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30
H. Tro id l
thought of some time ago has increased the diculty from itself enormously and this in a tremendous pace. is applies to both the technology
and the necessary manual skills as well as particularly to make the right decisions with regard to
risk assessment and risk minimization.
Increasing dependence on technology such as
in endoscopic surgery, which reduces the cogni-
4
tive and perceptual apparatus mainly on the
visual, leads to completely new grades of diculty. However, quite a few enthusiastically
praised technical innovations have disappeared. I
remember the high favourite lithotripter for gallstones, not to forget the myth laser and the “beams
bomber”– devices that consumed so much energy
that they could not be put into operation never
having proven their eectiveness.
Diculties in medicine are also economic dif-
weighting (evaluation) calling the easiest climb-
ing route I.At level II, for example, the “three-
point stance” (three limbs contact the rock) is
necessary for the rst time. In IV the force
increases and the security cable is required. In
addition, then physical tness, experience and
training are necessary, etc. You can, if you just
want to, learn from similarities. Nevertheless, the
question remains, why? For vanity, for teaching
purposes, risk reduction!?
And, of course, there is not only one single
classication. us the already branded primary
problem of denitions is revealed. It goes without
saying that the French have their own one.
Moreover, there is another truth: In reality, none
of the routes known for its diculty has ever been
tested by a study on eectiveness. Do you want to
bet? And– it will probably never happen.
culties (!), prot maximisation and nancial
objectives (guidelines). is topic aects into so
many areas of medicine and has thereby replaced
the ethos of medicine to a large extent.
Additionally, the surgeon’s self-selected diculty
looking upon the patient as a test subject to
become famous with leads to dicult situations.
e thyroid gland need not be approached from
the axilla or from behind the ear.
e question is: why is it so hard for surgeons
also to agree with a clear denition of “dicult
situation”? Is it the real circumstances or negative
experiences with denitions (e.g. acceptance) or
the scientic and methodological diculties or is
such a denition not required at all?
Since 1984 (!) the mountaineers have divided
their routes in degrees of diculty, e.g. the socalled Benesch scale. is scale has seven levels of
diculty. With stage VII Benesch evaluated the
easiest routes, with stage I the most dicult one.
References
1. Ambe P, Esfahani BJ, Tasci I, Christ H, Kohler L. Is
laparoscopic cholecystectomy more challenging in
male patients? Surg Endosc. 2011;25(7):2236–40.
doi:10.1007/s00464-010-1539-3. Epub 2011 Feb 7.
2. Feinstein AR. Clinical biostatistics. St Louis: The
C.V.Mosby Company; 1977.
3. Kohler L, et al. Myths in management of colorectal
malignancy. Br J Surg. 1997;2:248–51. doi:10.1046
/j.1365-2168.1997.02485.x.
4. Korenkov Symposium: Individualität statt Uniformität.
Prinzipien und Grundlagen der individualisierten
Chirurgie CHAZ, 11. Jahrgang, 5. Heft, 2010.
5. Rohde H, Troidl H. Das Magenkarzinom. Stuttgart:
Thieme; 1984. The writing committee on behalf of
the ASTEC study group. Ecacy of systematic pelvic
lymphadenectomy in endometrial cancer (MRC
ASTEC trial): a randomised study. Lancet. 2009;373:
125–36.
6. Troidl H.Tauschen und Tarnen. MIC. 2003;7.
One can draw good inspiration from this if you
try to nd a classication of surgical severity (?).
e method chosen by Benesch is simply a listing
of facts, their number, intensity and specicity
increasing with the diculty of the routes. But
even in this area, the classications had to be
changed. at means the most popular UIAA
scale of Central Europe reversed the numerical
Further Reading
1. Bernstein PL.Wider die Gotter– Die Geschichte der
modernen Risikogesellschaft. Hamburg: Muhrmann;
1996.
2. Benesch C, McDaniel K, Cox C, Hamill KW. Endstage
Alzheimer’s disease Glasgow Coma Scale and the
neurologic examination. Archives of Neurology.
1993;50:1309–15.
