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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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POSTERIORGASTRICATTACHMENTS

■ Tocompletethecirculardissection,thesurgeon’slefthandandassistantsplay thestomachtotheanteromedialdirectionandomentumtotheleft.This revealsattachmentsposteriorlyfromthesplenicvesselstotheleft gastroepiploicvessels.Thesecanbetakenalsowithultrasonicdissection. Afterreductionoftheposteriorsac(FIG11),thiscompletesthe360-degree mobilization(FIG12).APenrosedraincanencircletheGEJforatraumatic retraction.

HERNIASACEXCISION

■ Ifproperlyperformed,theherniasaccanberemovedenblocbyevidenceofthe mediastinalcomponentoftheherniasacbeingcontiguouswiththatofthe anterioresophagusandfatpad(FIG13A,B),whichmayalsoneedexcisionin ordertoproperlyperformtheantirefluxportionoftheoperation.

■ Iftheherniasacislargeandwillobstructmediastinaldissection,excisionofthe saciswarranted.Startontheleftcruswithtractionontheherniasacanduse combinationsofbluntdissectionwhenneartheesophagealbodyand ultrasonicdissectiontoremovetheherniasacwhenatasaferdistance.

Manipulationoftissuestoofarawayfromtheesophagusmaycompromisethe pleuralcavityandmanipulationtooclosetotheesophagusmayincurthermal injury,oftenunrecognizedattimeofoperation.FIG14demonstratesaclose, butsafe,distanceofdissectiontotheesophagus.

FUNDOPLICATIONTAKEDOWN

■ Ifthereexistsapreviousfundoplicationandpreoperativetestingdemonstrates incompetenceoftheantirefluxprocedure,thewrapismandatedtobetaken downandredone.

■ Extremecareshouldbeimplementedasthisisthestepthatcarriesthemostrisk ofenterotomyeitheratthestomachorattheesophagus.Oncecompletely dissected,inspectionandreinspectionofthetakendownwrapshouldtake place.Often,thegastriclumenmayresembletheshinyplanesbetweenthe fundusandesophagealbody.

MEDIASTINALDISSECTION

■

Adequatemediastinaldissectionforesophageallengthisencounteredwhenthe endothoracicfascia/pleuraisplacedlaterally,andthemediastinalesophagus isvisualizedina360-degreefashionuptothelevelofthecarinaorright atrium(FIG15).

ASSESSMENTOFINTRAABDOMINAL ESOPHAGEALLENGTH

■ Theleftcrusisnowpulledfromlefttoright,andwithoutanybougieor orogastrictubeinplace,theintraabdominalesophageallengthcanbeassessed inarelaxedposition.Ifthelengthisshorterthan2.5to3cm,performaCollis gastroplasty(seeChapter2).

CRURALCLOSURE

■ Overa42-Frbougie,thehiatusissuturedwiththeappropriatenumberofcoated, braidednonabsorbablesuture(0Ti-Cron,Covidien,Mansfield,MA).Spacing ofsuturesisapproximately1cmapartfromeachotherandisplaced1cm backfromthecruraledges(FIG16A,B).

■ Pledgetsareusedonthesutureswiththeexceptionofthelastsuturesneededto avoidpledgetingrowthintotheesophagus.

■ Thequantityofsuturesusuallynumberstwotofour,untilthereisagapleft betweentheesophagusandcruratoeasilyinterposelaparoscopicgraspers betweentheclosure.

■ Iftheesophagealhiatusisgigantic,thenanterior,inadditiontoposterior,crural closurecanbesafelyperformedtopreventsevereangulationoftheesophagus atthenewlyreconstructedhiatus.

MESHPLACEMENT

■ Ifmeshistobeused,twomainstrategiesexist,andbothmaybeaffixedbyTiCronsuture(see“PearlsandPitfalls”):

■

Keyhole(three-sided)meshcanbesuturedorgluedtothediaphragm(FIG

17A).

■

Rectangularmeshissecuredalongthediaphragmposteriorly(FIG17B).

ANTIREFLUXPROCEDURE

■ Theprinciplesoffundoplicationapplyhere,whetheracomplete(Nissen)(FIG

18A,B)orpartial(Toupet)wrapisindicated.Thiscompletesthegoalof

reconstructingtheangleofHisandvalvularmechanismoftheLES.Referto thecorrespondingchaptersaccordingly.

LEAKTEST

■ Twoleaktestscanbeperformed.

■ Methyleneblue:Withdilutemethylenebluedrippedliberallyintoa nasogastrictubewiththetipabovetheGEJ,intracorporealplacementof tworadiopaquewhitespongescandetectsubtleleaks.Inspecttheremoved spongesagainstawhitebackgroundandback-tablelight.Anypositivetest ismandatedtobeinvestigatedthoroughlywiththetearorenterotomy repaired.

■ Bubbleleaktest(alternativetomethyleneblue):Withtheplacementofan endoscopeandTrendelenburgpositioning,irrigatesterilesaline intracorporeallyanddistendthestomachandloweresophaguswith insufflation.Anybubblesemanatingmandatesinvestigation.

UPPERENDOSCOPY

■ Thelastportionoftheprocedureentailsdirectvisualizationwithanupper endoscopetoseethepositionoftheZline,GEJ,andintegrityofthewrap. Withretroflexion,theendoscopeshouldmovebackandforthfreelywithout bucklingofthemucosaofthenewlyreconstructedLES.

