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

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☆
PEHs(typesIItoIV)shouldgenerallyberepairedifsymptomatic.Inyounger (<60yearsofage)andhealthierpatients,repairofevenrelatively asymptomaticherniasisindicatedgiventheriskofincarceration,although thisriskissmallerthanoncethought.
■ Meshhiatalherniarepairsgenerallyneedtobeconsideredonlyinpatients withPEHs(largerhernias).
■ Manypatientswithhiatalherniasareelderly,andtheymayhaveserious comorbiditiesorfrailty.Inthesepatients,athoroughmedicalevaluation shouldbecompletedpriortoanyelectiveherniarepair.
■ Someofthemmaybetoofrailorhighriskforafullhiatalherniarepairwith fundoplicationbutareverysymptomaticandneedintervention.Inthese patients,itmaybemoreprudenttoplanforashorterprocedurewithoutfull dissectionoftheherniasac;herniareductionwithgastrostomytube gastropexymaybemoreappropriateinthesepatients.
Positioning
■ Asforotherforegutprocedures,patientsshouldbeinlowlithotomywitha beanbagsupportandbotharmstucked(FIG2).
■ ThepatientwillbeinsteepreverseTrendelenburgformostofthecase.
■ Thesurgeoncanoperatefromthefootofthetable,withtheassistantonthe patient’sleft.
TECHNIQUES
SETUPANDPORTPLACEMENT
■ Aftersterileprep,theupperabdomenisdraped.Equipmentforlaparoscopyis passedoffandsecured.
■
TheperitonealcavityisaccessedusingaVeressneedle,andpneumoperitoneum isobtained.
■ An11-mmcuttingopticaltrocarisinsertedintheleftsubcostalposition.
■ Additionalportsareplacedunderdirectvisionasfollows(FIG3):
■ Cameraport(11mm)inepigastricposition;a5-mmportcanalsobeplaced heredependingonsurgeonpreferenceforscopesize.
■ Assistant(5mm)portinleftlateralposition
■ Surgeon’slefthandport(5mm)inrightupperquadrant
■ ANathansonliverretractoristhenplacedintheuppermidlineforretractionof theleftlobe.
REDUCTION
■ Thestomachandanyotherherniacontentsarereducedintotheabdominalcavity aspossible;withaPEH,thestomachwillalmostneverfullyreduceandthe surgeonshouldnotattempttodoso.Justreducethestomachthatisfreeand notattachedwithinthemediastinum.
MOBILIZATION
■ Theshortgastricvesselsareligatedwithanelectricalorultrasonicsealing deviceinordertomobilizethefundusfully.Beginligationneartheinferior borderofthespleen(seeFIG3).
■ Caremustbetakentoalsodivideanyattachmentsorvesselsbetweenthefundus andtheretroperitoneumasadhesionsarecommon.
DISSECTIONOFHIATUSANDHERNIASAC
■ Thephrenoesophagealmembraneandherniasacaredividedatthemuscular edgeofthecrus.
■ Oncethecrusisvisualized,thesurgeoncanbeassuredthatalllayersofthesac havebeendivided.Inthisway,thesurgeonbeginstodevelopaplaneoutside oftheherniasacandnotwithinit.
■ Theattachmentofthesactothehiatusisdivideduntilitisfreed circumferentially.Afterthisiscomplete,thesacisreleasedfromthe mediastinum,withcaretoavoidthepleura(FIGS4and5).Thisisfacilitated withtheuseofgentletractionandthediffusionofcarbondioxide(CO2)from
thepneumoperitoneum.
■ Theappropriateplaneshouldappearareolarandlargelyavascular.
ESOPHAGEALMOBILIZATION
■ APenrosedrainisthenplacedaroundthedistalesophagusandusedtoplace downwardandalternatinglateraltractionontheesophagusasitis circumferentiallymobilizedinthemediastinum.
■ Careistakentoligateorcauterizesmallvesselsinthemediastinumasneeded.
■ MobilizationiscontinueduntiltheGEjunctionliesintheabdomenwithout
tension,preferablywith3cmofesophagusintheabdomen.
■ InthesettingofalargehiatalorPEH,theesophagusisalwaysrelatively foreshortened.Ifaggressivemobilizationofthemediastinalesophagusis performed,inourexperience,adequateesophageallengthcanbeobtained.If not,thenanesophageallengtheningprocedurewillbeneeded(seeChapter2).
■ Alightedbougieisthenplacedintotheesophagusandstomachbytheanesthesia team.Carefulcommunicationbetweentheanesthesiaandsurgicalteamsis requiredtoavoidcomplicationsduringplacementofthebougie.The anesthetistshouldbeabletoseeoneofthelaparoscopymonitors.Ifthereis anyquestionastothelocationoftheesophagusearlierintheprocedure,the lightedbougiecanbehelpfulinlocatingit.
