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51
Surgical Technique
andDicult Situations
fromKarl-Hermann Fuchs
Karl-HermannFuchs, W.Breithaupt, G.Varga, T.Schulz,
andB.Babic
8.1 Introduction – 52
8.2 Preparation – 53
8.3 Operative Technique – 53
8.4 Division oftheShort Gastric Vessels – 54
8
8.5 Hiatoplasty – 54
8.6 Fundoplication – 55
8.7 Summary – 56
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_8
52
K.-H. Fuchs et al.
8.1 Introduction
e terms paraesophageal hernia, large hiatal
a
d
hernia, upside-down stomach, and mixed hiatal
hernia are used sometimes with a remarkable
amount of confusion without a clear dierentiation. However, these dierent entities are not only
dierent anatomical situations, but they also do
b
e
c
have a dierent pathophysiologic background with
it is specic functional changes, which are important to dierentiate in the surgical management.
e term large hiatal hernia is used world-
wide usually for a sliding or xed hiatal hernia,
which has developed to such an extent that the
. Fig. 8.1 Axial hiatal hernias a, b, c and paraesopha-
geal hernia d, e
cardia and the hiatal opening is longer than 5cm
apart. is anatomical situation is very oen
associated with the gastroesophageal reux dis-
8
ease (GERD).
e term mixed hiatal hernia describes a
large axial hiatal hernia, in which the complete
fundus including the angle of His is migrated
into the lower mediastinum and one can nd
quite oen the hiatal crura at the level of the gastric corpus. is anatomical situation is also very
frequently associated with GERD.e size of the
hiatal hernia, i.e., the portion of the stomach,
migrated in the mediastinum, can be 50 % of the
gastric volume and more. Quite frequently, these
patients may have even decreasing reux symptoms such as heartburn over the past years; however, the size of the hiatal hernia will increase
their problems with massive regurgitation of
uid and food, respiratory symptoms, cardiac
sensations in the postprandial phase, and other
mechanical pressure symptoms due to the volume of the hernia.
e true paraesophageal hernia is a migration
of part of the gastric fundus locally into the mediastinum. In this case, the defect in the phrenoesophageal ligament is limited to a small portion
on the circumference of this ligament. erefore,
only a small portion of the gastric fundus migrates
through this limited defect parallel to the esophagus into the mediastinum (
. Fig. 8.1). ese
patients usually have no presence of a gastroesophageal reux problem.
An upside-down stomach can develop when
through a limited defect in the circumference of
the phreno-esophageal ligament over time the
complete stomach migrates up into the lower
mediastinum. In this situation, the cardia
remains still xed with its attachments of
phreno- esophageal ligament at the hiatal level.
e greater curvature of the stomach moves up
into the chest, turning the stomach upside down.
Avery constant nding is a brous scar strand
between the le crus and the gastric fundus near
the angle of His.
e term short esophagus describes an anatomical situation, in which the esophagus is shortened
and does not reach down to the intra- abdominal
level with sucient length of the lower esophageal
sphincter. In these cases, the esophagus has shortened usually over time with a long- standing and
persisting gastroesophageal reux disease and
esophagitis, causing inammation and subsequent
shrinkage and shortening. In addition, in these
cases, it is not possible to mobilize the esophagus
to re-create an intra- abdominal segment of the
lower esophageal sphincter (Mattioli).
e most important indication for operative
therapy of large hiatal hernias and its variations is
the patients’ reduced quality of life, due to massive
uid and food regurgitation, respiratory symptoms, heart sensations, and volume reux.
Especially in older patients, respiratory limitations can be devastating for the quality of life.
Since most of these symptoms cannot be compensated by proton pump inhibitors, only surgical
therapy can cure the problem.
