Файловый архив студентов. Файловый архив студентов.
1327 вузов, 5482 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

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

.pdf
Скачиваний:
0
Добавлен:
31.08.2026
Размер:
23 Мб
Скачать
☆
recurrences.
COMPLICATIONS
■ Aswithanymajorabdominalsurgery,complicationscanincludebleeding, infection(eitheratthesurgicalsiteorelsewhere),orthromboembolicevents.
■ ComplicationsthatareparticulartoPEHrepaircanincludepostoperative respiratorycompromise.
■ Changingpulmonaryphysiologyafterreductionoftheherniatedstomach, generalanesthesia,andpostoperativeabdominalpaincanleadtoincreased dyspneaandoxygenrequirementduringtheimmediatepostoperative period.
■ Thisgenerallystabilizesenoughfordischargewithin1to2daysorthepatient canbedischargedonashortcourseofhomeoxygen.
■ Pneumothoraxcanoccurintraoperativelyduringmediastinaldissection.The pleurashouldberepairedtopreventfurtherinsufflationofthepleuralcavity withCO2.Oncethepleuraisclosedandtheabdomenisdesufflated,theCO
2
isreabsorbedquicklyanddecompressionisnotgenerallyrequired.
■ Followingfundoplication,therecanbesomedysphagiaduringtheearly postoperativeperiod.Thiscangenerallybemanagedwithdietary modification.Bloatingcanalsobeacomplaintearlyon.
■ Herniarecurrenceisapotentialcomplication.Recurrencewascoveredinthe “Outcomes”section.
REFERENCES
1.OelschlagerBK,YamamotoK,WoltmanT,etal.Vagotomyduringhiatalherniarepair:abenign
esophageallengtheningprocedure.JGastrointestSurg.2008;12:1155–1162.
2.LuketichJD,GrondinSC,PearsonFG.Minimallyinvasiveapproachestoacquiredshorteningof theesophagus:laparoscopicCollis-Nissengastroplasty.SeminThoracCardiovascSurg.2000;12(3): 173–178.
3.Cuenca-AbenteF,ParraJD,OelschlagerBK.Laparoscopicsleevegastrectomy:analternativefor recurrentparaesophagealherniasinobesepatients.JSLS.2006;10:86–89.
4.TatumRP,ShalhubS,OelschlagerBK.ComplicationsofPTFEmeshatthediaphragmatichiatus. JGastrointestSurg.2008;12:953–957.
5.OelschlagerBK,PellegriniCA,HunterJG,etal.Biologicprosthesisreducesrecurrenceafter laparoscopicparaesophagealherniarepair:amulticenter,prospective,randomizedtrial.AnnSurg. 2006;244(4):481–490.
6.OelschlagerBK,PellegriniCA,HunterJG,etal.Biologicprosthesistopreventrecurrenceafter laparopscopicparaesophagealherniarepair:long-termfollow-upfromamulticenter,prospective, randomizedtrial.JAmCollSurg.2011;213:461–468.
7.OelschlagerBK,PetersenRP,BruntLM,etal.Laparoscopicparaesophagealherniarepair: defininglong-termclinicalandanatomicoutcomes.JGastrointestSurg.2012;16:453–459.
Chapter4
TransthoracicHiatalHernia Repair
JulesLinMarkOrringer
DEFINITION
■ ThecombinedCollis-Nissentransthoracichiatalherniarepairdescribedinthis chapterinvolvesmobilizationofthedistalesophagus,herniatedstomachand herniasac,preservationofthevagusnerves,andafundoplicationthrougha leftposterolateralthoracotomywithanesophageallengtheningprocedure whennecessary(toallowa3-to5-cmtension-freeintraabdominalsegmentof distal“esophagus”).
■ Thetwomajorcategoriesofhiatalherniasincludesliding(typeI)and paraesophageal(typeII,pureparaesophagealherniawiththe gastroesophagealjunctionfixedatthehiatus;typeIII,combinedhiatalhernia wherethecardiaisabovethediaphragmandthefundusisherniatedalongside theesophagus;andtypeIV,withherniationofthestomachalongwiththe colon,smallbowel,orspleen)(FIG1).
