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The text is illustrated throughout by line drawings and photographs that depict anatomic or technical principles. TheIllustrated Handbook of Cardiac Surgery should appealto all individuals caring for cardiac surgical patients: cardiologists, anesthesiologists, radiologists, general surgery residents rotatingon cardiac surgery, medical students, This text is organized by organ system and the illustrations highlight surgical pearls borne of experience and polished by the study of pertinent references.
Shabino PJ et al: Gastric and duodenal surgery. Remaining superficial to the investing fascia of the serratus will avoid injury, but the position of the nerve should be verified throughout the dissection see Fig. I request that my anesthesia colleagues avoid paralytics in all breast cases. If necessary, I pinch the long thoracic or thoracodorsal nerve with a forceps to confirm their identity, although I try to avoid this if possible. Injury to the thoracodorsal nerve will result in weakness of adduction and internal rotation, but no obvious physical deformity is present.
However, injury to the long thoracic nerve results in a winged scapula. This will become evident by the physical deformity in time. The subscapular nerve is at low risk for injury unless dissection is carried out to include level 3 axillary nodes. This should only be done when there is evidence of gross 60 M. The subscapular nerve lies against the subscapularis muscle near the apex of the axilla. Drain placement has recently been debated in preference of an axillary bolster by some surgeons.
However, I prefer to place a 19 French Blake drain from medial to lateral within the axilla. This is sutured to the skin with a Nylon stitch and placed to bulb suction. Both breast and axillary drains can generally be removed after output falls below 30 mL over 24 h. Infrequently a seroma will occur after drain removal. I prefer to observe these unless symptomatic or if they delay adjuvant treatment. Raut, CP et al. Anaphylactoid reactions to isosulfan blue dye during breast cancer lymphatic mapping in patients given preoperative prophylaxis.
Journal of Clinical Oncology , Feb; 22 3 —8. When medical therapy fails to adequately control symptoms, antireflux surgery is generally indicated. The most commonly performed antireflux operation is currently the laparoscopic Nissen fundoplication.
During surgery, a consistent step-wise approach with attention to proper setup and common pitfalls can lead to good and durable clinical results with minimal long-term side effects. Symptoms related to GERD can vary widely from patient to patient. Other patients may suffer from extraesophageal GERD-related complaints such as cough, hoarseness, or severe asthma.
Some patients experience a combination of esophageal and extraesophageal symptoms. Nissen fundoplication is indicated for cases of medically refractory GERD. Although several types of fundoplications can be performed degree posterior Toupet, degree anterior Dor , a full degree Nissen fundoplication remains the most common antireflux operation.
Most Nissen fundoplications are currently performed laparoscopically. As many symptoms related to GERD can also be caused by other conditions, it is important to confirm the diagnosis of GERD and the relationship of this condition to the symptom in question before proceeding with antireflux surgery. Gould In patients with esophageal symptoms and esophagitis, additional testing to confirm the diagnosis is usually not necessary.
In patients with non-erosive reflux disease and in those with extraesophageal symptoms, which may be related to GERD, a hour pH study or multichannel esophageal impedance testing is indicated to confirm the diagnosis. Additional tests that may prove helpful in some patients include Upper GI series, which can help to identify the anatomy.
A nuclear medicine gastric emptying study is sometimes helpful in diagnosing gastroparesis in patients with GERD symptoms and significant bloating, nausea, or vomiting, especially in diabetic patients. Esophageal manometry is often performed prior to antireflux surgery to identify motility disorders that may affect surgical decision-making.
Monitors are placed eye level at the head of the table. Steep reverse Trendelenburg position helps to expose the esophageal hiatus. Be certain that the patient is secured well to the table and that arms are padded and secured to the arm boards to avoid brachial plexus or other nerve injuries. The table height should be set such that the surgeon can operate with shoulders relaxed and forearms parallel to the floor.
An orogastric tube to decompress the stomach prior to placement of the esophageal bougie later in the case is a good idea before ports are placed. We prefer to place a Veress needle at about the midclavicular line in the left subcostal position.
Once pneumoperitoneum is established, we place a 5-mm optical trocar in this location. The abdominal pressure is set at 15 mmHg. This port site serves as the right hand operating port. Under direct visualization from within the abdominal cavity and using a degree angled laparoscope, the camera port is placed next. This 5-mm port is placed superior to and slightly to the left of the 10 Laparoscopic Nissen Fundoplication 65 umbilicus.
