addressed
by local wound care unless large in size and causing systemic symptoms. Patient
can also have breast asymmetry, breast contour and shape irregularities, and standing deformities. When addressing complications, it is important to note if patient
has had radiation prior, currently receiving radiation, or has plans for radiation.
Revision surgery would not be recommended to be performed during radiation
treatment and up to 6months upon completion of radiation treatment due to wound
healing concerns. However, it is also important to highlight that a risk and benet
analysis should be performed if patient has had radiation treatment and desires revision surgery. As mentioned before, radiation can cause subcutaneous induration and
brosis, decreased vascularity, and would healing complications. If patient plans for
radiation treatment, complications should be addressed prior to radiation in order to
avoid a delay in receiving treatment.
Options for patients who develop breast asymmetry due to radiation brosis
include fat grafting to the affected breast to increase the volume, or mastopexy
reduction of the contralateral breast. Fat grafting to the breast involves liposuction
most often of the abdomen or thighs and then transfer of the liposuction lipoaspirate
via syringe injection. The volume increase is often modest as only so much fat can
be injected without risks of necrosis. Therefore, these patients should be counseled
that more than one procedure may be necessary to achieve volume goals.
7.4 Risk ofPositive Margins
The risk of positive margins in oncoplastic surgery is low overall given the ability to
perform larger initial excisions compared to the traditional breast conserving therapy approach [36]. The percentages reported for rate of positive margins ranges
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from 7–16% [4, 36–38]. For management of positive margins after oncoplastic surgery, patients can undergo re-excision or mastectomy, with the latter being the more
common approach [39].
8 Conclusion
As a combined procedure with breast surgical oncology and plastic surgery, oncoplastic breast reduction is a feasible and attractive option for breast reconstruction
in the appropriate patient. Many studies have demonstrated low rates of re-excision,
low rates of complications, and overall improved patient condence and satisfaction
with comparable survival rates. This team approach allows for positive outcomes
for patients, aesthetically and functionally. All breast and plastic surgeons should be
familiar with this option and offer to patients who are candidates.
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Part III
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Esophageal and Gastric Surgery
Minimally Invasive Anti-Reux Surgery
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MadisonGrasty andVictoriaGershuni
1 Introduction
The incidence of gastroesophageal reux disease (GERD) and its related complications (erosive esophagitis, peptic stricture, Barrett’s esophagus (BE), and esophageal adenocarcinoma) is increasing worldwide [1]. Exacerbating this issue is the
increasing rate of obesity and a rapidly aging population. GERD is among the most
common admitting diagnoses for Emergency Room visits, with an estimated 7% of
U.S. adults reporting heartburn once a day and 42% once a month [2–4], with signicant impact on quality of life. Between 1990 and 2017 the prevalence of GERD
increased by 18.1%. The associated cost is astronomical [5], surpassing $12 billion
dollars annually. It has been estimated that the care for patients with GERD is $8.6
million more than for those without GERD [6, 7]. In addition to the economic burden, 10–20% of this population will develop Barrett’s esophagus, placing them at
risk for esophageal cancer, thus the drive to reduce and prevent gastroesophageal
reux is multifold [8].
GERD is dened as reux symptoms severe enough to impact quality of life or
“mucosal damage produced by the abnormal reux of gastric contents into the
esophagus.” [9] Typical GERD symptoms include heartburn and regurgitation, but
patients may also complain of atypical, extraesophageal symptoms like cough,
hoarseness, asthma, tooth decay, and aspiration pneumonia [10]. However, atypical
symptoms in the absence of other signs and symptoms of reux are rarely due to
GERD alone.
M. Grasty · V. Gershuni (*)
Department of Surgery, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA
e-mail: Madison.Grasty@pennmedicine.upenn.edu;
Victoria.Gershuni@pennmedicine.upenn.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_14
139© The Author(s), under exclusive license to Springer Nature
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While many patients can be managed with lifestyle modications and antacid
medications, surgery is an option to provide long-term symptom relief. Previously
performed only via laparotomy or thoracotomy, today a laparoscopic or robotic
approach to anti-reux surgery (ARS) is considered the gold standard and will be
presented in the following sections.
M. Grasty and V. Gershuni
2 Indications, Patient Selection andPreoperative Workup
Initial treatment of a patient diagnosed with GERD should include a trial of conservative management. This is comprised of lifestyle modications along with the initiation of a PPI. An important component of treatment is identifying common
etiologies for reux and its aggravating factors, especially those that are modiable.
Timing of meals, especially avoidance of eating immediately prior to bed, and
sleeping with the head of bed elevated, can improve symptoms. Larger volume
meals can cause distension of the stomach and contribute to relaxation of the lower
esophageal sphincter with resultant reux. Many individuals also nd that particular
foods exacerbate their symptoms, including acidic, fatty, fried, and spicy foods.