Individual Surgery
for Upside Down
Stomach and
Antireflux Surgery
Contents
Chapter 5 Introduction – 33
MichaelKorenkov, Christoph-omasGermer,
andHaukeLang
31
II
Chapter 6 Surgical Technique and Difficult Situations
from Bernard Dallemagne – 39
BernardDallemagne
Chapter 7 Surgical Technique and Difficult Situations
from Hubertus Feussner – 43
HubertusFeussner andDirkWilhelm
Chapter 8 Surgical Technique and Difficult Situations
from Karl-Hermann Fuchs – 51
Karl-HermannFuchs, W.Breithaupt, G.Varga,
T.Schulz, andB.Babic
Chapter 9 Surgical Technique and Difficult Situations
from Sumeet K. Mittal – 57
PradeepPallati andSumeetK.Mittal
Chapter 10 Surgical Technique and Difficult Situations
from Nathaniel J. Soper – 65
EricS.Hungness andNathanielJ.Soper
32
Chapter 11 Surgical Technique and Difficult Situations
from David J. Watson – 69
DavidI.Watson
Chapter 12 Single-Access-Laparoscopy and
Foregut-Surgery from Giovanni Dapri – 77
GiovanniDapri
Chapter 13 Gastric Bypass After Failed Fundoplication
from Dimitrios Stefanidis – 87
DimitriosStefanidis
33
Introduction
MichaelKorenkov, Christoph-omasGermer, andHaukeLang
5.1 Laparoscopic Antireux Surgery – 34
5.1.1 Approach – 34
5.2 Laparoscopic Upside-Down
Stomach Surgery – 36
5.3 Classication ofIntraoperative Diculties – 38
Reference – 38
5
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_5
34
M. Korenkov et al.
ere are a lot of technical variants and modication
in surgical treatment of gastroesophageal reux diseases (GERD). e key phases in an operation are:
5 Dissection of the phrenicoesophageal liga-
ment and the angle of His
5 Opening of pars accida and retrocardial
mobilization with a loop around the
esophagus
e topic upside-down stomach is closely
connected with an antireux surgery and is also
presented in this chapter. Due to didactic reasons,
we decided also to include in this chapter a contribution from Giovanni Dapri about single access
surgery and a contribution from Dimitros
Stefanidis about gastric bypass aer failure fundoplication.
5 Mobilization of the fundus and transection of
the short gastric vessels (not obligate)
5
5 Hiatoplasty
5 Fundoplication
Contrary to the reconstruction of the cardio-
5.1 Laparoscopic Antireux
Surgery
5.1.1 Approach
esophageal junction through the fundoplication,
there are not so many technical variants for the
rst four steps. Establishing of laparoscopic techniques led to increasing ratesof surgical treatment
of GERD. ereby itincreases also the recurrence
rates of GERD. e surgical treatment of GERD
recurrence is much more dicult and connected
oen with technical problems and controversial
decision situations.
e laparoscopic antireux surgery is commonly
performed with the use of four or ve trocars.
Depending on the patient’s constitution and
surgical preference, trocar will be placed in a high,
lower, or compact-pyramidal position (. Fig.5.1).
e specic features of SILS technique, which has
been currently not considered as a standard therapy, will be presented in the contribution of Dapri.
a
c
b
. Fig. 5.1 a “High” trocar placement, b “lower” trocar placement, c compact-pyramidal trocar position
V-point
Retroesophageal fat pad
Introduction
kFirst Step
Dissection of phrenicoesophageal liga ment and
the angle of His
Mostly this step is not considered to raise technical diculties. By means of the caudal tension of the
stomach, the phrenicoesophageal ligament will be
gut perceivable. For the dissection can be used different instruments like hook with monopolar cautery, ultracision scissors, LigaSure, or Metzenbaum
scissor. e technical problems and dicult decision can occur in the following situations:
Severely obese patient. It is sometimes dicult to view
a His angle in severely obese patients with signicantly enlarged le hepatic lobe. In such situation
it is helpful to introduce an additional trocar.
Dissection of pericardiac fat deposits. During the
dissection of the pericardiac fat deposits
(so- called fat pad), diuse bleeding especially
in obese patients can occur. e excessive
using of energy devices can lead to thermal
injury of cardioesophageal junction with early
postoperative perforation. To avoid such problems, the following steps might be useful:
1. To perform incomplete or no fat pad
dissection.
2. e dissection of the fat pad should be
beginning on the gastric wall (not on the
esophagus or cardioesophageal junction!).
e further dissection should be performed
along the gastric wall toward the esophagus.
kSecond Step
Opening the pars accida and retrocardiac mobilization with encircle of the esophagus
Technical problems and dicult decision situations can be presented as follows:
Dissection in mediastinum. In case of unclear view,
the dissection can be performed behind of the
le diaphragmatic crus in mediastinum. In
order to avoid it, we recommend dissecting at
rst the right diaphragmatic crus till to its base
and identify the contact point (so-called v-point)
with the le crus (. Fig. 5.2). Sometimes an
additional distal dissection of the lesser curvature is necessary for this step. Aer the clear
identication of the v-point is the further dissection between the posterior esophageal wall and
v-point mostly unproblematic.
Severe bleeding. Predisposed for it is excess retrocar-
diac fat storage (retroesophageal fat pad), which
is closely connected with the posterior esophageal wall (. Fig. 5.2). is fat tissue has good
35
. Fig. 5.2 V-point and retroesophageal fat pad
vascularization; that’s why the dissection
through the fat pad is almost always connected
with the bleeding from the dierent intensity. In
order to avoid this problem, it is helpful at rst to
identify the v-point clearly. Aer that a dissection should be performed between the v-point
and the fad pad in the relative avascular plain.