1–3
PATIENTHISTORYANDPHYSICALFINDINGS
■ Adetailedhistoryandphysicalmustbeperformedfocusingonheartburnand refluxsymptoms,responsetomedicaltreatmentaswellasthecharacteristics anddegreeofdysphagia,regurgitation,pain,bloating,oranemia.Inaseries of240patientswithaparaesophagealhernia,Pateletal.4foundthat68%of patientshadrefluxsymptoms,67%abdominalorchestpain,33%anemia,and 33%dysphagia.Theabsenceofsevererefluxsymptomsinmostpatientswith paraesophagealhiatalherniasdoesnotdiminishtheseriousnessofthis problemwithitsunpredictablepotentialforstrangulation,perforation, bleeding,andaspirationpneumonia.Moresubtlesymptomsmayincludeearly satietyand/orleftshoulderandbackpainwitheating,loudborborygmioften heardacrosstheroombythepatient’sfamily,oracuteshortnessofbreath
withbendingforward.
■ Anypreviouschestorabdominaloperationsorendoscopicdilationsshouldbe noted.
■ Thehistoryshouldincludethepatient’scurrentfunctionalstatusandexercise tolerance.
■ Acompletephysicalexaminationshouldbeperformedwithattentionto auscultationoftheheartandlungsandpalpationoftheabdomen.
■ Routinelaboratorystudies,includingacompletebloodcountandabasic chemistrypanel,shouldbeincludedaspartofthepreoperativeevaluation.
IMAGINGANDOTHERDIAGNOSTICSTUDIES
■ Achestx-ray(FIG2)mayshowamediastinalairfluidlevel,suggestingthe presenceofaparaesophagealhernia.
■
Abariumswallow(FIG3)shouldbeperformedtodelineatetheesophagealand gastricanatomyandmayshowreflux,althoughthisisnotareliablefinding. Accompanyingesophagealdysmotilityfromthe“accordioned”esophagusis common.Theesophagramcanalsobeusefulwhenobstructionfromgastric volvulusissuspected(FIG4).
■ Anesophagoscopy(FIG5)shouldbeperformedtoevaluateforevidenceof
esophagitis,Barrett’smucosa,esophagealcarcinoma,oresophageal shortening.Suspiciousareasshouldbebiopsied.Thegastricmucosashould alsobeexaminedforCameronerosions,especiallywhenthereisahistoryof anemia.Cautionshouldbeexercisedtoavoidexcessiveairinsufflationduring flexibleesophagogastroscopyinthepatientwithaparaesophagealhiatal hernialesttheintrathoracicstomachbecomesoverdistended,resultingin hemodynamicinstability.
■ Forpatientscomplainingofpersistentnausea,agastricemptyingstudymaybe obtainedtoevaluateforgastroparesis.
■ Whenthereisnohiatalherniaorasmallslidinghiatalhernia,esophageal manometryand24-hourpHprobemonitoringwithimpedanceareperformed, withantirefluxmedicationsdiscontinuedfor72hours,todocumentthe presenceofgastroesophagealreflux,associationwiththepatient’ssymptoms, andtoevaluateforesophagealdysmotility.However,inthepresenceofa paraesophagealhernia,wedonotroutinelyperformthesestudies.Manyof thesepatientswillhavesomedegreeofdysmotilityinthepresenceofa chronichiatalherniathatfrequentlyimprovesafterhiatalherniarepair.The presenceofasymptomatichiatalherniaisamechanicalissue,andthe indicationforrepairistheparaesophagealherniaitselfregardlessofthe presenceofacidreflux.
■ Patientssuspectedofhavinganincarceratedhiatalhernia(FIG4)withsevere epigastricpainandregurgitationshouldundergoanesophagramand nasogastrictubedecompressionfollowedbyanemergenthiatalherniarepair.
