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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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laparoscopic approach, the surgeon stands between the patient’s legs with the assistant on the patient’s left side. If using robotic-assistance, after the robot is docked,
the assistant can sit between the patient’s legs while the surgeon is at the robotic
console.
M. Grasty and V. Gershuni
5 Technical Steps forMinimally Invasive
Anti-Reux Procedure
5.1 Placement ofTrocars
Five trocars are used for the operation. The initial trocar is placed about 15cm
below the xiphoid process about 1–2cm to the left of the midline; this port is used
for the laparoscope. The method for rst trocar insertion will vary depending on
patient’s specic characteristics and surgeon’s preference; this can include the
Hasson technique, Veress needle, or direct trocar insertion with or without pneumoperitoneum. The second port (5mm) is placed at the same level as the initial entry
port between the left midclavicular and the left anterior axillary line; this is the
assistant’s port utilized for retraction via Babcock or Penrose drain. The third port
(5mm) is placed at the same level as the previous two ports but in the right midclavicular line or the sub-xiphoid location. It is used for insertion of the diamond liver
retractor, the purpose of which is to lift the lateral segment of the left lobe of the
liver and expose the esophagogastric junction. The last two trocars (5mm on the
right of the patients and 11mm on the left) are placed as high as possible under the
costal margin and about 5–6cm to the right and the left of the midline; these are the
surgeon’s working ports. For the robotic approach, multiple port placement options
are possible, including using the right lateral port as a dynamic liver retractor in
place of a stationary laparoscopic retractor. This has advantages for high mediastinal dissection. In addition to the four 8mm robotic ports, a peri-umbilical laparoscopic 11 mm assistant port is placed. After port placement, pneumoperitoneum
should be dropped to 12mmHg, so long as the working space is not compromised.
A smoke evacuator can also help with maintaining visualization throughout the case.
6 Essential Technical Elements ofMinimally Invasive
Anti- Reux Surgery (ARS)
There are ve key technical steps of ARS:
1. Complete phrenoesophageal ligament/crural dissection with identication and
preservation of both anterior and posterior vagus nerve and reduction/excision of
hiatal hernia sac if present,
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2. Circumferential dissection of the esophagus and posterior mediastinum to obtain
adequate abdominal esophageal length (at least 3cm),
3. Crural closure,
4. Mobilization of gastric fundus with division of short gastric vessels, and
5. Fundoplication—partial or complete.
The principals of the operation remain the same, whether a laparoscopic or robotic
approach is utilized. However, like any new technical approach, there is a learning
curve and considerations that should be made to optimize the technique for best
patient outcomes.
7 Dissection oftheEsophageal Hiatus
andEsophageal Mobilization
The procedure begins with division of the gastrohepatic ligament above the caudate
lobe of the liver, where this ligament usually is very thin, and continues toward the
diaphragm until the right crus is identied (Fig.1). In 15% of patients an accessory
or replaced left hepatic artery, branching off the left gastric artery, may run in the
gastrohepatic ligament altogether with the always present hepatic branch of the
vagus nerve. This should be preserved, but if exposure is compromised and the vessel has a small size (indicative that it may be an accessory not a replaced left hepatic
artery) it can generally be divided without consequence. The peritoneum and the
phrenoesophageal membrane above the esophagus are divided (Fig.2) and the ante-
rior vagus nerve is identied (Fig.3). The Phrenoesophageal fad pad maybe excised
and left crus of the diaphragm is exposed (Fig.4).
The right crus is then separated from the right side of the esophagus by sharp and
blunt dissection (Fig.5), and the posterior vagus nerve is identied. The right crus
Fig. 1 Division of the
gastrohepatic ligament
(A left lobe of the liver,
B gastrohepatic ligament,
C diaphragm)
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Fig. 2 Opening of the
phrenoesophageal
membrane and initial
dissection into the
posterior mediastinum
(A caudate lobe of the
liver, B right crus, C
areolar tissue of posterior
mediastinum, D divided
phrenoesophageal ligament
and fat pad E left crus,
F gastric fundus)
Fig. 3 The anterior vagus
nerve (Arrow) is identied
(A caudate lobe of liver,
B right crus, C left crus,
D esophagus)
M. Grasty and V. Gershuni
Fig. 4 Exposure of the left
crus and dissection of the
angle of his (A right crus,
B posterior mediastinum, C
left crus, D
gastroesophageal junction
(excised phrenoesophageal
fat pad), E stomach)
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Fig. 5 Dividing the
peritoneum in between the
right crus and esophagus
(A right crus, B esophagus,
C left crus, D stomach)
Fig. 6 Dissecting the right
crus inferiorly towards the
junction with the left crus
(A caudate lobe of liver, B
inferior vena cava, C right
crus, D esophagus, E left
crus)
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is dissected inferiorly toward the junction with the left crus (Fig.6). Care should be
taken to leave the peritoneal lining on the right crus in preparation for crural closure.