PEARLSANDPITFALLS

Enterotomy ■ItiswellestablishedthatthePEHrepaircarriesup

toa20%riskofenterotomyalongtheesophagusor stomach,especiallyinredooperations.Ifan enterotomyisnoticed,forexample,during dissectionofaslippedNissenfundoplication,a linearstaplefiringiswarrantedacrossthe

enterotomy.

Deepherniasac dissection

■Thereisafinelinebetweenremovingtheherniasac

andperforatingorcausingthermalinjurytothe esophagusand/orvagalnerves.Withproper superficialdissectionattheoutsetofhiatal dissectionallowsthesurgeontostayabovethe esophagusandallowstheherniasactobeexcised enbloc.

Pneumothorax ■Prepareintothefieldthebilaterallowerchest

cavitiesthatwouldaccesseachhemithoraxincasea percutaneoustubethoracostomyisneeded.Ourfirst recommendation,however,ifpeakventilatory pressuresarehighfromapneumothorax,isto decompresstheaffectedsidewiththeplacementof aredrubbercatheterthroughaworking12-mmport andlayitfromthehemithoraxinquestionwiththe oppositeendintraabdominally.Thelowerchestwall shouldbepreppedintothefieldincasechesttube placementisneeded.However,whena pneumothoraxisidentified,a14Frenchredrubber cathetercanbeplacedthroughtheholewiththetip inthechestandthebuttintheabdomen.Atthe completionoftheprocedurethebuttispulledouta trocarsiteandisplacedinatubofwater(water seal)whiletheanesthesiologistreinflatesthelung withpositivepressureventilations.Whenthe bubblingstopsthetubeispulledoutthetrocarsite. Achestxrayintherecoveryroomconfirmsreexpansionofthelung.

Inadequateantireflux procedure

■Ifredofundoplicationisbeingperformed,itis

imperativetoobtainpreoperativemanometrytotest theintegrityofa“slipped”Nissenversusasimple herniation.Ifmanometryindicatesrefluxabovethe wrap,thepreviousfundoplicationshouldbe

completelydissectedandredone.

Shortgastricvessel ligation

■Donotassumeduringaredooperationthatthe

previoussurgeonhasperformedadequateshort gastricdissection.Thistethersthefundoplication, thereforeplacingimproperphysiologicvectorson thewrap.Dissectcompletelytheshortgastric vesselstoavoidtethering.

Intraabdominal esophageallength

■Inadequatemediastinaldissectionresultsin

incompleteabdominallengthoftheesophagus. Completeandhigh360-degreemediastinal dissectionallowsthetruedeterminationifan esophageallengtheningprocedure(Collis)is requiredwhenperformingtheantirefluxportionof theoperation.

Meshuseandmaterial ■Severalstudieshaveinvestigatedthecontroversyto

useornottousemesh,butnostandardizationin practiceexistsduetothemanytypesofmesh materialavailable,shapesintowhichitisfashioned, andlengthofstudyinvestigated.

10–13

Theefficacy ofmeshtoreinforcetheclosedcruratapersover time,althoughthedegreeofthisdegenerationisa movingtargetintheliterature.Thematerialchoice iswidelysubjecttodebatewithlongertermstudies showingnoeffectonrecurrencewithsmallintestine submucosa(Surgisis,CookMedical,Bloomington, IN),whileshortertermstudieswithhumanacellular dermalmatrix(AlloDerm,LifeCellCorporation, Bridgewater,NJ).Studiesongoingcurrentlyinvolve bioabsorbablewovensuture(BIO-A,W.L.Gore& Associates,Inc,Flagstaff,AZ)andporcineacellular dermalmatrix(AlloDerm,LifeCellCorporation, Bridgewater,NJ).Wecurrentlyespousetheuseofa rectangular,lightweight,polypropylene,synthetic

meshwithfourfixationpointsalongthecrura (Parietex,Covidien,Inc,Mansfield,MA).

Mesherosion ■Toavoidmesherosion,donotplaceacircularpiece

ofmesharoundtheclosedcrura.KeyholeorUshapedmeshisacceptablewiththeopenendfacing anteriorly.Also,arectangularmeshcanbeused insteadoftheUshapewithplacementfromleftto rightalongtheclosedcrura.Carewithsuture fixationtonotplacethemeshincontactwiththe esophaguscanalleviatemeshingrowthand perforationofthatorgan.

POSTOPERATIVECARE

■ Therearetwomainstrataofpostoperativecaregiventopatientswhoundergo PEHrepair:withsignificantadhesiolysisandwithoutsignificantadhesiolysis.

■ Withoutsignificantadhesiolysis:Forthoseundergoingtheirfirstrepair,the dissectioncanbeassimpleasan“easy”typeIorslidinghiatalhernia. Therefore,ifadhesiolysisissimpleandstraightforward,weelecttogivethe patientssipsofclearliquidsimmediatelypostoperativelyandadvancetofull liquidsbypostoperativeday(POD)1,withdischargefor4weeksonaproton pumpinhibitor.Wedonotadvocateforsamedaydischarge.Home medicationsshouldbeinliquidorcrushableform,andpatientsareprescribed antinausea,analgesia,andbowelregimenmedications.Dietconsistsoffull liquidsfor2weeksthensoftmechanicalforanother2weeks.

■ Withsignificantadhesiolysis:Redoantirefluxdiseaseandtechnically challengingPEHrepairsareusuallythemainstayofsuchoperations.Therisk ofperforation,missedornoticedatthetimeofsurgery,isincreased,and therefore,thesepatientsfollowadifferentpostoperativepathway.Theyare keptnihilperos(NPO)overnightandstudiedwithaformalesophagramin

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