Dissection of the retroesophageal fat pad. An excess
retroesophageal fat pad should be removed as
recurrence prevention, although there is no
valid evidence for the eectivity of this step.
Otherwise as a result of such dissection, the
diuse bleeding, esophageal injury, as well as
the injury of the posterior vagal trunk can
occur. is step is technically sophisticated
and required high concentration and precision. e question “should you continue the fat
pad removal in a dicult technical situation?”
is not being cleared.
e injury of the posterior vagal trunk. During the
retrocardiac dissection, the posterior vagal
trunk will be oen separated from the posterior
esophageal wall. In case of the excess retroesophageal fat pad, the vagal nerve can be confused with the fat tissue and injured accidentally.
In order to avoid this complication, no cablelike looking structures should be transected
before the clear identication between the fat
tissue, blood vessels, and posterior vagal trunk.
kThird Step
Mobilization of the fundus with division of the
short gastric vessels
5
36
M. Korenkov et al.
has their particular pitfalls, which will be discussed in the following chapters. Independent
on the type of fundoplication, the intraoperative
diculties can occur in the following situations:
Small fundus. Some obese patients have a small
fundus, so that the tension-free fundoplication
independent from it type can be dicult. Also
a division of the short gastric vessels cannot
solve the problem always. In such situation, a
complete retrogastric mobilization of the pos-
5
terior gastric wall with the dissection of all
adhesions in omental bursa can be helpful.
In this book, we didn’t discuss deliberately
the question if the short esophagus really
. Fig. 5.3 “Bridging” the tissue portion before the tran-
section with energy device (From M.Korenkov. Bariatric
surgery. By courtesy of Hans Huber Publisher, Bern 2010)
exists, or this is only a matter of the sucient
mobilization.
Short esophagus. Basically one can distinguish
between a “real” short esophagus (long- segment
is step is not obligatory and depends from
the surgeon preference and mobility of the fundus. ereby the technical diculties occur
seldom. Most common is diuse bleeding or
bleeding from the short gastric vessels, which
occur mostly at the beginning of the dissection. It
is recommendable to begin the dissection in an
avascular zone close to gastric wall and perform
the “tissue bridging” before the division
(. Fig.5.3). An injury of the spleen capsule is not
usual for the laparoscopic technique.
Barrett esophagus), in which it is not possible
despite on extended pericardiac dissection to
replace the cardioesophageal junction in abdomen, and a so-called “pseudo”-short esophagus
(short-segment Barrett esophagus), in which the
desired reposition can be reached through an
adequate mobilization. Accordingly the antireux
surgery for patients with a “real” short esophagus
can be related with dierent dicult situations. In
the literature the dierent technical variants from
two basic procedures will be presented:
5 Collis Plasty: Technical details of this proce-
kFourth Step
Hiatoplasty
Posterior or anterior hiatoplasty as well a
combination of both techniques will be used for
the repair of hiatal hernia. Until now there is no
valid data which of these techniques yield better
results. In spite of the fact that the anterior hiato-
dure will be presented in chapters from Dallemagne (Chap. 6), Fuchs (Chap. 8), Mittal
(Chap. 9), and Soper (Chap. 10).
5 Fundoplication with the intrathoracal
placement of the fundoplication cu in
combination with a distal gastric resection
with Roux-en-Y loop anastomosis [1].
plasty is technical more easily, most surgeons prefer a posterior repair. If the both cruses can be
good identied is this step technical unproblematic. In case of confusion between the le crus
5.2 Laparoscopic Upside-Down
Stomach Surgery
and aorta, the last can be sticking accidentally. In
such situation, a suture should be immediately
removed without tying a knot. e bleeding can
be managed by prolonged compression with a
swab or gauze compress.
e technical steps of this procedure consist of:
5 Repositioning of the stomach in the abdo-
men
5 Opening and removing (partial removing) of
hernia sac and mobilization of the cardio-
kFifth Step
Reconstruction of the cardioesophageal junction
e reconstruction of the cardioesophageal
junction can be performed by 360°-, 270°-, or
180°-fundoplication. Any one of such procedures
esophageal junction with the placement of
the traction band around it
5 Hiatoplasty with mesh augmentation when
indicated
5 Fundopexy/fundoplication
Introduction
37
5
. Fig. 5.4 Hernia sac tissue between the left diaphrag-
matic crus and stomach/esophagus (see arrow)
kFirst Step
Repositioning of the stomach
is step is mostly unproblematic. All three edi-
tors have until now no especial diculties with the
repositioning of the stomach, although it is known
both from the literature and from the personal communication about some cases of the failed gastric
reposition or only partial gastric reposition. In the
rst situation, the dierent decisions from “not to
do” till thoracotomy can be chosen. In the case of
the partial reposition, some surgeons recommend
the gastric xation with the PEG tube.
kSecond Step
Opening and removing (partial removing) of hernia sac and mobilization of the cardioesophageal
junction with the placement of the traction band
around it
is step provides tremendous scope regard-
ing the technical problems and dicult decision
situation. One reason for this is a special anatomy
of the hernia sac (very thick walls, sliding hernia).
In this situation, it is sometimes dicult to distinguish between the hernia sac and esophageal or
gastric wall. Also a good vascularization of the
hernia sac can lead to severe bleeding in case of an
accidental vessel injury.
When considering the surgical anatomy, fol-
lowing the structures of upside-down stomach
should be considered:
5 Hernia sac tissue between the le crus and
stomach/esophagus (
. Fig.5.4)
5 Hernia sac tissue with part of the greater
omentum between the right crus and stomach/esophagus (. Fig.5.5)
. Fig. 5.5 Hernia sac tissue with part of the greater omen-
tum between the right crus and stomach/esophagus
(see arrow)
. Fig. 5.6 Sail-like sagittal fold form between the esopha-
gus and mediastinal pleura (see arrow)
5 Sail-like sagittal fold form between the esoph-
agus and mediastinal pleura (
. Fig.5.6)
5 Retroesophageal fat pad
Dierent surgeons favor quite dierent ways in the
dissection of the hernia sac (see chapters from
Dallemagne ( Chap. 6), Feussner (Chap. 7), Fuchs
(Chap. 8), Mittal (Chap. 9), and Soper (Chap. 10).
e most dicult situations occur in case of the
limited view because of the enlarged le lobe of the
liver, highly developed perivisceral fat deposits, as
well as diuse bleeding by an unlocated site of it.
kThird Step
Hiatoplasty
In case of adequate performed dissection of
the hernia sac and mobilization of the cardioesophageal junction is hiatoplasty technical
38
M. Korenkov et al.
mostly unproblematic. Dicult decision situation
occurs by:
5 Excessive tension of the hiatoplasty sutures.
5 “inned out” and denuded cruses (espe-
. Table 5.1 Grading of operative diculties for
the antireux surgery
Grading Case type
cially the right crus), which are not gut
suitable for the hiatoplasty.
5 In such situation, the following steps
should be discussed:
5 Indication for the hiatal mesh augmentation
I (ideal cases)
It is easy to operate;
every operative
technique is technically
unproblematic
5 Combination from anterior and posterior
5
hiatoplasty
kFourth Step
Fundopexy/fundoplication
is step is mostly unproblematic. In case of a
“not ideal” hiatoplasty favor some surgeons the
fundopexy. One of the editors performs additional to anterior semi-fundoplication, a gastropexy with the suturing of the stomach body to the
abdominal wall (. Fig.5.7). e signicance of
this procedure is unclear.
II (not quite ideal)
Some minor technical
diculties may occur;
some operative
techniques can be more
dicult as other
III (problematic)
Dicult to operate, some
operative techniques are
considerably more
dicult than others
IV (very problematic)
Every operative step is
very dicult
Slender or normal
weight patient
No previous major
abdominal surgery or
minor upper
abdominal surgery
Clear exposition of the
cardioesophageal
junction
Sucient mobile and
long enough fundus
Moderate obese
patient (BMI around
2
30kg/m
Otherwise similar to
grade I
Overweight patient
(BMI > 35kg/m
Enlarged left lobe of
liver
Highly developed
perivisceral fat
deposits
Short not sucient
mobile fundus
Extreme form of
grade III factors
)
2
)
. Fig. 5.7 Gastropexy with the suturing of stomach body
to the abdominal wall
5.3 Classication ofIntraoperative
Diculties
e operative diculty for the antireux surgery
can be classied as summarized in a . Table5.1.
Reference
1. Braghetto I, Korn O, Csendes A, Valladares H, Chacon
M. Laparoscopic treatment of obese patients with
gastroesophageal reux disease and Barrett’s esophagus: a prospective study. Obes Surg. 2012;22(5):
764–772.
39
Surgical Technique
and Difficult Situations
from Bernard Dallemagne
BernardDallemagne
6.1 Introduction – 40
6.2 Patient Setup and Surgical Technique – 40
6.2.1 Reduction of the Stomach
into the Abdominal Cavity – 40
6.2.2 Esophageal Dissection:
Short Esophagus Assessment – 41
6.2.3 Crural Repair – 41
6
6.3 Should an Anti-reflux Procedure
Be Performed Routinely? – 42
6.4 Postoperative Care and Investigations – 42
Electronic supplementary material The online version of this chapter (doi:10.1007/978-
3-662-49878-1_6) contains supplementary material, which is available to authorized users.
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_6