■ Theherniasacisthenamputatedandremoved.Theanteriorvagusnerveshould beidentifiedandpreservedhereaslongasadequateesophagealmobilization hasbeenobtained.Thisisdonebyonlyremovingtheanteriorsactotheleft ofthevagusnerve.
■ Adequateremovaloftheherniasacfacilitatesthefundoplicationlater.
■ Ifesophagealmobilizationhasbeeninadequate,thevaguscanbeligatedhere,
1
oraCollisorwedgegastroplastycanbeperformed.
2
CRURALCLOSURE
■ Thecruraarereapproximatedusingpermanentsuture(FIG6).
■ Mostoftheclosureshouldbeposterior,asthemuscleismorerobustthere.
■ Occasionally,adequateclosurecannotbeachievedwithonlyposteriorsuturing duetothesizeofthedefect;inthiscase,arelaxingincisionoranterior suturesmayberequired.
■ Arelaxingincisioncanbemadeontherightsideoftherightcrustoreleasethe rightcrustowardtheleftandallowforhiatalclosure.
MESHPLACEMENT
■ Abiologicmeshisthencuttocoverthedefect,usuallyinaUorCshape.
■ Thisisintroducedthroughan11-mmportandplacedflatagainstthehiatus.
■ Permanentsuturesarethenusedtosecurethesuperioraspectsofthemeshtothe crusoneitherside(FIG7).
■ Themeshcanbecompletelysecuredwithsuture,ortheremainingfixationcan beperformedwithfibringlue.
■ Ifarelaxingincisionwasnecessary,itshouldalsobecoveredbythemesh.
FUNDOPLICATION
■ Fullfundoplicationshouldbeperformedaslongasthepatient’sesophageal motilityallows,totreatrefluxandtopreventreherniation.Fundoplication techniqueisdescribedinanotherchapter(FIG8).
■ Intraoperativeendoscopyshouldbeperformedattheconclusionofthecaseto confirmwrappositioningandlocationoftheGEjunctionintheabdomen.
PEARLSANDPITFALLS
Indications ■Onlysymptomatic(GERDassociated)sliding
herniasshouldberepaired.
■AllPEHs(typesIItoIV)canbeconsideredfor
repairgiventherisksofvolvulusandobstruction.
Patientselection ■Inelderlyorinfirmpatients,considergastropexyas
analternativetoPEHrepair.
■Inmorbidlyobesepatients,considerlaparoscopic
sleevegastrectomyorgastricbypassasan alternativeoperation.
3
Dissection ■Fulldissectionaroundthesacmustbe
accomplished.Dividethesacoffofthecrusand thenmaintainanareolarplaneinthemediastinum
Esophageal mobilization
■Mustbecarriedsuperiorlyintothemediastinumto
ensureadequateintraabdominalesophageallength (3cm).
Meshplacement ■Afterprimaryrepairofalargehiataldefect,mesh
reinforcementmaybeused.Biologicmeshhas fewerpotentialcomplications4butmayhavea higherrecurrencerate.
5
POSTOPERATIVECARE
■ Thepatientgenerallyhasanovernightstayinthehospital.
■ Patientsshouldbegivenanincentivespirometer,havechemicaldeepvein
thrombosis(DVT)prophylaxis,andpromptFoleycatheterremoval.
■ Patientscanbegivenclearliquidsonthenightofsurgeryandthedietcanbe advancedthefollowingday.Theyshouldbedischargedonapureeddietand shouldprogresstosoftdietoverthenextmonth.Pillsshouldbecrushedor convertedtoelixirsfor1month.
■ Patientsshouldanticipateatleast2moreweeksofrecoveryathome,depending ontheirageandcomorbidities.
■ Activityislargelyunrestricted,butheavyliftingorotherValsalvamaneuvers shouldbeavoidedtokeeptheintraabdominalpressuredownandavoidearly herniarecurrence.
OUTCOMES
■ ArecentrandomizedcontrolledtrialoflaparoscopicPEHrepairwithand withoutbiologicmeshdemonstratedalowerrecurrencerateat6monthswith biologicmesh.
5
■ Thisdifferenceinoutcomesdidnotpersistwhenpatientswerereexaminedwith upperGIseriesatamedianfollow-uptimeof5years.
6
■ Atthattime,therecurrenceratewasfoundtobethesamebetweenthetwo groups;therewasa50%radiographicrecurrencerate.
■ Mostoftheserecurrencesweresmallanddidnotcorrelatewithpatient symptomsexceptamildlyincreasedrateofheartburn.
7
■ Despitethehighrateofradiographicrecurrence,allsymptomswereimprovedat long-termfollow-up.
■ Only3%ofpatientsinthistrialultimatelyrequiredreoperationforhernia
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