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Ростовский Государственный Медицинский Университет

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■ Thegastrohepaticligamentisdivided,beginningthedissectionabovethe caudatelobeoftheliver,wheretheligamentisthinner,andcontinuingtoward thediaphragmuntiltherightpillarofthecrusisidentifiedandseparatedfrom theesophagusbybluntdissection.

■ Subsequently,theperitoneumandthephrenoesophagealmembraneoverlyingthe esophagusaredividedandtheanteriorvagusnerveisidentified(FIG5A).

■ Theleftpillarofthecrusisthenseparatedfromtheesophagus(FIG5B).

■ Bluntdissectionisfinallyperformedintheposteriormediastinum,laterallyand anteriorlytotheesophagusinordertohaveabout4to5cmofesophagus withoutanytensionbelowthediaphragm.Posteriordissectionisnecessary onlyifapartialposteriorfundoplicationisplanned.

DIVISIONOFTHESHORTGASTRICVESSELS

■ Theshortgastricvesselsaretakendownallthewaytotheleftpillarofthecrus, startingfromapointmidwayalongthegreatercurvatureofthestomach(FIG

6).

MYOTOMY

■ Thefatpadshouldberemovedtoexposethegastroesophagealjunctionafter identificationoftheanteriorvagusnerve.

■ TractionisthenappliedwithaBabcockclamp,graspingbelowthe gastroesophagealjunctionandpullingdownwardandtotheleftinorderto exposetherightsideoftheesophagus.

■ Amyotomyisperformedontherightsideoftheesophagusinthe11o’clock positionusingahookcautery.Thepropersubmucosalplaneisfoundusing thecautery,about3cmabovethegastroesophagealjunction.

■ Oncethemucosaisexposed,themyotomyisextendedproximallyforabout6 cmabovethegastroesophagealjunctionanddistallyfor2.5to3cmontothe gastricwall(FIG7).

■ Theedgesofthemusclesarethenseparatedwithadissectorinordertohave 30%to40%ofthemucosanotcoveredbymuscles.

■ Intraoperativeendoscopyisrarelynecessary,particularlywhenenough experienceispresentandalongmyotomyontothegastricwallisperformed.

PARTIALFUNDOPLICATION

■ Themaingoalofthesurgicaltreatmentisreliefofdysphagiawhilepreventing GER.

■ AlaparoscopicHellermyotomy(LHM)aloneisassociatedwithpostoperative GERinabout50%to60%ofpatients.

■ Betterfunctionalresultsareachievedwithapartialfundoplicationaddedtothe myotomycomparedtoatotalfundoplicationthatisassociatedwithhigher ratesofpostoperativedysphagia.

■ Regardingthetypeofpartialfundoplication,nosignificantdifferencesare evidentintermsofcontrolofGERafterthepartialanteriorandpartial posteriorfundoplication.

■ Wepreferthepartialanteriorfundoplicationbecauseitissimplertoperform,as posteriordissectionisnotnecessary,andbecauseitcoverstheexposed esophagealmucosa.

PartialAnteriorFundoplication(Dor)

■ TheDorfundoplicationisa180-degreeanteriorfundoplication.

■ Tworowsofsutures(2-0silk)areused.Thefirstrowisontheleftsideofthe esophagusandhasthreestitches.Thetopstitchincorporatesthefundusofthe stomach,themuscularlayeroftheleftsideoftheesophagus,andtheleft pillarofthecrus(FIG8).

■ Thesecondandthirdstitchesincorporatethegastricfundusandthemuscular layeroftheleftsideoftheesophagus(FIG9).

■ Thefundusisthenfoldedovertheexposedmucosasothatthegreatercurvature ofthestomachisnexttotherightpillarofthecrus.

■ Thesecondrowofsuturesontherightsideoftheesophagusconsistsofthree stitchesbetweenthefundusandtherightpillarofthecrus(FIG10).

■ Finally,twoadditionalstitchesareplacedbetweenthefundusandtherimofthe esophagealhiatustoeliminateanytensionfromthefundoplication(FIG11).

PARTIALPOSTERIORFUNDOPLICATION

■ Someauthorsarguethattheposteriorpartialfundoplicationshouldbeusedasit mightbemoreeffectiveinpreventingGERandbecauseitkeepsthedistal edgesofthemyotomyseparated.

■ Theposteriorfundoplicationrequiresthecreationofaposteriorwindowbetween theleftpillarofthecrus,thestomach,andtheesophagusfollowedbythe passageofthegastricfundusundertheesophagus.

■ Thehiatusislooselyclosedposteriortotheesophagus.

■ Subsequently,eachsideofthewrapisattachedtotheesophagealwalllateralto themyotomywiththreestitches.Theresultingwrapmeasuresabout220to 240degrees.

PEARLSANDPITFALLS

Indications ■Acarefulevaluationincludingmanometry,24-hour

pHmonitoring,upperendoscopy,andbarium swallowmustbedone.