Care should be taken to avoid the epigastric artery on the left side with this port. Ideally, this port will be directly inline with the esophageal hiatus and approximately 10—15 cm below the base of the sternum. This usually winds up being about two fingers right of the xiphoid. It is important to make sure that this port is at about the lower edge of the left lobe of the liver, especially for patients with very large livers.
If optimally placed, these three ports will triangulate the esophageal hiatus with the optical axis of the laparoscope looking straight ahead at the hiatus.
A Nathanson liver retractor is placed through a 5-mm incision between the xiphoid and the left costal margin. The left lobe of the liver is retracted anteriorly and this retractor is connected to a robotic arm. If a ski-shaped or other low profile needle is used in suturing, all ports can be 5 mm. If a larger needle is used, one of these ports usually the left subcostal midclavicular port needs to be at least 10 mm. The optimal location of these ports is illustrated in Fig.
The hiatal dissection typically begins at the gastrohepatic omentum. There is usually an area of this omentum that is transparent through which the caudate lobe of the liver can be seen. This should be identified and preserved if 66 J. Gould possible. The dissection of the gastrohepatic omentum should be carried up to the right crus of the diaphragm.
The assistant can grasp either the gastroesophageal fat pad, or some fat at the base of the right crus to facilitate this exposure. The phrenoesophageal membrane is then opened at the base of the right crus Fig. Care should be taken to avoid damaging the crural muscle during this step. The phrenoesophageal muscle can then be divided to its apex on the right using electrocautery, an ultrasonic dissector, or scissors. Once this membrane is divided, it is fairly easy to insert a blunt-tipped instrument medial to the right crus in the mediastinum.
The posterior vagus nerve is usually clearly seen and should be swept along with the esophagus to the left. The right pleura and aorta are commonly encountered during this portion of the dissection as well.
The left crural dissection is often best left until the fundus has been thoroughly mobilized and the medial border of the base of the left crus can be identified in the retroesophageal space from the anatomic left side.
This usually correlates with a point at about the lower pole of the spleen. Once in the lesser sac, traction is maintained on the stomach and counter traction on 10 Laparoscopic Nissen Fundoplication 67 Fig. The short gastric arteries and all other posterior attachments of the stomach are then divided, usually with an ultrasonic dissector.
It is important to avoid injuring the stomach by applying energy close to the gastric wall. It is also essential to avoid excessive traction, which may tear a short gastric artery or the splenic capsule.
In some patients, the proximal fundus and upper pole of the spleen are seemingly fused, making this part of the dissection quite difficult. Once the fundus is fully mobilized, the base of the left crus can be visualized in the retroesophageal space from the left side Fig.
The medial border of the left crus can then be dissected anteriorly back to the previously established plane Fig. Gould between the apex of the right crus and the mediastinum. A window posterior to the esophagus and proximal stomach can then be created from the anatomic left side. Using the Penrose drain as a retractor, the distal esophagus can be circumferentially mobilized until at least 2—4 cm of distal esophagus lies comfortably on the abdominal side of the crura without tension.
Take care not to injure the anterior or posterior vagus nerve, left or right pleura, or the aorta during this dissection. If either pleura is lacerated during this dissection, this must be communicated to the anesthesiologist. As long as the lung parenchyma itself is not injured, a small adjustment in airway pressure and intraabdominal pressure are usually all it takes to maintain normal ventilation.
The Penrose can be secure with an endoloop suture and used for atraumatic retraction of the esophagus Passing the bougie can lead to an esophageal perforation and some experienced surgeons avoid this step [3]. We prefer to pass a bougie prior to approximating the crura.
Most of the distal esophagus is visible at this stage of the operation. The keys to safe passage of the esophageal bougie are communication with the anesthesiologist, good visualization, and non-angulation of the gastroesophageal junction. We feel that a posterior cruropexy can angulate the esophagus anteriorly. Lifting the esophagus anteriorly for the cruropexy with a bougie within it can be difficult. The 10 Laparoscopic Nissen Fundoplication 69 use of a Penrose drain for retraction makes this easier.
It is important to be sure that the bougie is not in so far that the tip is against the greater curve of the stomach, stretching the stomach along its longitudinal axis. This makes lifting the esophagus to expose the crura even more difficult. We use the bougie to calibrate our cruropexy. With a bougie in place, the crura should be approximated until there is just enough room to easily insert a blunt tipped 5-mm instrument into the mediastinum. The absolute size of the esophageal bougie is not terribly important.