One would think that the simple anatomical
reconstruction of the hiatal region should be sufcient. However, clinical evidence and literature
shows that oen this is not enough. e necessity
of a combination of anatomical reconstruction
and an antireux procedure are discussed controversially among surgeons. erefore, it is
important to dierentiate in a preoperative diagnostic workup accurately what type of hiatal
Surgical Technique and Dicult Situations from Karl-Hermann Fuchs
53
8
hernia is present in a given patient. Also a precise
assessment of the anatomical situation must be
performed, i.e., measurements of the length of
the esophagus, the level of the cardia, and the
level of the hiatal hernia, allowing for the determination of the size and the shape of the hernia.
is can be done very preciously by endoscopy
and radiography.
e question remains, whether an antireux
procedure is necessary aer anatomical correction of a hernia and reconstruction of the hiatus.
When a patient with an upside-down stomach is
operated and its hiatal anatomy is dissected in
order to reconstruct the altered anatomy, all
anchoring structures of the cardia within the hiatal opening are disconnected. e probability of
developing a postoperative reux problem aer
taking down all these structures is substantial,
and therefore, it is also recommended in literature
that an anatomical reconstruction in a large hiatal
hernia should be followed by some kind of fundoplication as antireux procedure.
8.2 Preparation
e patient is prepared in a supine position with
spread legs on the operation table and xed. en
the whole body is brought into a 45° position
aer supporting the legs and the feet in order to
use the gravity to pull the intra-abdominal organs
down, resulting usually in a great view on the hiatal region. In total 5 ports in the upper two quadrants of the abdomen are needed to perform the
operation.
8.3 Operative Technique
A complete dissection of the gastroesophageal
junction with the careful identication and preservation of the vagal trunks and the integrity of
the esophagus as well as the proximal stomach is
absolutely important. is can be achieved without problems by focussing the dissection on the
hiatal crura. It is important to nd these anatomical landmarks of the right and le crus as well as
the ventral hiatal arch and dissect them extensively. As a result of this dissection, the esophagus and the vagal trunks emerge in the middle of
the dissection area. In large hiatal hernias, there
is usually a large hiatal hernia sac, which also
should be completely dissected rst along the
hiatal crura and arch. is technique will prevent the surgeon from creating accidental holes
in the stomach or in the esophagus. e stomach
and the esophagus should be kept under moderate tension with the strong grasper or by a loop
to be able to dissect the circumference of the
esophagus.
e technical principles of dissection are similar in all the abovementioned dierent anatomical
variations and entities of large hiatal hernias. We
start the dissection at the le crus by dividing the
short gastric vessels between the upper pole of the
spleen and the angle of His and the le crus. en
we drive the mobilization of the fundus and dissection of the gastroesophageal junction toward
the le crus and stay with the dissection line at the
borderline of the hiatus.
In the next step, all redundant tissue at the cardia including the anterior esophageal fat pad and
the hiatal hernia sac must be removed. is
includes also frequently positioned lipomas and/
or fatty tissue in the mediastinum between aorta
and esophagus. Before resecting the hernia sac
and lipomas, it is absolutely important to make a
precise identication of the vagal trunks in order
to avoid damage.
e next step is the full mobilization of the
esophagus. e aim of this mobilization is the
positioning of a tension-free segment of the lower
esophageal sphincter of 2–3cm within the intraabdominal pressure system of the cavity. is can
be archieved by pulling on the gastroesophageal
junction with a loop around the esophagus. e
latter allows for stretching of the esophagus from
the mediastinum to the abdomen. As a result, the
esophagus can usually be mobilized with a long
swap from the mid-mediastinum at the level of
the pulmonary vessels.
If the preoperative diagnostic workup shows
a large hiatal hernia exceeding the length from
the cardia to hiatal level of more than 5cm, the
probability of a true short esophagus is higher,
and the surgeon should be prepared to handle
the special problems of a short esophagus during
this operation.
Dissection of the hernia sac and esophagus in
the mediastinum can increase the risk for pneumothorax during the operation. is is no problem for the experienced surgeon to deate the
pleural cavity via an external incision and a temporary drainage during the operation.