It is at the beginning of the dissection that care must be taken to identify and
excise any potentially present hiatal hernia sac. If present, the sac needs to be
reduced in the abdominal cavity and excised in its entirety.
The dissection is continued cranially into the posterior mediastinum to ensure
proper mobilization of the distal esophagus, which will then translate into adequate
abdominal esophageal length. This posterior dissection is essential to prevent axial
tension on the GEJ and decrease risk of recurrence. To avoid the risk of injuring the
inferior vena cava or the left gastric artery at the beginning of the dissection, some
surgeons use a different method—the so-called left crus approach. In this approach,
the operation begins with identication of the left crus of the diaphragm and division of the peritoneum and the phrenoesophageal membrane overlying it. The next
step is division of the short gastric vessels, starting midway along the greater
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M. Grasty and V. Gershuni
curvature of the stomach and continuing upward to join the area of the previous dissection. When the fundus has been thoroughly mobilized, the peritoneum is divided
from the left to the right crus, and the right crus is dissected downward to expose the
junction of the right and left crura. With this technique, the vena cava is never at
risk. In addition, the branches of the anterior vagus nerve and the left gastric artery
are less exposed to danger. This technique can be very useful, particularly for management of very large paraesophageal hernias and for re-operative anti-reux
operations.
8 Mobilization ofGreater Curvature withDivision ofShort
Gastric Vessels
Dissection and division of the short gastric vessels begins at the level of the superior
portion of the gastric body (Fig.7) and continues upward until the most proximal
short gastric vessel is divided (Figs.8 and 9). Importantly, all the attachments of the
posterior aspect of the gastric fundus to the left crura and the pancreas should also
be divided (Fig.10).
Care must be taken to avoid bleeding, either from the short gastric vessels or
from the spleen, and damage to the gastric wall. Use of an electrosurgical device
with both sealing and cutting properties is often sufcient; however, if there is concern, placement of endoscopic clips in the more proximal short gastric vessels may
also be used to prevent bleeding.
Fig. 7 Mobilization of
greater curvature with
division of SGV (A greater
curvature of the stomach,
B SGV, C spleen)
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Fig. 8 Mobilization of
greater curvature with
division of SGV (A greater
curvature of the stomach,
B SGV, C spleen)
Fig. 9 Mobilization of
greater curvature with
division of SGV (A greater
curvature of the stomach,
B SGV, C spleen)
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Fig. 10 Final aspect of
complete mobilization of
greater curvature with
division of SGV (A liver,
B left crus, C pancreas,
D greater curvature of the
stomach)
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M. Grasty and V. Gershuni
9 Creation ofaRetroesophageal Window
The esophagus is retracted upward with a Babcock clamp applied at the level of the
esophagogastric junction. By blunt and sharp dissection, a window is created under
the esophagus between the gastric fundus and esophagus, and the left pillar of the
crus. The window is enlarged and a Penrose drain is passed around the esophagus.
This drain is then used for traction (Fig.11). Alternatively, for the robotic approach,
a laparoscopic instrument (i.e. atraumatic bowel grasper or suction irrigator) can be
inserted via an assist port and used for anterior and upward retraction within the
retroesophageal space (Fig.12).
During this part of the procedure the surgeon should be aware of potential common complications such inadvertent pleurotomy and creation of a capnothorax.
Entering the pleural cavity usually occurs during high mediastinal dissection or
Fig. 11 Final aspect of the
creation of the
retroesophageal window
(A right crus, B left crus,
C esophagus, D penrose
drain around the GE
junction)
Fig. 12 Robotic view after
completion of hiatal
dissection and creation of
retroesophageal window
(A right crus, B esophagus.
Note: lap grasper through
retroesophageal window
for retraction of GE
junction)
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during redo hernia repairs when there is scarring. This problem can be avoided by
properly identifying the pleura and separating it by using blunt dissection.
If the pleural space is entered, the surgeon should immediately notify the anesthesiologist. The anesthesiologist may observe that peak airway pressure has
increased; it is usually managed by adjusting ventilation mode and reducing the
pneumoperitoneum pressure down to 8 or 10mmHg. If needed, enlarging the hole
in the pleura can minimize any potential for tension physiology by equilibrating the
compartments. At the end of the procedure, while deating the CO2 pneumoperitoneum, the surgeon should ask the anesthesiologist to provide the patient a few large
volume breaths. Residual CO2 in the pleural space is absorbed within 1 to 2h and
chest drainage is not necessary in most cases. Capnothoraces tend to resolve spontaneously, rendering insertion of a chest tube unnecessary. Neck and face emphysema related to progression of the pneumomediastinum into the subcutaneous tissue
resolves without intervention within a few hours of the end of the procedure. Unless
there is a clinical indication, chest radiographs are not particularly helpful immediately post-operatively and can lead to unnecessary intervention.
10 Crural Closure
The diaphragmatic crura are closed with interrupted 0 non-absorbable braided
sutures. For laparoscopic repair, either an Endostitch device (Autosuture, Norwalk,
CT) or free-needle approach can be utilized to close the crura. Depending on preference, the sutures can be tied intracorporeally or extracorporeally. The Endostitch
device, when used properly, allows for large crura bites while protecting the needle
from inadvertently damaging the aorta or IVC (Figs.13 and 14). Exposure is provided by retracting the esophagus upward and toward the patient’s left with the
Penrose drain. The rst stitch should be placed just above the junction of the two
Fig. 13 Closure of the
diaphragmatic crura
(A right crus, B esophagus,
C aorta, D left crus,
E suture device)
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Fig. 14 Closure of the
diaphragmatic crura (A
caudate lobe of the liver, B
IVC, C right crus, D aorta,
E left crus, F suture
device)
Fig. 15 Crural closure—
nal aspect (A liver, B right
crus, C esophagus, D
penrose drain, E left crus)
M. Grasty and V. Gershuni
pillars. We prefer a gure of eight stich conguration. Additional stitches are placed
1cm apart, and a space of about 1cm is left between the uppermost stitch and the
esophagus (Fig.15). For a robotic approach, the crura can be closed and the suture
can be tied using two needle drivers (Figs.16 and 17). A slipknot is helpful for plac-
ing the knots when under tension. Occasionally, an anterior crural stitch may be
helpful to re-establish the crural relationship around the esophagus and minimize
risk of anterior hiatal hernia recurrence.
The bougie is not placed inside the esophagus during this part of the procedure.
If a Nissen 360° fundoplication is planned, a 56 French bougie should be inserted
by the anesthesiologist and passed through the esophagogastric junction under laparoscopic vision. Routine Bougie insertion is not necessary when a partial fundoplication is planned. The crura must be snug around the esophagus but not overly tight:
a closed grasper should slide easily between the esophagus and the crura.
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Fig. 16 Robotic closure of
the diaphragmatic crura (A
caudate lobe of the liver, B
esophagus, C right crus, D
aorta, E left crus)
Fig. 17 Robotic crural
closure
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11 Fundoplication
The choice of a posterior complete (360° Nissen) versus posterior partial (270°
Toupet) or anterior partial (180° Dor) fundoplication is based on individual patient
characteristics and surgeon preferences. While laparoscopic Nissen predominated
for many years, more surgeons are preferentially performing a partial Toupet fundoplication. In numerous studies, there has been equivalent heartburn relief when
comparing between complete and partial posterior fundoplication [29]. Many centers in Europe and North America favor the 270° posterior or 180° anterior partial
fundoplication, as recent randomized controlled trials have shown their association
with lower rates of re-intervention and post-operative side effect such as gas bloat
or dysphagia [16–18]. Of note, however, anterior partial fundoplication has been
associated with increased use of antisecretory medications and higher prevalence of
heartburn at long-term follow-up [30].
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