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D.I. Watson72
. Fig. 11.5 Completed anterior 180° partial fundoplica-
tion. The fundus sits loosely across the oesophagus and
anterior hiatus
. Fig. 11.7 Completed Nissen fundoplication (A), sitting
above the preserved hepatic branch of the vagus nerve (B)
which expects problems at every operation, and
anticipates abnormal anatomy and other dicul-
ties, will minimise the risk of serious diculties.
11
. Fig. 11.6 Construction of a Nissen fundoplication. The
fundus sits loosely behind the oesophagus. A piece of the
fundus which will form anterior component of the wrap, B
piece of the fundus which will form posterior component
of the wrap
(1 or 2 also including the anterior oesophageal
wall) and calibrated using a 52-Fr intra-oesophageal bougie (. Fig.11.7). When care is taken to
select the most appropriate piece of the anterior
fundus, the short gastric vessels almost never need
to be divided. e fundoplication is not sutured to
the diaphragm.
11.2 Dicult andUnusual
Intraoperative Situations
A systematic and consistent approach to hiatal dissection minimises the risk of problems during laparoscopic fundoplication. A “defensive” approach
11.2.1 Abnormal Vascular Anatomy
Failure to recognise aberrant vascular anatomy in
the region of the oesophageal hiatus can lead to
vascular injury and bleeding, necessitating con-
version to open surgery to control haemorrhage,
and in rare situations bleeding can be life threat-
ening. Awareness of anatomical variations, and a
strategy during dissection which avoids injury, is
the best approach to this problem. To do this, the
use of energy sources such as diathermy or ultra-
sonic shears should be minimised. Ultrasonic
shears have an active blade, which can press
against other structures when dividing tissue.
is has led to inadvertent injury to the inferior
vena cava (IVC) or aorta at the level of the
oesophageal hiatus, or immediately inferior [3].
IVC injury is more likely when a large hiatus her-
nia is present, as the space between the edge of
the right hiatal pillar and the IVC can be less than
10mm. Opening the avascular part of the lesser
omentum below the hepatic branch of the vagus
nerve using a blunt dissection technique allows
early identication of this vessel, and dissection
can then be directed away from the IVC.
e aorta is at risk in a small number of individuals when it lies more anteriorly, posterolaterally on the le side of the oesophagus. In these
Surgical Technique andDicult Situations fromDavid I.Watson
73
11
individuals, the muscle of the le hiatal pillar
can be thinner and merge into the anterior
aspect of the aorta. In such individuals, the use
of energy sources posterolateral to the oesophagus, in the vicinity of the angle of His, can result
in inadvertent injury. Blunt dissection in this
region minimises risk. Care also needs to be
taken to not place posterior hiatal repair sutures
through the wall of the aorta when repairing the
hiatus.
The left inferior phrenic artery arises from
the left gastric artery and runs along the edge
of the right hiatal pillar in 5–10 % of individuals. When located in this position, this vessel
should be ligated or clipped and then divided
to allow the right anterolateral aspect of the
oesophageal hiatus to open adequately. Care
should be taken to look for this vessel before
hiatal dissection commences. The vessel is easily seen, but will be injured if not ligated at an
early stage.
An aberrant le hepatic artery can arise from
the le gastric artery, and run through the upper
aspect of the lesser omentum, adjacent to the
hepatic branch of the vagus nerve. In the absence
of a large hiatus hernia, this vessel can usually be
preserved, with dissection occurring above and
below the vessel. When a very large hiatus hernia
is present, however, preservation of this vessel is
more dicult, and it will usually need to be ligated
and divided to open up space on the right side of
the oesophageal hiatus.