SURGICALMANAGEMENT
Indications
■ Slidinghiatalherniasarerepairedwhentherehasbeenincompletecontrolof refluxsymptomsdespitemedicaltherapy(Table1)andafterconfirmationof abnormalacidrefluxon24-hourpHprobe.Otherindicationsinclude complicationsofgastroesophagealrefluxdisease(GERD)—recurrent aspiration,thedevelopmentofarefluxstricture,andrecurrentbleedingfrom esophagitis.
■ Paraesophagealherniasaremorelikelytopresentwithobstructivesymptoms duetothechronicgastricvolvulusandrepairisgenerallyrecommendedinthe functionalpatient.
3
■ Therehasbeencontroversyregardingtheoptimalsurgicalapproach (laparoscopicvs.transthoracic),theneedforanantirefluxprocedure,andthe assessmentofesophagealshortening.
1,5–19
Thepneumoperitoneumused duringlaparoscopicrepairdisplacesthediaphragmupward,making intraoperativeassessmentofesophagealshorteningmorechallenging.In addition,performingalengtheningprocedurelaparoscopicallyismore difficultduetotheangleoftheapproach.Takingadequatebitesofthe attenuatedcruraisalsomoredifficultduetothetensioninducedbythe
pneumoperitoneum,whichcouldcontributetoherniarecurrenceafter laparoscopicrepair.Atransthoracicapproachwithanesophageallengthening procedure,similartoarelaxingincisionforaninguinalherniarepair,maybe optimalevenforasmallslidinghiatalherniainmorbidlyobesepatientsdue totheincreasedriskofrecurrence.Inaseriesof240patientswith paraesophagealhiatalhernias,documentedacidrefluxdecreasedfrom88% preoperativelyto4%afteratransthoracicCollis-Nissenprocedure,whereas
Williamsonetal.6reportedan18%incidenceofpostoperativerefluxaftera selectiveapproachtoaddinganantirefluxprocedure.Asaresult,weadvocate
anantirefluxprocedurewithallparaesophagealhiatalherniarepairs.
4,6
■ Withlargerparaesophagealhernias,transthoracicCollis-Nissenrepairremains thestandardagainstwhichotherapproachesmustbecompared.
4
PreoperativePlanning
■ Preoperativeriskassessmentdetermineswhetherapatientwilltoleratea thoracotomybasedonexercisetoleranceandpulmonaryfunctiontesting (PFT)ifthereisasubstantialsmokinghistoryorshortnessofbreath.Patients withcardiovascularriskfactorsorsymptomsshouldundergopreoperative cardiacevaluation.
■ Patientsshouldbeinformedofchangesintheirdietafterundergoinga fundoplication,includingavoidinglargepillsandcarbonateddrinksandthe possibilityofgasbloatanddumpingsyndrome.
■ Inthepreoperativearea,thehistoryandphysicalshouldbereviewedand consentshouldbeobtained.Theoperativesiteontheleftchestshouldbe appropriatelymarked.
■ Forpaincontrol,anepiduralcathetercanbeplacedinthepreoperativearea,ora paraspinouscathetercanbeinsertedpriortothoracotomyclosure.
■ Onceintheoperatingroom(OR),aflexibleesophagoscopyshouldbeperformed
toevaluatetheanatomyandanyesophagealmucosallesions.Overdistention ofthestomachwithairinsufflationmustbeavoided.Afterthescopeis removed,a16-Frnasogastrictubeisplacedtodecompressthestomach.
■ Single-lungventilationisachievedwitheitheraleft-sideddoublelumen endotrachealtubeorabronchialblocker.
Positioning
■ Thepatientshouldbeplacedintherightlateraldecubitusposition(FIG6).The armsshouldbeplacedinanarmholderinneutralposition.Thebedisflexed andthepatientshouldbesecuredwithallpressurepointspadded.
■ Followingpositioning,theendotrachealtubepositionshouldbeconfirmedagain bytheanesthesiologist.
TECHNIQUES
THORACOTOMY
■ Astandardposterolateralthoracotomyisgenerallyperformedthroughthe6th intercostalspace,althoughthe7thintercostalspacecanbeusedwithsmaller
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности