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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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■ Thefirststapledtrajectoryisusuallyperformedwithoneortwofiringsofa rotatingandarticulatingendoscopicstaplerwithmedium-sizedloads(3to4 mm)usinga45-mmlengthEndoGIApurpleload(Covidien,Mansfield, MA).Withtheendoscopicstaplerarticulatedtothemaximumdegreeinthe surgeon’srighthand,a90-degreestaplingisperformeduptothebodyofthe dilatorontheleftsideofthepatientjustdistaltothepointpredeterminedand markedwithelectrocautery(FIG7A–C).
SECONDSTAPLETRAJECTORY
■ Thesecondstapledtrajectoryisparalleltothedilatorandcephalad(FIG8A,B Again,oneortwomedium-sizedstapleloadsmightbeneeded.Becarefulto notincludethePenrosedraininthestapleline;itmaybeplacedintothe mediastinumtemporarilyduringthesecondsetofstaplefirings.Theproper Collisgastroplastyjuxtaposestheresultantparallelstaplelineabuttingthe esophagus(FIG8C).
REMOVALOFTHESTOMACHWEDGE
■ Removethewedgeofstomachthroughanymeans,whetherdirectlythroughthe trocar,viaanendoscopicbag,orbyremovingtheentiretrocar.This concludestheCollisgastroplastyportionoftheprocedure.
COMPLETIONOFTHEFUNDOPLICATION
■ Performtheintendedcompleteorpartialwrapasdescribedinotherchapters, alongwithcruralclosure.Whetheracomplete(Nissen;360degrees)or partial(Toupet;270degrees)fundoplicationisperformed(FIG9),thestapled wedgeCollisgastroplastyshouldeventuallyorientthestaplelineposteriorly asassessedonEGD.
PEARLSANDPITFALLS
Inadequatefirststaple firing
■Itissometimesdisconcertingtostapleontoan
endoluminalforeignbody(dilator),butitis virtuallyimpossibletostapleacrossa48-Frdilator. Failuretostapleuptoandabuttingthedilatorwill resultinafloppydistalesophagusanddecreasethe efficacyofthefundoplication.
Useofshortstaple loadsforfirststaple firing
■Theregionoftheesophagealhiatusistightquarters.
Thearticulatingstaplerof45mmispreferredover alongerstaplerbecauseofthesteepangulation neededinthesetightspaces.Multiplefiringsmay beneeded.
Mismeasureof intraabdominallength
■Keytothemeasurementoftrueintraabdominal
lengthisthenaturallayoftheesophagusinthe steepreverseTrendelenburgposition.Donotinsert adilator,nasogastric,ororogastrictubeduringthis step.Remembertoclosethecruramanuallyand assessthelayoftheesophagusbeforemeasuring thislength.
Inadequate mediastinaldissection
■Inadequatemediastinaldissectionresultsin
incompleteabdominallengthoftheesophagus. Hence,theuseofaCollisgastroplasty,and thereforeriskofstaplelineleak,canbeavoided withintraoperativediligence.
Pneumothorax ■Prep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anesthesiologist canassistwithmanualbaggingValsalva maneuvers.Ifthisstepisrefractory,placethetipof theredrubbercatheterintrathoracicallyandpullthe endthroughatrocarportintoabowlofsterile saline,desufflatetheabdomen,andagain,askthe anesthesiologisttoassistwithValsalva.
Leftlateralwedge ■Uponfulldissection,thewedgeremovedshouldlie
ontheleftlateralaspectalongtheGEJ,thatis,the angleofHis,inaplaneparalleltotheoperating table.
POSTOPERATIVECARE
■ Nasogastrictubedecompressionisnotroutine.Evenifinjuryorperforation occurstothestomachduringdissection,aslongasthetissueisrepaired properlyandaresultantnegativeintraoperativeleaktest(methyleneblue infusionthroughtheintraoperativeorogastrictubeorEGDairinsufflationin pooledintracorporealsalineinTrendelenburgposition)occurs,nasogastric
decompressionisnotanecessity.
■ Withextensivemediastinaldissectionandstapledgastroplasty,theriskof (missed)perforationandleakshouldbeassessed.Strictnilperos(NPO) statusovernight,followedbyapostoperativeday(POD)1water-soluble contrastesophagramisperformedtoassessleakaswellasfunctional clearanceofcontrastmaterial.Ifnegative,thepatientisadvancedtoaclear liquiddietonPOD1anddischargedoneithertheeveofPOD1oronPOD2 withafullliquidorpureeddiet.
■ Acidsuppressiontherapyiswarrantedasthegastroplastyinvolvedgastric mucosaintheregionofthenewlyreconstructedGEJ.
OUTCOMES
■ TheuseoftheCollisgastroplastyisusuallyrelegatedtotheforeshortened esophagusduringantirefluxsurgery,withetiologyincludinglargetypeIII paraesophagealherniasandacid-relatedstrictures.Thisprocedurehas historicallyevolved,especiallywiththeadventoflaparoscopy.Theoutcomes oftheprocedurearedifficulttoquantifyintermsofefficacybecausethe procedureisoftencombinedwithfundoplication(partialandcomplete)and/or hiatalherniarepair(typesItoIV).Ingeneral,inexperiencedhands,therate ofrecurrenceofhernia,postoperativeleakrate,andstricturearelow
8,9
and canbequantifiedaslowas0%in4-yearfollow-uptolowdouble-digit percentagesinlongerstudies.
COMPLICATIONS
■ Recurrenthiatalhernia
■ “Slipped”Nissen
■
Postoperativestaplelineleak
■ Leakfromextensivemediastinaldissection
■ Esophagealstricture
REFERENCES
1.CollisJL.Anoperationforhiatusherniawithshortoesophagus.Thorax.1957;12(3):181–188.
2.TerryML,VernonA,HunterJG.Stapled-wedgeCollisgastroplastyfortheshortenedesophagus.
AmJSurg.2004;188(2):195–199.
3.JohnsonAB,OddsdottirM,HunterJG.LaparoscopicCollisgastroplastyandNissen fundoplication.Anewtechniqueforthemanagementofesophagealforeshortening.SurgEndosc. 1998;12(8):1055–1060.
4.SwanstromLL,MarcusDR,GallowayGQ.LaparoscopicCollisgastroplastyisthetreatmentof choicefortheshortenedesophagus.AmJSurg.1996;171(5):477–481.
5.O’RourkeRW,KhajancheeYS,UrbachDR,etal.Extendedtransmediastinaldissection:an alternativetogastroplastyforshortesophagus.ArchSurg.2003;138(7):735–740.
6.HorvathKD,SwanstromLL,JobeBA.Theshortesophagus:pathophysiology,incidence, presentation,andtreatmentintheeraoflaparoscopicantirefluxsurgery.AnnSurg.2000;232(5):630–
640.
7.LimpertPA,NaunheimKS.Partialversuscompletefundoplication:isthereacorrectanswer? SurgClinNorthAm.2005;85(3):399–410.
8.DurandL,DeAntónR,CaracocheM,etal.Shortesophagus:selectionofpatientsforsurgery andlong-termresults.SurgEndosc.2012;26(3):704–713.
9.NasonKS,LuketichJD,AwaisO,etal.Qualityoflifeaftercollisgastroplastyforshort esophagusinpatientswithparaesophagealhernia.AnnThoracSurg.2011;92(5):1854–1860; discussion1860–1861.
Chapter3
LaparoscopicMeshHiatal HerniaRepair
EllenH.MorrowBrantK.Oelschlager
DEFINITION
■ Ahiatalherniaisanenlargeddiaphragmatichiatus,allowingforpassageofthe stomachorotherorgansintothechest.
■ Hiatalherniaistraditionallydividedintoseveraltypes;theprincipledifferenceis slidingversusparaesophageal.Theslidingtypeismuchmorecommon.This istypeI.
■ ParaesophagealistypeII.Thisinvolvesherniationofthestomachabovethe gastroesophageal(GE)junction,whichremainsintheabdomen.
■ TypeIIIisacombinationoftypesIandII,withtheGEjunctioninthechest,but withstomachherniatingaboveit.Thisisalsoreferredtoasaparaesophageal hernia(PEH)andismuchmorecommonthanatypeII.
■ AtypeIVPEHinvolvesherniationofadditionalorgansotherthanstomachsuch asthetransversecolon.
DIFFERENTIALDIAGNOSIS
■
Thetypeofhiatalherniashouldbediscernedasdescribedunderdefinitionand differentiatedfromothernonhiataldiaphragmatichernias.
■ Thisisadiagnosisthatisoftenmadewithimagingpriortosurgicalreferral.If imaginghasnotyetbeenperformed,thereareotherentitiesthatcouldhave similarclinicalpresentation.
■ Theseincludegastroesophagealrefluxdisease(GERD),gastritis,pepticulcer disease,chronicmesentericischemia,angina,myocardialinfarction,oraortic dissection.
PATIENTHISTORYANDPHYSICALFINDINGS
■ LiketypeIhernias,thesepatientsmaypresentwithGERDsymptoms(e.g., heartburn,regurgitation,symptomsrelatedtoaspiration,etc.);however,at leasthalfofpatientswillnotcomplainofsignificantGERD.Patientswill oftenpresentwithahistoryofpostprandialabdominalorchestpain,early satiety,dysphagia,andregurgitation.Symptomsarefrequentlyrelatedtothe volumeoffoodtheyhaveconsumed.Theymayhaveassociatedweightloss.
■ PEHscanalsopresentwithrespiratorysymptomssuchasdyspneaorcough. Anemiaisacommonpresentingsymptomofalargehiatalherniaandisoften theonlyfindinginagastrointestinal(GI)workup.
■ Rarely,PEHscanpresentwithacuteobstruction.
■
Thisisoftencausedbygastricvolvulus.
■ Thiswillpresentwithincreasedseverityofsymptoms;completeintolerance tooralintake;severepain;andoccasionally,evensystemicinflammatory responseorsepsisifthestomachbecomesischemic.
■ Therearenotgenerallyphysicalfindingsspecifictothiscondition.
■ ThepatientcanbeexaminedforchangesassociatedwithGERDinthe oropharynx.
■ Abdominalexammayrevealsomeepigastrictenderness.
■ Theremaybesignsofweightlossoroverallfrailty.
■ Theremaybediminishedbreathsounds.
IMAGINGANDOTHERDIAGNOSTICSTUDIES
■ TheworkupforhiatalherniaissimilartotheGERDworkup.
■ Anesophagramisoftenthemostvaluablestudy;thisprovidesimagesofthe herniainadynamicfashionusingfluoroscopy(FIG1).Thisisthebeststudy forgettinganoverallsizeandpositionofthestomachwithinthehernia.
■
Herniasarefrequentlydiagnosedoncomputedtomography(CT)forabdominal pain,althoughthisisnottheinitialtesttoobtainifyouaremostsuspiciousof hiatalhernia.Itwill,however,usuallymakethediagnosisandcanruleinor outotherthings.
■ Upperendoscopycanbehelpfulforvisualizingthesizeoftheherniaandmore forexaminingthemucosaforassociatedconditions.
■ Cameron’serosionsarelinearerosionsthatcanbefoundinthestomach relatedtoconstrictionbythediaphragm.
■ ChangesrelatedtoassociatedGERDcanalsobeseenintheesophagussuch aserosiveesophagitisandBarrett’sesophagus.
■ Anyneoplasticlesionshouldberuledoutpriortooperativerepair.
■ Manometryisvaluableinplanningtheantirefluxprocedurethatwillbe performedinconjunctionwithrepairofthehernia.Normalmotilitywillallow forcreationofafullwrap,asopposedtopartial.
■ pHtestingisnotgenerallyrequired,unlessthepatientispresentingprimarily withGERDsymptoms.Inthiscase,itmaybeusefulasabaseline.
SURGICALMANAGEMENT
PreoperativePlanning
■ Indicationsforrepairofhiatalhernias:
■ Slidinghiatalhernias(typeI)shouldnotberepairedunlesstheindicationis associatedGERD,inwhichcase,theyshouldberepairedatthetimeof plannedfundoplication.
■
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