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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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IdentificationandDivisionofthePosterior(Right)VagusNerve

■ Theright(posterior)vagusisfoundatthe7o’clockpositionandisoftenuptoa centimeterawayfromtheesophagealwallbetweentheesophagusandthe rightcrus(FIG5).

■ Inabout15%ofcases,itmaybelocatedtotheleftofmidline.

■ Toidentifytheposteriorvagustrunk(s),thesurgeonshouldagainapply downwardtractiononthePenrosewhilesweepingtheindexfingerofthe righthandposteriortotheesophagusfromtheleftcrustotheright.

■ Thesurgeon’sfingershouldberightontheesophagealwallandanytense bandsidentifiedshouldbehookedwitharightangleanddissectedfree fromtheesophagealwall(FIG6).

■ Aclipshouldbeplacedatthelevelofthediaphragmandasecondclipisplaced onthenerve3to4cmdistal.Thesegmentofnerve(s)betweentheclipsis excisedandsentforpathologytoverifynervoustissue.

■ Continuewithgastricdrainageprocedureasindicated:pyloroplasty, gastrojejunostomy,orgastricresectionwithreconstruction(seeChapter17).

AssessmentofHemostasisandClosure

■ Afterverifyingthatnoadditionalvagaltrunkscanbeidentified,thesurgeon shouldinspectthediaphragmatichiatus.DuringbluntmobilizationoftheGE junction,ahiatalherniaissometimescreated.

■ Ifthesurgeoncaninsertmorethantheonefingeradjacenttotheesophagus throughthehiatus,therightandleftcrurashouldbereapproximatedwith oneortwo0braidedpolyesterorsilksuturestopreventthedevelopment ofapostoperativehiatalhernia.

■ Atthecompletionoftherepair,asinglefingershouldbeabletobeinserted alongsidetheesophagustoavoidpostoperativedysphagia.

■ Afterhemostasisisverified,themidlineisclosedinusualstandardfashion.

LAPAROSCOPICTRUNCALVAGOTOMY

PortPlacementandLiverRetraction

■ Portplacement(FIG7)

■ 5-mmperiumbilicalcameraport2cmtotheleftofmidline

■ 5-mmsubxyphoidtrocarforliverretraction

■ 5-mmrightmidclavicularline,twofingerbreadthsbelowcostalmargin:left handworkingport

■ 5-mmtrocarbetweentherightmidclavicularlineandcameratrocar

■ 5-mmleftanterioraxillaryline,belowcostalmargin:stomachretraction

■ ANathansonliverretractorisplacedtoelevatetheleftlobeoftheliver.

■ Thepatientispositionedsupinewiththerightarmtucked.

■ Thesurgeonsstandstothepatient’srightandtheassistanttothepatient’sleft.

ExposureoftheEsophagus

■ Theperitoneumoftheparsflaccidaandthephrenoesophagealligamentis incisedwithaHarmonicscalpelorbipolarcauterydevicetoexposetheright crusofthediaphragmontotheanteriorsurfaceoftheesophagusandacrossto theleftcrustoexposetheentiresurfaceoftheesophagus.

■ Thepositionoftheesophaguscanbeverifiedbypalpationofthenasogastric tubewithinthelumenoftheesophagusorbyperforminganintraoperative EGD.

■ Theperitoneumoverlyingthemedialedgeoftherightcrusofthediaphragmis identifiedandincised,andthen,bluntdissectionisusedtoelevatethe esophagusoffoftherightandleftcrustomakearetroesophagealwindow.

■ AgrasperisthenpassedthoughthewindowandaPenrosedrainisusedto encircletheesophagus.

IdentificationandDivisionoftheAnterior(Left)VagusNerve

■

Withthemagnificationinherentinlaparoscopy,theanteriorvaguscanoftenbe visualizeddirectlyontheanteriorsurfaceoftheesophagus(FIG3).

■ Ifthenervecannotbeeasilyvisualized,downwardtractionontheGE junctionobtainedbyhavingtheassistantpulldownonthePenrosewill makethenervetenselikeaguitarstringandwillallowforeithervisualor tactileidentificationoftheanteriorvagus.

■ UsingaMarylanddissector,thesurgeonshouldcarefullydissecttheanterior vagusawayfromtheesophagealmuscleandelevatethenerve.

■ UsingsharpdissectionwiththeHarmonicscalpelorbipolarcauterydevice,the surgeonshouldfreeupthevagustothediaphragmatichiatus.