11.2.2 Adipose Tissue
Excessive amounts of adipose tissue in the
region of the oesophageal hiatus make dissection difficult, and this is more common in
males than females. Some perivisceral and
omental adipose tissue can be displaced away
from the operative field by tilting the operating
table head up, with 25–30° head-up tilt often
needed to achieve adequate exposure. An
enlarged fatty liver in combination with intraabdominal obesity restricts surgical access further, and this type of liver is fragile and easily
damaged by hand-held liver retractors. The use
of a “fixed” Nathanson liver retractor usually
solves this problem, provides better and more
stable exposure of the oesophageal hiatus and
also minimises the risk of liver injury. When
using this device, adequate exposure is usually
obtained.
Occasionally a “lipoma” or extension of fatty
tissue from the posterior aspect of pericardial
fat pad is present, particularly in obese males.
is extends through the oesophageal hiatus,
posterior to the oesophagus, into the mediastinum, and it can ll the hiatus and make dissection of the posterior hiatus dicult. A posterior
hiatal “lipoma” should be pulled fully downwards into the abdomen and retracted by a
grasping instrument held by the assistant, whilst
posterior hiatal dissection and repair is completed. Once the hiatus is repaired with posterior sutures, the “lipoma” sits below the
diaphragm and the operation can be completed
in the usual manner.
11.2.3 Adhesions
Upper abdominal adhesions following previous open surgery can limit access and port
placement, particularly if previous upper midline or right upper quadrant subcostal abdominal incisions have been used. Much time can be
spent dividing adhesions to gain sufficient
access for conventional laparoscopic port
placement in the midline and right upper
quadrant. An optical entry technique can be
used in the left subcostal region for rapid
placement of the first port, instead of entry via
the midline. To place the right upper quadrant
port, the avascular area of the falciform ligament can be opened to visualise and enter an
adhesions free space anterior to the right lobe
of the liver. Under vision, the right upper quadrant port can then be placed above any adhesions, and the operation will subsequently
proceed in a conventional fashion. If these
techniques are not feasible, all ports can be
moved further to the left to create enough
room and triangulation to allow the procedure
to be completed laparoscopically.
11.2.4 “Small Gastric” Fundus
A small gastric fundus may occasionally limit
mobility when forming a Nissen fundoplication
without dividing the short gastric vessels. If this is
encountered, the short gastric vessels can be divided
D.I. Watson
74
11
to fully mobilise the fundus, or alternatively a partial fundoplication can be constructed. is situation is encountered in less than 2 % of cases.
11.2.5 Intrathoracic Stomach
Most Western series now report an increasing
proportion of patients presenting with a giant
hiatus hernia, including intrathoracic stomach
[4]. If encountered, the stomach can consistently
be reduced into the abdomen, by rst focusing
on dissection of the sac, rather than the stomach
from the mediastinum. Full reduction of the
hiatal sac progressively delivers the stomach
into the abdomen, and the problem of oesophageal shortening is rarely encountered. When
dissecting the sac, care must be taken to protect
the fascia covering the muscle at the edge of the
hiatal defect. is is achieved by dissecting
5–10mm inside the edge of the hiatal defect. If
dissection is at the muscle edge, bare muscle will
be exposed and the hiatal defect will be larger
and more dicult to close than if the fascial covering is protected.
. Table 11.1 Operative diculty for surgery for
intrathoracic stomach
Grading Case type
I (ideal cases) Thin patient, normal-size liver,
less than 50 % of the stomach
in hernia sac
II (not quite
ideal)
III (problematic) Overweight patient, enlarged
IV (very
problematic)
Thin patient, normal-size liver,
most of the stomach in hernia
sac
fatty liver, most of the
stomach in hernia sac
Or thin patient undergoing
revision surgery with less than
50 % of the stomach in
herniasac
Overweight patient, enlarged
fatty liver, more than 50 % of
the stomach in hernia sac and
undergoing revision surgery
e operative diculty for surgery for intrathoracic stomach can be classied as summarised
in . Table11.1.
11.3 Personal Experiences
Case 1
Situation
An 88-year-old woman underwent
laparoscopic repair of a giant hiatus
hernia with an intrathoracic
stomach. Presurgery symptoms were
consistent with intermittent
episodes of gastric volvulus, and no
reux symptoms were present. The
hernia sac is reduced from the chest,
but the gastroesophageal junction
can only be brought to the level of
the diaphragm, but not below
without tension. A short oesophagus
is thought to be the problem.