54
K.-H. Fuchs et al.
If all technical measures have been taken to
mobilize the esophagus and it is impossible to create a tension-free segment of lower esophageal
sphincter of 2–3cm within in the abdominal cavity, a short esophagus is conrmed and the option
of a Collis gastroplasty must be considered during
the operation.
Once the situation is conrmed, a boogie is
inserted into the esophagus and a marking stitch
is set at the angle of His, which determines the
segment that the esophagus should be lengthened. en a rotatable linear stapling system is
inserted through one trocar and a Collis gastroplasty is performed (. Fig.8.6).
Using a 2-cm-long wedge-shaped resection of
the subcardial stomach at the angle of His, the
esophageal tube is lengthened for 2cm. us, the
8
enlarged fundic aps have enough mobility to be
used as fundoplication.
8.4 Division oftheShort Gastric
Vessels
There is a controversial discussion about the
benefit of this maneuver among surgeons.
Several randomized trials have been performed
to clarify this technical question. It is important
to understand that a mobile fundus is important not only during the operation for a floppy
fundoplication but postoperatively during eating. The filling of the gastric lumen with food
and fluid must be possible to allow for a free
accommodation of the fundus, since it is important for an appropriate postprandial physiologic
filling and emptying function of the gastric
fundus.
As a consequence, a symmetric fundoplication around the lower esophageal sphincter
should be the aim, when the plication of the fundus is shaped. To reach this goal, the posterior
detachments of the fundus must be divided,
more than the short gastric vessels of the fundus.
Aer fundoplication, it is important for gastric
function that the fundus is mobile, when gastric
lling occurs. erefore, it is very important for
postoperative eating function that the fundus is
proximally mobilized and has the possibility of
free movement around the gastroesophageal
junction. If these posterior fundic attachments
between the retroperitoneum and the fundus are
seperated via the greater curvature, the short
gastric vessels have to be divided to approach
this region.
During redo-antireux surgery, quite oen
these tissue connections at the posterior fundus
are not divided, causing possible dysphagia or
eating discomforts. In the randomized trials
concerning the division of the short gastric vessels, dierent denitions of the mobilization of
the fundus have been used. As a consequence,
these results are not clinically relevant and cannot
be compared. Today, it is le to the judgment of
the individual surgeon to decide whether he or
she can achieve a good functional postoperative
result in the patients with or without fundic mobilization.
8.5 Hiatoplasty
A hiatoplasty to approximate the hiatal opening
during antireux surgery is absolutely important.
is should be performed with non-resorbable
suture material (. Fig.8.2). We prefer one or several “gure of 8” stitches, starting with the posterior aspect of the crura at the arcuate ligament.
. Fig. 8.2 Posterior Hiatoplasty
Surgical Technique and Dicult Situations from Karl-Hermann Fuchs
55
8
. Fig. 8.3 Hiatoplasty
Quite oen, we also use an anterior approximation of the hiatal arch or complete the downsizing
of the hiatal opening (. Fig.8.3).
8.6 Fundoplication
Aer hiatoplasty, a fundoplication should be
performed. We use as a standard procedure the
short oppy Nissen fundoplication in the DeMeester-
sandwich technique. In severe esophageal motility
disorders, we favor a posterior partial fundoplication in the Toupet technique.
e fundoplication is shaped by pulling with
a loop the esophagus caudally and then moving
the posterior funding ap through the retroesophageal window to the right side of the
esophagus. en a large-size bougie (54 French)
is placed into the stomach, and a shaping of the
fundus is completed to gain a oppy fundoplica-
. Fig.8.4).
tion (
e anterior and the posterior fundic aps are
sutured together with one U-stitch in the
DeMeester-sandwich technique, allowing for a
continous identication of the anterior vagus during the stitch. It is important that the fundus is
placed around the lower esophageal sphincter
symmetrically and the fundoplication sutures are
positioned on the right lateral side of the esophagus (. Fig. 8.5).