Additionally, obesity is associated with higher rates of GERD; weight loss can help
with symptom management. Patients with morbid obesity have higher failure rates
after fundoplication and may benet from alternative surgical approaches, including
Roux-en-Y gastric bypass.
Patients are considered candidates for ARS once they have objective documentation of the presence of GERD, have failed medical management, have developed
complications from GERD, or have experienced adverse side effects from medications. There are three independent predictors of a successful outcome after ARS
[11, 12], they are:
1. GERD symptoms are responsive to acid suppressive therapy,
2. Main symptoms are heartburn and regurgitation (‘typical’ GERD symptoms), and
3. Patient has abnormal esophageal acid exposure determined by 24-h pH
monitoring.
Patients may opt for surgery despite successful medical treatment (due to concerns
related to side effects of long term medication use, expense, quality of life) or if they
have GERD related complications (peptic stricture or Barrett’s Esophagus).
Patients with extraesophageal or atypical GERD symptoms experience lower
rates of symptom improvement with ARS compared to those with typical symptoms, but when pathologic reux is proven via objective testing then ARS should be
offered [11]. Studies have indicated that inadequate pre-operative work-up is a main
contributor to poor outcomes after ARS [13].
Prior to operative intervention, a thorough preoperative workup must be completed in order to: (a) conrm the diagnosis, (b) rule out alternative pathology as the
etiology of the patient’s symptoms and presence of coexisting conditions (i.e. stricture, diverticulum, ineffective esophageal motility, eosinophilic esophagitis), (c)
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plan the most appropriate surgical procedure, and (d) set clear expectations for the
patient.
In accordance with the recently published Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES) Esophageal Diagnostic Advisory Panel consensus guidelines, diagnostic evaluation for GERD should include the following
[14, 15]
1. Symptomatic evaluation: consideration of typical (heartburn, dysphagia, regur-
gitation) and atypical symptoms (cough, asthma, chest pain, dental erosions, and
hoarseness) as well as response to proton pump inhibitors.
2. Barium esophagram: this study, ideally video recorded, provides anatomic
description of the esophageal anatomic landmarks such as length and diameter,
presence/size/type of hiatal hernia, presence of diverticulum or strictures, and a
basic evaluation of esophageal motility.
3. Upper endoscopy: evaluates for mucosal injury and presence/size/type of hiatal
hernia, and assess Hill grade.
4. High Resolution Manometry: rules out achalasia, identies esophageal dysmotil-
ity disorders, and aids in selecting full or partial fundoplication.
5. 24-h Multichannel Intraluminal Impedance (MII)-pH study (off PPI): conrms
pathologic reux. This may be omitted in patients with LA Grade C or D esophagitis or BE on Endoscopy. MII-pH demonstrates several kinds of reux (acid vs.
weakly acidic, liquid vs. gas vs. mixed). Critical to the assessment and diagnosis
is the symptom association probability with a reux event (generally
within 2min).
This extensive work-up is of particular importance because patients with abnormal
impedance testing and increased acid exposure within the esophagus had statistically signicant symptom resolution, decreased dysphagia and less PPI requirement
after anti-reux surgery when compared to those with normal pH [12]. It is also
important to identify concurrent hiatal hernia as this can increase the risk of recurrence post-operatively. This is particularly important when selecting patients and
setting expectations for symptom resolution in the post-operative period.
Of note, patients with Los Angeles Grade C or D esophagitis on endoscopy do
not need further pH testing, as the presence of esophagitis is objective evidence of
pathologic reux. Additionally, patients with recurrent symptoms of nausea, vomiting, bloating or retained food on upper endoscopy after overnight fasting should
undergo a 4h gastric emptying study to rule out gastroparesis as a potential cause
of their symptoms. The presence of gastroparesis should prompt the surgeon and
clinician to re-evaluate indication for ARS.
Surgeons must be familiar with the indications for and performing different
types of fundoplication, including 360° posterior (Nissen) complete fundoplication,
270° posterior (Toupet) partial fundoplication, and the 180° anterior (Dor) fundoplication. Partial wraps are of particular benet for patients with ineffective esophageal motility and have been found in recent RCT’s to provide equivalent long-term
results with fewer side effects and need for re-operation when compared to complete fundoplication [16–18].
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M. Grasty and V. Gershuni
3 Historical Principles andCurrent Practice
With advances in imaging, endoscopy, high-resolution manometry and surgical
technology, the signicance of the reux barrier along with a greater understanding
of the anatomic contributions to the gastroesophageal junction have encouraged an
evolution in the surgical treatment of GERD.Initially surgical management was
focused on addressing the LES by ensuring adequate intra-abdominal esophageal
length, recreating the angle of His and LES augmentation (either via fundoplication
or magnetic sphincter augmentation) [19]. Management now involves a combination of closing the crura and re-establishing the LES, with the ultimate goal to recreate the complex anti-reux barrier.
Historically, variations of the Nissen fundoplication (posterior 360° fundoplication) have been the most commonly performed anti-reux in the US and was the
standard of care. The Nissen fundoplication has been considered a superior surgical
option as it provides signicant reux control with increased durability and low
recurrence rate. However, as more long term data has become available regarding
the outcomes of the Nissen fundoplication, unanticipated side-effects like bloating,
inability to belch, and dysphagia have prompted a move toward alternatives to the
complete wrap [20]. Consequently, the 270° posterior (Toupet) partial fundoplication has become increasingly popular. Multiple RCTs have demonstrated that
patients undergoing a partial fundoplication have equivalent reux symptom
improvement with decreased risk of short-term side effects described by those with
a complete fundoplication, including dysphagia and gas-bloat [21–25]. The 180°
anterior (Dor) partial fundoplication is another option, however long-term reux
control is less promising.
Surgical approaches to anti-reux surgery now include open, laparoscopic, and
robotic. Robotics is of particular use in foregut surgery to help navigate the conned
spaces of the mediastinum. Some of the benets of the robotic approach include
increased dexterity due to wristed instrumentation, 3-dimensional visualization
with a stable platform, and better visualization when performing a high mediastinal
dissection with resultant increased intra-abdominal esophageal length. Together,
these technological advances allow for potential improvement in the minimally
invasive approach to anti-reux surgery. When looking at the robotic versus laparoscopic approach, recurrence rate, costs and morbidity are often compared. The literature supports shorter hospital length of stay, lower complication rates, and
decreased recurrence rate for both robotic fundoplication and Heller myotomy [26,
27]. Additionally, benets of the robotic approach for complex and re-operative
foregut pathology have been demonstrated, including decreased readmission rates
and improved outcomes [28]. The implications of this are vast; the costs of surgical
interventions and new technology are always considered and have to be weighed in
conjunction with the efcacy of the procedure. The use of robotics in anti-reux
surgery has shown to be benecial.
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4 Operative Planning, Positioning andRoom Setup
forAnti-Reux Surgery
The procedure requires general anesthesia with the patient intubated with a singlelumen endotracheal tube. Adequate muscle relaxation is critical as it improves
abdominal wall compliance allowing for better exposure with adequate pneumoperitoneum. An orogastric tube can be inserted to decompress the stomach or the
surgeon may elect to perform intraoperative endoscopy prior to incision to assess
pre-operative Hill grade and baseline EndoFLIP measurement.
Pneumatic compression stockings and subcutaneous heparin are routinely used
for deep vein thrombosis prophylaxis. The patient is placed in a modied lithotomy
position with legs on stirrups or, if a split table is available, supine with legs parted
and foot boards. Care must be taken to secure the patient to the bed with all pressure
points padded and protected. The procedure will be conducted using a steep reverse
Trendelenburg position. It is generally recommended to conrm patient’s stability
on the table by briey placing the patient in the proposed position prior to prepping
and draping (test ight); this practice minimizes surprises after the laparoscopic
procedure has begun.
The procedure usually requires ve trocars. The equipment required for either
laparoscopic or robotic-assisted anti-reux surgery are listed in Table 1. For a
Table 1 Basic instrumentation for Laparoscopic or Robotic-assisted anti-reux surgery
Laparoscopic Robotic-assisted
Hasson 12mm trocar (1) Veress needle or 5mm optical access trocar
5mm blunt trocar (3) 8mm robotic port (4)
11mm blunt trocar (1) 10–12mm assist port with balloon tip (1)
10mm—30° scope 8mm—30° scope
Atraumatic laparoscopic graspers Atraumatic laparoscopic graspers
Laparoscopic needle driver Laparoscopic needle driver
Babcock clamp Laparoscopic 10mm paddle Babcock
L-shaped hook cautery with suction-
irrigation capacity
Laparoscopic scissors Large Needle Driver
Vessel sealing system Vessel Sealer Extend
Liver retractor Small Grasping Retractor (Dynamic liver retractor) or
Fast clamp or laparoscopic BookWalter
retractor
Penrose drain Penrose drain (optional)
0 and 2-0 SurgiDac sutures 0 Ethibond/Surgidac/Ticron 9″ (6)
56 French esophageal bougie Endoscope
Laparoscopic clip applier Smoke evacuator
Mega Suture Cut Needle Driver
Liver retractor (optional)
Cadiere or Fenestrated Bipolar Grasper
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