Dilemma
(1) Perform a Collis gastroplasty to
get the “gastroesophageal junction”
into the abdomen, or (2) allow the
gastroesophageal junction to be
anchored at the level of the
diaphragm with some tension?
Solution
Do not add a Collis gastroplasty.
Just repair the hernia and anchor
the stomach using a partial
fundoplication.
Outcome
Good clinical outcome and no
symptoms. Radiological follow-up
at 6 months shows a 3-cm sliding
hiatus hernia.
Analysis
This is an elderly patient who
does not have gastroesophageal
reflux. A Collis gastroplasty
adds a risk of leakage from the
staple line used to create the
neo-oesophagus, and if leakage
occurs, the morbidity and
mortality risk in this patient will
be substantial. A small recurrent
hiatus hernia which is fixed by
adhesions at the level of the
diaphragm will be asymptomatic,
and cannot rotate and twist, or
cause any significant problem.
The risk of a symptomatic
recurrent hernia is less than 3%,
probably less than the risk of an
performing a Collis gastroplasty in
an elderly patient.
Surgical Technique andDicult Situations fromDavid I.Watson
Case 2
75
11
Situation
An 82-year-old woman underwent
laparoscopic repair of a very large
hiatus hernia. The hernia sac was
dissected and removed from the
mediastinum, and the hernia was
repaired with posterior sutures
placed between the right and left
hiatal pillars. After placing four
sutures, it became apparent that
the repair was under tension, and
when tightening the fourth suture,
the right hiatal pillar started to split.
Dilemma
How can the hernia be repaired
satisfactorily?
Solution
Options are
1. Reduce the insuation pressure
from 12 to 15mmHg to approxi-
Case 3
Situation
A 52-year-old man underwent
laparoscopic fundoplication for
gastroesophageal reux. After
dissecting the hiatus, a suture was
placed posterior to the oesophagus
to repair the hiatus. The suture was
placed rst through the left hiatal
pillar. Next, as it was placed through
the right hiatal pillar, bright red
bleeding occurred with blood
gradually lling the operative eld.
Dilemma
The aorta lies behind the dissected
oesophageal hiatus, close to the
mately 8mmHg. This reduces
the tension on the diaphragm
and often allows the pillars to
be approximated without significant tension.
2. Supplement the posterior hiatal
repair with additional anterior
sutures, as this area will usually
be under less tension.
3. Reinforce the hiatal repair with
a piece of mesh.
Outcome
Use these three strategies as a
series of escalating steps. If the rst
fails, move to the second option. If
all else fails, reinforce with a piece
of mesh placed across the
posterior hiatal repair.
Analysis
Although randomised trials
suggest a lower risk of barium
junction of the right and left hiatal
pillars, and it is likely that the
suture needle has been placed
through the aorta.
Solution
Carefully withdraw the suture
needle when bleeding of this type
occurs, aspirate the blood and
then use a blunt-ended grasping
instrument to place gentle
pressure over the bleeding site.
Outcome
Bleeding stops and the operation
proceeds satisfactorily
meal-detected recurrent hiatus
hernia at short-term follow-up
following mesh repair of large
hiatus hernia, the only trial
reporting longer-term outcomes
failed to show any longer-term
benefit following mesh repair.
When dissecting the hernia sac,
care should be taken to preserve
the fascial coverings over both
hiatal pillars. If this is achieved,
suture repair can almost always
be completed using steps (1) and
(2). If mesh is used, it is best
placed posterior to the
oesophagus, aiming only to
reinforce the suture repair. Mesh
should not encircle the
oesophagus as this can erode into
the lumen of the oesophagus or
lead to dense scarring and
narrowing of the
gastroesophageal junction.