. Fig. 8.4 Shaping the fundoplication
. Fig. 8.5 Completed Nissen fundoplication
. Fig. 8.6 Placing of linear stapler at angle of His to
complete Collis gastroplasty
56
K.-H. Fuchs et al.
8.7 Summary
e operative therapy of dierent entities of
large hiatal hernias such as paraesophageal her-
nia, large mixed hernias, and upside-down
stomachs should be performed aer extensive
diagnostic workup to make sure that the right
anatomical situation is identied and also all
functional parameters and defects are deter-
mined.
We think that not only an anatomical reconstruction in large hiatal hernias but also a fundoplication is necessary. Laparoscopic fundoplications as
full wrap or partial wrap are the standard procedures in the operative treatment of gastroesophageal reux disease. ese procedures can be done in
experienced hands with a very low morbidity and a
short postoperative hospitalization. e functional
results in experience centers are excellent. Especially
redo surgery should be performed in such centers.
8
Surgical Technique
and Difficult Situations
from Sumeet K. Mittal
PradeepPallati andSumeetK.Mittal
9.1 Introduction – 58
9.2 Preoperative Workup – 58
9.3 Preparation – 58
9.4 Surgical Technique – 58
9.4.1 Reduction of Hernia Sac – 59
9.4.2 Mediastinal Dissection – 60
9.4.3 Crural Closure – 60
9.4.4 Anti-reflux Procedure – 61
9.4.5 Gastrostomy Tube Placement with Endoscopy – 62
57
9
9.5 Difficult Situations – 62
9.5.1 Short Esophagus – 62
9.5.2 Inability to Reduce the Stomach – 62
9.5.3 Bleeding – 62
9.5.4 Visceral Injury – 63
9.5.5 Tearing of the Crus with Primary Closure – 63
9.6 Classification of the Difficult Situations – 63
References – 63
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_9
58
P. Pallati and S.K. Mittal
9.1 Introduction
Intrathoracic stomach represents herniation of
greater than 75 % of the stomach through the
esophageal hiatus into the thoracic cavity. e
most common symptoms include intermittent
dysphagia for solids, abdominal and chest pain
secondary to visceral torsion, gastrointestinal
bleeding from mucosal ischemia resulting in iron
deficiency anemia, and heartburn. A high incidence of acute volvulus with possible gangrene,
perforation, or hemorrhage requiring emergent
surgery has been reported, and elective repair has
been recommended [1] though not universally
accepted for asymptomatic patients. All symptomatic PEH should be repaired especially if they
have symptoms suggesting incarceration. e
operative repair was traditionally via le thora-
. Fig. 9.1 Showing the usual trocar placements. The
camera port is above and left of the umbilicus. Assistant
port is below the costal margin in the anterior axillary
l ine and the liver retractor is near the xyphoid. The
surgeons working ports are a 12 mm trocar in left mid
clavicular line 1-2 cm below the costal margin and a 55
mm trocar just right of the midline in the epigastrium
cotomy and subsequently via laparotomy though
laparoscopic repair is feasible in nearly all patients.
9
Cuscheri first reported laparoscopic repair of par-
9.3 Preparation
aesophageal hernia in 1992 [2]. Operative strategy includes sac and hernia reduction with hiatus
closure along with or without fundoplication.
e patient is placed in an inverted Y supine position (Alphamaxx, Maquet Inc., Germany). e
operating surgeon stands in between the legs, the
first assistant on the le side of the patient, and
9.2 Preoperative Workup
the camera operator on the right side of the
patient.