Placementofports ■Extremecaremustbetakenwhenpositioningport1,

becausethesiteofinsertionisjustabovetheaorta.

■Werecommendusinganopticaltrocarwitha0-

degreescopetoobtainaccess.

■Ifport3istoolow,theleftlateralsegmentofthe

liverwillnotbeproperlyretractedandexposureof theesophagogastricjunctionmaybeinadequate.

■Ifport2istoolow,theesophagogastricjunctionor

theuppershortgastricvesselsmaybedifficultto access.

■Ifports4and5aretoolow,thedissectionatthe

beginningoftheprocedureandthesuturingatthe endwillbechallenging.

■Ifport3istoomedial,theliverretractormay

interferewiththeinstrumentusedthroughport4.

Dissection ■Anaccessorylefthepaticarteryoriginatingfromthe

leftgastricarteryisfrequentlypresentinthe gastrohepaticligament.Ifthisvessellimitsthe exposure,itmaybesafelydivided.

■Theelectrocauteryshouldbeusedwithextreme

caution.Becauseofthelateralspreadofthe monopolarcurrent,vagusnervesmaybedamaged evenwithoutdirectcontact.Abipolarinstrument representsasaferalternative.

Shortgastricvessels division

■Bleeding,eitherfromtheshortgastricvesselsor

fromthespleen,anddamagetothegastricwallare possiblecomplications.

■Excessivetractionanddivisionofavesselnot

completelycoagulatedarethemaincausesof bleeding.

■Aburncausedduringdissectionoftheshortgastric

vesselsortractionappliedwiththegraspersorthe Babcockclamparethemostcommonmechanisms ofdamagetothegastricwall.

Myotomy ■Inpatientswhohavehadprevioustreatmentwith

botulinumtoxininjection,themyotomyis technicallymorechallengingduetothefibrosisthat altersthenormalanatomicplanesandmayincrease theriskofperforation.

■Ifamucosalperforationoccurs,itcanberepaired

with5-0absorbablematerial.

■Incaseofbleedingfromthecutmuscularfibers,

gentlecompressionwithaspongeisrecommended ratherthantheelectrocautery,whichcancause thermaldamagetotheesophagealwall.

Partialanterior fundoplication

■Toreducetheriskofpostoperativedysphagiadueto

thefundoplication

■Theshortgastricvesselsshouldbedivided.

■Thewrapshouldbeperformedusingthefundus

ratherthanthebodyofthestomach.

POSTOPERATIVECARE

■ Patientsspendanaverageof1to2daysinthehospitalandreturntoworkin2to 3weeks.

■ Patientsarefedthemorningofthefirstpostoperativedaywithclearliquidsand thenasoftdiet.

■ Theyareinstructedtoavoidmeat,bread,andcarbonatedbeveragesforthe following2weeks.

■ Mostpatientsresumetheirregularactivitywithin2to3weeks.

OUTCOMES

■

Long-termfollow-upshowsthatsymptomsareimprovedin90%to95%of patientsat5yearsandin80%to90%at10years.

■ MostLHMfailurespresentwithinthefirst2to3yearsoffollow-upandmay reflectfibrosisofthedistaledgeofthemyotomythatcanbesuccessfully treatedinmostcaseswithpneumaticdilatation.

■ PostoperativeGERoccursinabout30%to40%ofpatients,anditisusually controlledbyacid-reducingmedications.

COMPLICATIONS

■ Esophagealleakmayoccurduringthefirst24to36hourspostoperatively,andit isusuallytheresultofathermalinjuryoftheesophagealmucosa.

■ Typicalsignsandsymptomsincludepain,fever,anddyspnea.Achestx-ray mayshowapleuraleffusion.

■ Anesophagogramconfirmsthelocationandtheextensionoftheleak.

■ Treatmentoptionsvarybasedonthetimeofdiagnosisandonthelocationand extensionoftheleak.Incaseofearlydiagnosis,smallleakscanberepaired directly.Ifthedamageistooextensiveortheinflammatoryreactionincase oflatediagnosisdoesnotallowadirectrepair,anesophagectomymaybe indicated.Inselectedcases,widedrainageandplacementofafeeding jejunostomytubewithorwithouttheuseofanesophagealstentmayallow theleaktohealwithoutesophagectomy.

■ Pneumothoraxoccursincaseofintraoperativeviolationoftheparietalpleura. Usually,itresolvesspontaneouslyanddoesnotrequiretubethoracostomyas theCO2israpidlyabsorbed.

■ Persistentdysphagiaisusuallyduetotechnicalerrors,suchasatooshortofa

myotomyoratooconstrictingfundoplication.

■ Recurrentdysphagiaafterasymptom-freeperiodmaybecausedbyscartissuein thedistaledgeofthemyotomy,postoperativeGER,technicalerrorscited earlier,oresophagealcancer.Ineithercase,athoroughevaluationis mandatorytoruleoutmalignanciesandmakeacorrectdiagnosis.Subsequent treatmentistailoredtotheresultsofthisworkupandincludespneumatic dilatationand/orareoperation.

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