■ Anendoclipshouldbeplacedacrossthenerveatthehiatusandasecondclip placed3to4cminferiortothefirst.Theportionofthenervebetweenthe clipsisthenexcisedandsenttopathology.

■ Asearchforadditionalanteriortrunksshouldbeconductedasdiscussed previously.

IdentificationandDivisionofthePosterior(Right)VagusNerve

■ Theposteriorvagusislesscloselyassociatedwiththeesophagealwall.

■ Toidentifytheposteriorvagustrunk(s),theassistantshouldapplycaudaland leftwardtractiononthePenrosedrainwithagrasperinsertedthroughtheleft upperquadrantport.

■ Theposteriorvagusshouldbecomevisibleatthispointasatightband traversingbetweentheposteriorwalloftheesophagusandtherightcrusof thediaphragm(FIG5).

■ Manytimes,theposteriorvagaltrunkwillbeencircledwithinthePenrose

drain,andthePenrosewillneedtoberepositionedtoallowthedissection ofthenervetrunkawayfromtheesophagus.

■ UsingsharpdissectionwiththeHarmonicscalpelorbipolarcauterydevice,the surgeonshouldfreeupthevagustothelevelofthediaphragmatichiatus

■ Anendoclipshouldbeplacedatthelevelofthediaphragmandasecondclipis placedonthenerve3to4cmdistal.Thesegmentofnerve(s)betweenthe clipsisexcisedandsentforpathologytoverifynervoustissuewasexcised.

AssessmentofHemostasisandClosure

■ Again,verifynoadditionalvagaltrunks

■ Inspectthediaphragmatichiatusasdescribedearlierandreapproximateif necessary.

■ Removelaparoscopicportsunderdirectvisiontoensurehemostasis.

■ Closeskinintheusualstandardfashion,withfascialclosureforportsitesgreater than5mm.

TRANSTHORACICVAGOTOMY

PortPlacement

■ 10-mmcameraportin7thor8thintercostalspace,posterioraxillaryline

■ 10-mminstrumenttrocaralonganterioraxillarylineat6thand10thintercostal space,formingasemicirclewiththecameraport

■ 5mmcanbeplacedin10thor11thintercostalspacealongposterioraxillaryline ifneeded(FIG8).

ExposureoftheEsophagus

■ Theleftlungwillneedtobecollapsedtovisualizethedistalesophagus.

■ Transectthepulmonaryligamentwithscissorsorelectrocauteryandretractthe collapsedlungsuperiorly(FIG9).

■ Incisethemediastinalpleuratoexposetheesophagus.

IdentificationandDivisionoftheAnterior(Left)VagusNerve

■ Withthemagnificationinlaparoscopy,theanteriorvaguscanoftenbevisualized directlyontheanteriorsurfaceoftheesophagus.

■ UsingaMarylanddissector,thesurgeonshouldcarefullydissecttheanterior vagusawayfromtheesophagealmuscleandelevatethenerve,placing tensionbypullingtowardthesurgeon.

■ UsingsharpdissectionwiththeHarmonicscalpelorbipolarcauterydevice,the surgeonshouldfreeup3to4cmofthevagusnerve(FIG10).

IdentificationandDivisionofthePosterior(Right)VagusNerve

■ Theposteriorvagusislesscloselyassociatedwiththeesophagealwall.

■ Placegentleupwardtractionontheesophagus.UsingaMarylanddissector, continuetospreadparalleltothenerveandesophagusintheretroesophageal plane.

■ Pullvagusagaintowardthesurgeontotensenervelikeaguitarstringinorder totransectthenerve.

■ UsingsharpdissectionwiththeHarmonicscalpelorbipolarcauterydevice,the surgeonshouldfreeup3to4cmofthevagusnerve(FIG11).

AssessmentofHemostasisandClosure

■ Afterhemostasisisensured,aredrubbershouldthenbeinsertedthroughonthe cameraportsandfedproximallyoverthelungtissuetoactasachesttube.

■ Thecameraportisthenwithdrawnandlungreinflatedunderdirectvisualization.

■ Closureoflaparoscopicportsitesinusualstandardfashion.

HIGHLYSELECTIVEVAGOTOMY

ExposureofEsophagus

■ Thephrenoesophagealligamentoverlyingtheesophagusisincisedandthe esophagusisencircledwithaPenrosedrain.

ExposureofVagusNerves,NerveofLatarjet

■ Theanteriorandposteriorvagusnervesareidentifiedandeachencircledwitha vesselloop.Dissectioniscarriedfarenoughintotheposteriormediastinumto identifymainvagaltrunks.

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