Preoperatively, all patients undergo esophageal studies including esophagogram, upper endoscopy, and
manometry. Esophagogram determines the extent of
herniation along with any evidence of volvulus. ere
is a high probability of short esophagus if the GEJ is
>5cm above the hiatus. Upper endoscopy is used to
rule out ischemia in acute setting and identify
Cameron’s ulcers, reflux esophagitis, and Barrett’s
esophagus (BE) in the chronic setting. Peptic stricture, BE, and endoscopic esophageal length index are
predictors of a short esophagus [3]. Manometry may
be difficult in these patients due to the angulation of
Port placement is as shown in . Fig 9.1. We
place a larger 12mm cannula for the operating
port (surgeon’s right hand) for ease of needle
insertion at the time of suturing. e port is also
placed close to the le subcostal region in such a
manner that it could be used for placement of
gastrostomy tube at the end of the procedure (if
needed). If there is a high degree of suspicion
for short esophagus based on preop assessment,
the le arm is extended on the arm board, and
the le chest is prepped in the field for Collis
gastroplasty.
the gastroesophageal junction, and we prefer to place
the catheter under endoscopic guidance. Manometry
identifies any extent of esophageal dysmotility and
9.4 Surgical Technique
helps in decision-making with regard to anti- reflux
procedure. General preoperative evaluation should
include cardiorespiratory risk assessment in these
oen elderly and frail patients. Laparoscopy is associated with greater intraoperative cardiopulmonary
compromise than open procedures.
orough evaluation is needed prior to surgical
intervention.
is operation can be divided into ve steps:
1. Reduction of hernia sac
2. Mediastinal dissection and assessment of
esophageal length
3. Crus closure
4. Anti-reflux procedure
5. Gastrostomy tube placement– selectively
Surgical Technique and Difficult Situations from Sumeet K. Mittal
59
9
. Fig. 9.2 Initial laparoscopic view showing majority of
stomach and omentum herniating thru a gigantic hiatal
defect
9.4.1 Reduction of Hernia Sac
Aer initial laparoscopy, the liver is retracted
with the use of a Nathanson® liver retractor
(Cook Surgical, Bloomington, Indianapolis,
USA) with a table-mounted Iron Intern®
(Automated Medical Products Corp., NewYork,
NY). We use a 30° angled lens during the procedure. Occasionally 0° lens is used for mediastinal dissection. e patient is placed in a steep
reverse Trendelenburg position to bring the
bowel contents away from the esophageal hiatus. e hernia, with its contents, is identified
(. Fig. 9.2). If the colon is herniated, it is reduced
with the use of blunt graspers using hand-overhand technique.
We do not attempt to reduce the stomach as
it obstructs proper visualization. Rather the sac
is retracted caudally bringing its edge of the
anterior most portion in clear view. We start the
dissection just inside the arch of the crus with
electrocautery. It is imperative that we enter the
correct plane outside the hernia sac. It is important to preserve the peritoneal lining of the crus.
e cut edge of the sac is grabbed by the assistant and pulled in the caudal direction. With
further countertraction with the surgeon’s le
hand, the cautery is used to continue dividing
the sac at the level of the hiatus. One must continuously reposition the assistant’s and the surgeon’s le-hand instruments to provide traction
at the leading edge of the sac dissection. One
can identify the correct plane by the fact that it
almost lends itself to dissection and there is no
bleeding.
It is important to enter the correct plane outside
the hernia sac. e correct plane is avascular and
dissects readily.
. Fig. 9.3 Initial line of dissection. The assistant (not
shown) grabs the hernia sac and everts it out of the mediastinum
On extending over the right crus, the gastrohepatic ligament is divided. In patients with aberrant le hepatic artery, we preserve only if it is
larger than 4mm. While extending onto the le
crus, the division of the short gastric vessels facilitates the exposure (
. Fig. 9.3). e dissection
along the le crus is technically challenging, as
the exposure can be difficult especially for the
novice. e inverted hernia sac is grasped and
pulled caudad and to the patient’s right to allow
for better traction. e sac is bluntly dissected and
pulled into the abdominal cavity. In obese
patients, if needed, an additional 5mm trocar can
be placed on the le side for the assistant’s second
hand to retract the bulky omentum that usually
obscures the view at this point.
e peritoneal lining on the undersurface of the
diaphragm is preserved at all times as this is incorporated in the sutures for the crural closure at the
end.
Once the dissection reaches the junction of
the right and le crus, a 6-inch-long 1/2-inch
Penrose drain is passed from right to le below
the esophagus and then secured with Endoloop
®
(Ethicon Endo-Surgery Inc., Cincinnati, Ohio). It
is important to place the retracting Penrose drain
at the gastroesophageal junction (GEJ) aer the
hernia sac has been reduced. If the hernia sac is
not below the retracting Penrose, the sac and the
accompanying fat are pulled through the loop to
appropriately position the Penrose. e retraction
with Penrose drain is safe and avoids inadvertent
injury to the GEJ.
We do not excise the hernia sac off the viscera,
though the sac is dissected off the greater curvature and the angle of His to correctly identify the
GEJ.It also allows for proper positioning of the
fundoplication over the distal esophagus.
60
P. Pallati and S.K. Mittal
9.4.2 Mediastinal Dissection
With adequate traction on the Penrose drain by
the assistant, the esophagus is stretched out.
Generous dissection of the mediastinum is performed with alternating blunt and sharp dissection (. Fig. 9.4). Using the two instruments in the
surgeon’s hand, the dissection is carried with
chopstick- like motion parallel to the esophagus.
Care is taken that the tip of the instruments does
not push in to the esophagus. Dissection between
the esophagus and the aorta is performed meticulously with harmonic scalpel, as there are direct
blood vessels to the esophagus from the aorta.
. Fig. 9.4 An avascular plane has been made between
the hernia sac and the crus and dissected into the medi-
astinum. Fascia/ peritoneum has been preserved on the
crus
Mediastinal dissection is to be carried as high as
possible up usually up to the inferior pulmonary
veins (. Fig. 9.5).
Inadvertent pneumothorax is encountered
occasionally. is needs to be conveyed to the
anesthesiologist and intra-abdominal pressure
9
may need to be decreased if any difficulties arise.
Rarely, a temporary chest tube may need to be
inserted to continue with the procedure.
e bleeding is minimal in this dissection if
performed meticulously. A gauze piece can be
inserted through the large port to absorb any
blood and to increase visibility. In obese patients
and when dissection is carried too high, we
. Fig. 9.5 Extensive mediastinal dissection is done usu-
ally above the inferior pulmonary veins. Care is taken to
avoid injury to the perforators and the aorta
sometimes switch to zero-degree lens for better
visualization.
9.4.3 Crural Closure
e crus closure is achieved with 0 Ethibond®
(Ethicon LLC, San Lorenzo, Puerto Rico) figureof- eight suture tied with the use of a Ti-Knot
device® (LSI Surgical Procedure Solutions, Victor,
NY). e first stitch is crucial and placed as posteriorly as possible. To aid in this, the le-hand
grasper of the surgeon is placed between the
aorta and the le limb of the crus (. Fig. 9.6).
is allows the surgeon to feel the grasper with
the needle and avoid aortic injury while allowing
for the deepest possible suture in the le crus.
Starting the suturing posteriorly decreases the
tension as the crus is progressively closed anteriorly. We avoid using any prosthetic material at
the hiatus and only rarely do we use a U-shaped
. Fig. 9.6 Crus closure is started as posteriorly as pos-
sible. Left hand gasper (shown) of the surgeon is placed
between the aorta and the left limb of curz. This grasper
is ‘felt’ with the needle as it is skived over it to the deepest
and most posterior cruz bite possible
bioprosthetic mesh Veritas
®
(Synovis Surgical
Innovations, St. Paul, MN).
A series of figure of eight sutures are placed
and serially tied (. Fig. 9.7). Occasionally, we