Добавил:

Sekretar 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:

Книга_1050_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

23 Мб

Скачать

☆

<<< < Предыдущая 7 8 9 10 11 12 13 14 15 16 17 1819 / 5019 20 21 22 23 24 25 26 27 28 29 30 31 > Следующая >>>

■ Aftertyingthesefundoplicationsutures,thesilksuturelineisoversewnwitha 4-0PDSrunningLembertsuturetominimizetheriskofaleakfromthe fundoplicationsutures(FIG13C).

CompletionoftheHiatalHerniaRepair

■ Theesophagealdilatorisremovedanda16-Frnasogastrictubeisplaced.

■ Thefundoplicationisreducedthroughthehiatusandissecuredtothe undersurfaceofthediaphragmwiththreeinterrupted2-0Prolenehorizontal seromuscularmattress“Belsey”sutures,whicharepassedthroughthe diaphragmaroundthecircumferenceofthehiatus(FIG14B,C).Caremustbe takenduringpassageofthemostanteromedialsuturetopreventinadvertent injurytotheheartandpericardialtamponade.

■ Theposteriorcruralsuturesaretieduntilthediaphragmatichiatuspermitsthe passageofanindexfingeralongsidethedistalesophagus(FIG15A,B).The Belseysuturesarethentied,andthecompletedfundoplicationshouldrest belowthediaphragmwithouttension(FIG15C).

■ Hemoclipsareusedtomarkthehiatusforlocalizationonimaging.

ThoracotomyClosure

■ Ifaparaspinouscatheterwillbeusedforpaincontrol,apleuralflapisraised posteriorly.Aparaspinouscatheterisplacedpercutaneouslyundertheflap andsecuredtotheskinwith2-0nylonsuture.Thepleuralflapis reapproximatedtothechestwallwith4-0Vicryl,allowinglocalanestheticto beinfuseddirectlytotheaffectedintercostalnerves.

■ A28-Frchesttubeisinsertedthroughalowintercostalincision,advancedtothe apex,securedtotheskin,andconnectedtounderwatersealdrainage.Theribs arereapproximatedwithinterruptedno.2Vicrylsuturesplacedaroundthe

6thribandthroughholesdrilledinthe7thribusingamicrodrilltoavoid nerveentrapmentagainstthelowerrib.

■ Thewoundisthenclosedinlayersreapproximatingtheserratusandlatissimus muscleswithrunning2-0Vicryl,thesubcutaneoustissueswith2-0Vicryl, andtheskinwitharunning4-0Monocrylsubcuticularsuture.

PEARLSANDPITFALLS

Preoperative evaluation

■Discussandmodifyriskfactorsforrecurrenthernia

preoperatively,especiallyweightlosswithagoal bodymassindex(BMI)<32.

■Atransthoracicapproachwithanesophageal

lengtheningprocedure,similartoarelaxingincision foraninguinalherniarepair,maybeoptimaleven forsmallslidinghiatalherniasinmorbidlyobese patientsduetotheincreasedriskofrecurrence.

Positioning ■Duetothepositionoftheliver,thehiatuscannotbe

adequatelyapproachedthroughtherightchest.All transthoracichiatalherniarepairsshouldbe approachedthroughaleftthoracotomyevenwhen theherniaisintherightchest.

Incisions ■Forsmallerhernias,thehiatalherniarepairmaybe

easiertoperformthroughthe7thintercostalspace, butthelowertheinterspaceincision,thegreaterthe degreeofpostthoracotomypainbecausemorechest wallsensorynervesaredivided.

Intraoperative ■Usingastockinette,acloth-coveredHarrington

retractorisusedtoretractthediaphragmdownward toimproveexposureofthehiatus,andaspoon retractorisusefultoprotecttheintraabdominal contentswhenplacingthecruralsutures.

■Theanteriorattachmentsofthehighlessercurvature

maycontaintheascendingbranchoftheleftgastric arteryandshouldbeligatedanddivided.

■Acounterincisionparalleltoand1to2cmfromthe

hiatuscanbemadeinthediaphragmifadditional exposureisneededduringaredohiatalhernia repair.

■Itisessentialtocommunicatewiththeperson

passingthebougietoensurethatthesurgeon’shand ispalpatingandguidingthebougieasitisbeing passedtopreventperforation.

■CareshouldbetakenduringformationoftheCollis

gastroplastynottoapplythestaplereithertoo tightlyagainstthebougie,narrowingthe gastroplastytubeor,soloosely,creatingapouch thatemptiespoorly.

■Wedonotrecommendtheroutineuseofmeshdue

totheriskofesophagealerosion.Atransthoracic approachallowsadequatebitestobetakenofthe crura,whicharethentiedwithoutunduetension.

■Hemoclipmarkersareplacedatthenew

gastroesophagealjunctionandthediaphragmatic hiatusforlocalizationonimaging.Thedistance betweenthetwolevelsofclipsrepresentsthe intraabdominallengthofthedistal“neoesophagus.”

Closure ■Theribsarereapproximatedwithinterruptedno.2

Vicrylsuturesplacedaroundthe6thribandthrough holesdrilledinthe7thribusingamicrodrillto avoidnerveentrapmentagainstthelowerrib.

■Achestx-rayisobtainedintheORattheendofthe

casetoconfirmreexpansionofthelungsandto evaluateforarightpneumothoraxoreffusion, whichmayrequirechesttubeplacementiftheright pleurawasentered.

POSTOPERATIVECARE

■ Thenasogastrictubeisplacedtolowcontinuoussuction.Onpostoperativeday 2,thenasogastrictubeisplacedtogravityandremovedonpostoperativeday 3iftoleratedandtheoutputremainslessthan200mLpershift.Thepatientis thenstartedonclearliquidswithnopills.Onpostoperativeday4,thedietis advancedtofullliquidsandthenasoftdiet.

■ Thechesttubeisplacedto20cmofwatersuction.Chesttubesmayberemoved onpostoperativeday2oncethedrainagehasdecreasedtolessthan60mLper shift.

■ Patientsshouldbegivenanadequatepaincontrolregimenandencouragedto ambulateandusetheincentivespirometer.

■ Onpostoperativeday5,abariumswallowisobtainedtoassessthatcontrast flowsfreelythroughtheesophagusandintothestomachandduodenumand thatthefundoplicationisintactbelowthediaphragm.Patientsareseenbya dieticianforeducationonapost–Nissenfundoplicationdiet.Theyare dischargedonasoftdietfor2to3weeksandremindedtoavoidlargepills andcarbonatedbeverages.

■ Mostpatientsaredischargedhomebetweenpostoperativedays5and7.At discharge,theimportanceofavoidingriskfactorsassociatedwithhernia recurrence,includingheavylifting,constipation,orchroniccoughing,is emphasized.

■ Milddysphagiaoccursinlessthan10%ofpatientsandusuallyimprovesover4 to6weeksasthepostoperativeedemasubsides.

OUTCOMES

■

Transthoracichiatalherniarepairremainsthestandardagainstwhichother approachesarecompared.Pateletal.4described240patientsundergoing repairofaparaesophagealhernia(92%typeIIIand8%typeIV)withan antirefluxprocedureinallpatientsandaCollisgastroplastyin96%.Five patients(2.1%)requiredanemergentrepair.Therewerethreeperioperative deaths(1.7%),andthemedianlengthofstaywas7days.4Earlycomplications includedrecurrenthernia(fourpatients),leak(threepatients),excessive narrowingofthehiatus(threepatients),andbleeding(onepatient).Eighty-six percentofpatientsweresatisfiedatlastfollow-up,withameanfollow-upof 42months.Ananatomicrecurrencewasfoundin23patients(10%),withfour requiringearlyrepairandfourrequiringlatereoperation.

■ Allenetal.9reportedtransthoracichiatalherniarepairsin147patientswith81 patients(68.1%)undergoingaCollis-Nissen,19(16.0%)aBelsey-MarkIV, 17aNissen(14.3%),and2aHarringtonrepair(1.7%).Therewereno operativedeaths,andcomplicationsoccurredin32patients(26.9%).Witha medianfollow-upof42months,resultswereexcellentin69patients(60%), goodin38patients(33%),fairin6patients(5.2%),andpoorin2patients (1.7%).Offivepatientswhounderwentemergentrepair,threehadgastric necrosisandonedied.

■ Maziaketal.5described94patientswithmassive,incarceratedparaesophageal hernias.Organoaxialvolvuluswaspresentin50%ofpatients.Agastroplasty wasperformedin75patients(80%)becauseofashortenedesophagus.There weretwooperativedeaths.Themeanfollow-upwas94months,with72 patients(80%)freeofsymptomsand13patients(13%)having inconsequentialsymptoms.Threepatients(4%)requiredmedicaltherapyor esophagealdilationsandtwopatientshadrecurrentherniasorseverereflux successfullytreatedwithareoperation.

■ Rogersetal.20reportedaseriesof60patientswithaparaesophagealhernia. Thirteenpatientsunderwentemergentrepair.Atransthoracichiatalhernia repairwasperformedinallpatientswithanantirefluxprocedureadded selectively.Therewasonedeathafteranemergentrepairandonerecurrence

(1.5%).Sevenpatients(12%)requiredasingleesophagealdilationandtwo patients(3%)developedsymptomaticreflux.

COMPLICATIONS

■ Bleeding

■ Splenectomy

■ Pericardialtamponade

■ Rightpneumothoraxorpleuraleffusion

■ Damagetothevagusnervesresultingingastricoutletobstructionordumping syndrome

■ Gastricleak

■ Persistentdysphagiarequiringdilations

■ Recurrenthernia

REFERENCES

1.StirlingMC,OrringerMB.Surgicaltreatmentafterthefailedantirefluxoperation.JThorac

CardiovascSurg.1986;92(4):667–672.

2.OrringerMB,SloanH.CombinedCollis-Nissenreconstructionoftheesophagogastricjunction.

AnnThoracSurg.1978;25(1):16–21.

3.SkinnerDB,BelseyRH.Surgicalmanagementofesophagealrefluxandhiatushernia.Long-term

resultswith1,030patients.JThoracCardiovascSurg.1967;53(1):33–54.

4.PatelHJ,TanBB,YeeJ,etal.A25-yearexperiencewithopenprimarytransthoracicrepairof

paraesophagealhiatalhernia.JThoracCardiovascSurg.2004;127(3):843–849.

5.MaziakDE,ToddTR,PearsonFG.Massivehiatushernia:evaluationandsurgicalmanagement.

JThoracCardiovascSurg.1998;115(1):53–60;discussion61–62.

6.WilliamsonWA,EllisFHJr,StreitzJMJr,etal.Paraesophagealhiatalhernia:isanantireflux

procedurenecessary?AnnThoracSurg.1993;53(3):447–451;discussion451–452.

7.GehaAS,MassadMG,SnowNJ,etal.A32-yearexperiencein100patientswithgiant paraesophagealhernia:thecaseforabdominalapproachandselectiveantirefluxrepair.Surgery. 2000;128(4):623–630.

8.AltorkiNK,YankelevitzD,SkinnerDB.Massivehiatalhernias:theanatomicbasisofrepair.J ThoracCardiovascSurg.1998;115(4):828–835.

9.AllenMS,TrastekVF,DeschampsC,etal.Intrathoracicstomach.Presentationandresultsof operation.JThoracCardiovascSurg.1993;105(2):253–258;discussion258–259.

10.SchauerPR,IkramuddinS,McLaughlinRH,etal.Comparisonoflaparoscopicversusopen

repairofparaesophagealhernia.AmJSurg.1998;176(6):659–665.

11.HorganS,EubanksTR,JacobsenG,etal.Repairofparaesophagealhernias.AmJSurg.

1999;177(5):354–358.

12.DahlbergPS,DeschampsC,MillerDL,etal.Laparoscopicrepairoflargeparaesophagealhiatal

hernia.AnnThoracSurg.2001;72(4):1125–1129.

13.SwanstromLL,JobeBA,KinzieLR,etal.Esophagealmotilityandoutcomesfollowing

laparoscopicparaesophagealherniarepairandfundoplication.AmJSurg.1999;177(5):359–363.

14.HashemiM,PetersJH,DeMeesterTR,etal.LaparoscopicrepairoflargetypeIIIhiatalhernia:

objectivefollowuprevealshighrecurrencerate.JAmCollSurg.2000;190(5):553–560.

15.WiechmannRJ,FergusonMK,NaunheimKS,etal.Laparoscopicmanagementofgiant

paraesophagealherniation.AnnThoracSurg.2001;71(4):1080–1086.

16.HunterJG,SmithCD,BranumGD,etal.Laparoscopicfundoplicationfailures:patternsof

failureandresponsetofundoplicationrevision.AnnSurg.1999;230(4):595–604;discussion604–606.

17.YauP,WatsonDI,JamiesonGG,etal.Theinfluenceofesophageallengthonoutcomesafter

laparoscopicfundoplication.JAmCollSurg.2000;191(4):360–365.

18.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.

19.LuketichJD,RajaS,FernandoHC,etal.Laparoscopicrepairofgiantparaesophagealhernia:

100consecutivecases.AnnSurg.2000;232(4):608–618.

20.RogersML,DuffyJP,BeggsFD,etal.Surgicaltreatmentofpara-oesophagealhiatalhernia.

AnnRCollSurgEngl.2001;83(6):394–398.

Chapter5

LaparoscopicNissen Fundoplication



ElizabethA.WarnerBrantK.Oelschlager

DEFINITION

■ Gastroesophagealrefluxdisease(GERD),asdefinedbytheMontrealConsensus Groupin2006,iscausedbygastricreflux,causingtroublesomesymptoms and/orcomplicationstothepatientthatadverselyaffecttheirwell-being.

Symptomscanincludeheartburn,acidbrash,regurgitation,dysphagia, noncardiacchestpain,andpulmonarysymptomssuchascoughand hoarseness.Complicationsincludeesophagitis,Barrett’sesophagus, esophagealstricture,andaspirationpneumonia.

■ GERDresultsfromincompetencyordysfunctionoftheloweresophageal sphincter(LES).ImportantfactorsforadequateLESfunctioninclude esophagealcontraction,gastriccardiaslingfibers,diaphragmaticcrus,and intraabdominalpositionoftheLEScomplex.Hiatalherniaseffacethenatural valveanatomy,allowingtheGEjunctiontobedisplacedintothechest, exposingtheLEStonegativeintrathoracicpressureandincreased gastroesophagealreflux.Acertainamountofgastroesophagealrefluxis physiologicandnotpathologic.However,oncesymptomsbecome troublesometothepatient,adiagnosisofGERDcanbemade.

■ GERDcanalsobeduetoinadequateesophagealmotilityresultinginpoor clearanceofphysiologicreflux.Similarly,delayedgastricemptyingcanlead

<<< < Предыдущая 7 8 9 10 11 12 13 14 15 16 17 1819 / 5019 20 21 22 23 24 25 26 27 28 29 30 31 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202624 Мб0Книга_1045_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1047_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1048_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1049_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202642 Мб0Книга_105_библиотеки_им_акад_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1050_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1052_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1053_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1054_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_1057_Библиотеки_им_академика_М_И_Перельмана.pdf