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

■ Theserratusanteriormusclecanbespared,althoughdividingthemusclecan providemoreanteriorexposurewhenneededandresultsinlittle,ifany, functionalimpairment.

■ Aftercarefullycountingtheribstoconfirmtheintercostalspace,thechestis entered.Ifaparaspinouscatheterwillbeusedforpostoperativepaincontrol, aposteriorpleuralflapcanberaisedatthistimetopreventtearingthepleura. ChestretractorssuchasaFinochiettoorRienhoffareusedtoprovide exposure.

■ Thedomeofthediaphragmisretracteddownwardtoimproveexposureusing cloth-coveredHarringtonretractors.Theinferiorpulmonaryligamentis divided,andthemediastinalpleuraisopened(FIG7A).

■ Theherniasacisdissectedfromtherightpleura,takingcarenottoenterthe rightchest.

■ Fourtosixshortgastricvesselsarethendividedbetweenclampsandligated with2-0silksutures(FIG9).Caremustbetakentoavoidexcesstensionon thestomachtopreventsplenicinjury.Theshortgastricvesselsmustbe carefullytied.Oncethevesselsretractunderneaththediaphragm,bleeding maybedifficulttorecognizeandcouldrequirealaparotomyforcontrol.

■ Theherniasacisresectedwithelectrocautery,takingcarenottodamagethe bloodsupplytotheproximallessercurvatureofthestomach.The gastroesophagealfatpadisexcisedtoexposethegastroesophagealjunction, takingcaretoprotecttheanteriorandposteriorvagusnerves(FIG10).

■ Esophagealshorteningisoftenpresentwithlargehiatalhernias,increasingthe riskofarecurrenthernia,andisbestassessedintraoperatively.

■ Withupwardtractiononthefundus,whichismobilizedbackthroughthehiatus andintothechest,thedilatorisdisplacedagainstthelessercurvatureofthe stomach.Anangledductusclampisusedtohelpapplythe3.5-mm gastrointestinalanastomosis(GIA)surgicalstaplertothestomachadjacentto thedilatorandparalleltothelessercurvature,lengtheningtheesophageal tubebyapproximately5cm(FIG12B).Careshouldbetakennottoapplythe staplereithertootightlyagainstthebougie,narrowingthegastroplastytube or,soloosely,creatingapouchthatemptiespoorly.

■ Theelongatedgastricfundusispassedposteriorlytotheleftofthegastroplasty tubeandpositionedfortheNissenfundoplication.A2-to3-cmlong fundoplicationisconstructedusinginterrupted2-0silksuturesplaced1cm apart,witheachstitchpassingfromthegastricfundustothegastroplastytube andthentogastricfundusagain(FIG13A,B).