Analysis
A needle puncture of the aorta
can occur when placing the first
posterior hiatal repair suture. If
the needle is withdrawn, the
bleeding will stop. Care must be
taken to avoid tearing the aorta,
as this will precipitate more
profuse bleeding, with the need
for formal vascular repair. If this
type of bleeding occurs, never tie
the suture knot as doing this will
tear a larger hole in the side of the
aorta.
References
1. Watson DI, Liu JF, Devitt PG, Game PA, Jamieson
GG. Outcome of laparoscopic anterior 180° partial
fundoplication for gastroesophageal reux disease.
JGastrointest Surg. 2000;4:486–92.
2. Jamieson GG, Watson DI, Britten-Jones R, Mitchell PC,
Anvari M. Laparoscopic nissen fundoplication. Ann
Surg. 1994;220:137–45.
3. Baigrie RJ, Watson DI, Game PA, Jamieson GG.Vascular
perils during laparoscopic dissection of the
oesophageal hiatus. Br JSurg. 1997;84:556–7.
4. Wijnhoven BPL, Watson DI.Laparoscopic repair of a
giant hiatus hernia– how i do it. J Gastrointest Surg.
2008;12:1459–64.
77
Single-Access- Laparoscopy
and Foregut- Surgery
fromGiovanni Dapri
GiovanniDapri
12.1 Introduction – 78
12.2 Technique – 78
12.2.1 S-Foregut Surgery: Patient Position,
Umbilical Access, andInstruments – 78
12.2.2 S-Nissen Fundoplication – 80
12.2.3 S-Gastric Resection – 81
12.2.4 S-Gastric Ulcer Repair – 83
12
12.3 Discussion – 84
References – 85
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_12
G. Dapri
78
12
12.1 Introduction
Laparoscopic surgery is considered to be among
the most signicant surgical advances of the
twentieth century. e benets of laparoscopic
surgery over open surgery include fewer adhesions, reduced postoperative pain, a shorter
length of stay, faster return to daily activities,
and improved cosmesis [1, 2]. Recently, the natural orice transluminal endoscopic surgery
(NOTES) further enhanced the cosmetic benets of minimally invasive surgery– while minimizing potential morbidity that is associated
with multiple incisions– by introducing single
(S)-incision, single-port, single-access laparoscopy (SAL). Studies investigating the ecacy of
SAL have demonstrated the safety and feasibility of this technique [3]. However, other potential advantages such as reduced pain and a
reduction in access-invasivity require further
investigation.
One of the challenges during SAL, in which
only a single access is used, is the conict between
the surgeon’s hands and the camera assistant. In
addition, instruments can clash, and their tips
can cross. Moreover, the procedure is more costly,
due to the disposable materials that are used [4,
5]. Other challenges include patient selection for
the procedure in terms of body mass index
(BMI), previous abdominal surgery, the surgeon’s
learning curve, and the exposure of the operative
eld [6, 7].
In this chapter, some of the foregut laparoscopic procedures (e.g., S-Nissen Fundoplication,
S-Gastric Resection, and S-Gastric Ulcer Repair)
performed through SAL are described. e technique that is reported here was developed while
considering the primary role of laparoscopy being
the optical system as the bisector of working
triangulation [8]. erefore, the classic straight
laparoscopic instruments (. Fig.12.1a) have been
curved outside the umbilicus (. Fig. 12.1b),
thereby providing improved working ergonomics,
and inside the access (. Fig.12.1c), thus establish-
ing the classic laparoscopic working triangulation. e technique that is described uses curved
reusable instruments that are inserted transumbilically into the abdomen without the use of a
trocar, together with an 11-mm reusable trocar
for a regular 10-mm optical system, which keeps
the cost of the procedure similar to the multi-trocar laparoscopy, due to the reusable materials that
are employed.
12.2 Technique
12.2.1 S-Foregut Surgery: Patient
Position, Umbilical Access,
andInstruments
e patient is placed in the supine position with the
arms alongside the body and the legs abducted. e
surgeon stands between the patient’s legs, the camera assistant stands at the patient’s right, and the
scrub nurse stands at the patient’s le (. Fig.12.2).
e umbilicus is incised, and the peritoneal cavity is
entered using the Hasson technique. A purse-string
suture using 1 polydiaxone (PDS) is placed in the
umbilical fascia at the 2, 4, 6, 8, 10, and 12 o’clock
positions. A reusable 11-mm trocar and a 10-mm,
30°-angled, rigid, standard-length scope (Karl
Storz Endoskope, Tuttlingen, Germany) are used.
Oncethe pneumoperitoneum is established, curved
ab c
. Fig. 12.1 The concept of the curved instruments is based on the straight classic instruments a of the triangulation
angle, both externally b and inside the abdominal cavity c
VIDEO
MONITOR
SCRUB - NURSE
SURGEON
CAMERA ASSISTANT
Single-Access-Laparoscopy andForegut-Surgery fromGiovanni Dapri
Fundoplication, S-Gastric Resection) are used in
the surgeon’s nondominant hand and are inserted
through the umbilical fascia using a separate opening that is outside of the purse-string suture at the
10 o’clock position. e instruments for the surgeon’s dominant hand include a curved coagulating
hook (
a curved bipolar scissors (. Fig.12.3e), a curved
needle holder I (. Fig. 12.3f, S-Gastric Ulcer
Repair), a curved needle holder II (. Fig. 12.3g,
S-Nissen Fundoplication, S-Gastric Resection),
. Fig. 12.2 The patient and team positionings
and a curved suction device, all of which are intro-
duced alongside the 11-mm trocar inside the
reusable instruments according to DAPRI (Karl
Storz Endoskope, Tuttlingen, Germany) are inserted
transumbilically without trocars. Curved grasping
forceps I (. Fig.12.3a, S-Gastric Ulcer Repair) and
curved grasping forceps III (. Fig.12.3b, S-Nissen
purse-string suture (. Fig.12.4).
Once the 11-mm trocar and the curved instruments have been inserted in the umbilicus, the
purse-string suture is adjusted to maintain a tight
seal around the 5-mm instruments and the
11-mm trocar, and the suture is opened only to
79
. Fig.12.3c), a cur ved scissors (. Fig.12.3d),
12
a
b
c
d
e
f
g
. Fig. 12.3 Curved reusable instruments according to
DAPRI (Courtesy of Karl Storz– Endoskope, Tuttlingen,
Germany): a grasping forceps I, b grasping forceps III, c
coagulating hook, d scissors, e bipolar scissors, f needle
holder I, g needle holder II
G. Dapri
80
Patient head
12
11
purse-string
suture
5
other
curved
instruments
5
grasper
I, III
Optical
system
. Fig. 12.4 Placement of the curved instruments, opti-
cal system, and purse-string suture through the umbilicus
permit the change of tools to the surgeon’s
dominant hand, or for the evacuation of smoke
that is created during the dissection.
12.2.2 S-Nissen Fundoplication
The curved grasping forceps III keeps the
distal curve to retract the left liver lobe and
expose the hiatal region simultaneously to the
dissection of the hepatogastric ligament by
the coagulating hook (
. Fig. 12.5). Both the
phrenogastric ligaments and the diaphragmatic
crura are freed to expose the lower esophagus
(. Fig.12.6). A piece of umbilical tape is inserted
in the abdomen through the 11-mm trocar
using a straight grasper, and is used to encircle
the gastroesophageal junction, thereby increasing the exposure of the hiatus (. Fig. 12.7).
Tension is maintained on the umbilical tape,
thus permitting the complete preparation of
both of the crura for plasty. Stitches using 2/0
silk are introduced in the abdomen through
the 11-mm trocar using a straight grasper.
Cruraplasty is performed using figure of 8
sutures with intracorporeal knots (. Fig.12.8).
The gastric fundus is moved behind the lower
esophagus, and the short gastric vessels are dissected “à la demande” by a medial- to- lateral
. Fig. 12.5 The distal curve of the grasping forceps III
permits the retraction of the left liver lobe simultaneously
to the exposure of the hepatogastric ligament for the
dissection
. Fig. 12.6 Both of the diaphragmatic crura are freed
until to expose the lower esophagus
. Fig. 12.7 The lower esophagus is encircled by a piece
of umbilical tape
Single-Access-Laparoscopy andForegut-Surgery fromGiovanni Dapri
a
81
12
. Fig. 12.8 The cruraplasty is performed easily due to
the opening jaw position of the curved needle holder II
(45° angle with respect to the main shaft)
. Fig. 12.9 The short gastric vessels are freed “à la
demande” after they pass the gastric fundus behind the
lower esophagus (using a medial-to-lateral approach)
approach using a coagulating hook or bipolar
scissors (. Fig.12.9). A 34-Fr orogastric bougie
is inserted transorally by the anesthesiologist.
A floppy 360° fundoplication is performed
using intracorporeal knots (. Fig.12.10a), and
thanks to the curvature of the instruments,
the surgeon can perform the entire procedure
in an ergonomic position with flexed arms
(. Fig.12.10b). At the end of the procedure, the
orogastric bougie, umbilical tape, stitches, and
curved instruments are removed under control.
Absorbable sutures are used to close both the
umbilical fascia and the separate opening that
was used for the grasper. The final scar length
is approximately 15mm (. Fig.12.11).
b
. Fig. 12.10 Because of the curvature of the instruments,
a working triangulation is established inside the abdomen
a, and the surgeon can work ergonomically with exed
arms b
. Fig. 12.11 The nal scar length
12.2.3 S-Gastric Resection
(e resection of benign or borderline lesions such
as gastrointestinal stromal tumor (GIST), carcinoid,
and others can be performed using SAL [9]).
Perioperative gastroscopy is used to locate the
endoluminal gastric lesion (e.g., in the case of a
smaller gastric curvature, 1cm down to the gastroesophageal junction). A stitch using 2-0 Vicryl
G. Dapri
82
a
12
b
. Fig. 12.12 A supercial simple suture is placed in the
center of the lesion under endoscopic control a to retract
the lesion for dissection b
is introduced in the abdomen through the 11-mm
trocar using a straight grasper, and a supercial
simple suture is placed in the center of the lesion
under endoscopic control (. Fig.12.12a) to retract
the lesion for dissection (. Fig.12.12b). Harmonic
shears (Ethicon Endo-surgery, Cincinnati, OH,
US) are introduced together with the other curved
instruments for the surgeon’s dominant hand
(alongside the 11-mm trocar and inside the pursestring suture), and the lesion is full-thickness
resected; a gastroscopic grasper is used to help
delineate the edges of the resection (. Fig.12.13).
e gastrostomy can be closed using a stapler line;
however, to avoid potential stricture, two converting absorbable 2/0 PDS running sutures are
inserted in the abdomen via the 11-mm trocar
and implanted. Because of the curvature of the
instruments, there is no conict between the tips
of the instruments inside the abdomen
(. Fig. 12.14a) or between the surgeon’s hands
outside the abdomen (. Fig. 12.14b). Finally, a
. Fig. 12.13 A gastroscopic grasper is used to delineate
the edges of the resection
a
b
. Fig. 12.14 Because of the curvature of the instru-
ments, no conict exists between the instrument tips
within the abdomen a, or between the surgeon’s hands
outside of the abdomen b
leak-test using the gastroscope is performed to
test the integrity of the suture. A custom-made
plastic bag is introduced through the 11-mm tro-
car using a straight grasper (
. Fig. 12.15a), and
the specimen is retrieved through the umbilicus
(. Fig.12.15b). At the end of the procedure, the
stitches and curved instruments are removed
under control. Both the umbilical fascia and the
separate opening that was used for the grasper are