We generally use a 60 French bougie for men and a 56 French bougie for women and smaller men. If the bougie does not pass easily the first time, we select a bougie 2—4 French smaller and try again. Most surgeons perform a posterior as opposed to an anterior cruropexy. We use 0-guage, non-absorbable, polyester suture Fig. The intraabdominal crural fascia is incorporated into the sutures rather than the muscle body alone.
If the crural repair is under some tension, pledgets can be used. There is evidence to suggest that reinforcement of the hiatal closure with a biologic material may decrease the incidence of hiatal disruption in paraesophageal hernial repair [5]. Mesh, especially polypropylene, should be used with great caution when it may come into contact with the esophagus as erosions can occur [6]. The internal 70 J. Gould diameter of the wrap should exceed external diameter of the esophagus.
It is important to use the correct piece of both anterior and posterior fundus well mobilized to achieve this goal. It is easy to twist the fundus as it is passed behind the esophagus and good visualization via a large retroesophageal window can help minimize the chance of this happening.
Use the divided short gastric arteries for orientation and remember that when the fundus is passed from anatomic left to right, the posterior fundus actually is oriented towards the anterior abdominal wall [7]. These patients can suffer from persistent GERD symptoms, dysphagia, or both.
Once the proper portion of the anterior and posterior fundus is identified to create a loose and floppy wrap, deep seromuscular stomach bites with a non-absorbable, braided polyester suture are used to create the wrap.
The first bite is anterior to posterior fundus without incorporating any esophagus. The wrap is checked to ensure that the geometry is correct as described above before placing additional sutures.
Ideally, the stumps of the divided short gastric arteries will lie on the anatomic left side of the wrap, directly opposite the suture line of the fundoplication. Additional fundoplication sutures another 2—3 sutures should include anterior esophageal muscle. Care should be taken to ensure that these are not full-thickness bites that might penetrate the esophageal mucosa. The proper wrap should be about 2—3 cm long and clearly located on the esophagus.
Optimally, a small bit of distal esophagus will be visible distal to the wrap when complete. Identify and avoid the anterior vagus nerve. Once the fundoplication is completed, the esophageal bougie is removed. At this time, the fundoplication can be anchored to the intraabdominal diaphragm if desired. We Fig. We also place sutures between the anterior crural pillar on both the left and the right and the anterior portion of the wrap on each side Fig.
Each port site is infiltrated with bupivacaine for local anesthesia. The ports are removed under direct visualization from within the abdomen to ensure that there is no bleeding.
This is rarely a clinically significant pneumothorax. For most cases transhiatal suction in the mediastinum with the ports open coupled with large vital capacity breaths administered by the anesthesiologist minimize the size of the pneumothorax. What little CO2 remains in the pleural space is usually rapidly systemically absorbed.
Chest radiographs are not necessary unless the patient experiences respiratory distress. We routinely administer ketorolac and ondansetron empirically to minimize the need for narcotics and to decrease the incidence of postoperative nausea and vomiting. Vomiting and retching in the immediate perioperative period has been shown to be associated with anatomic failure of the wrap or crural repair [8]. It is important for patients to take small bites, chew thoroughly, and to eat slowly during these first few weeks.
Strenuous physical activity that may require diaphragm straining abdominal exercises, heavy lifting should be avoided for about the first 4 weeks postoperatively Most patients will improve with time if this is related to wrap edema. In these cases an improperly constructed wrap, excessively tight hiatal closure, or underlying motility disorder may exist.
Endoscopy, upper GI series, and manometry can help to differentiate these causes of severe persistent dysphagia that lasts beyond 6—12 months. Occasionally, patients will require revisional surgery to take the wrap down, to revise it, or to convert a full to a partial wrap. Bloating symptoms and increased flatus following fundoplication are extremely common. Delayed gastric emptying can result, presumably from inadvertent vagus nerve injury during the esophageal dissection, although the incidence of this is poorly defined.
Recurrent reflux can occur, usually related to anatomic fundoplication failure. Gould References 1. McCarthy D Living with chronic heartburn: insights into its debilitating affects. Gastroenterol Clin N Am 32 3 suppl :S1—9 2. Richter JE Severe reflux esophagitis. Gastrointest Endosc Clin N Am —98 3. Am J Surg 6 —70 4. Ann Surg 6 —71 5. Ann Surg 4 —90 6. Surg Endosc 21 12 — 7. Surg Endosc —4 8. J Gastrointest Surg 10 1 —21 9. The rationale for this approach was prophylactic, based largely on a concern for life-threatening hernia-related complications such as strangulation and gastric ischemia.
This notion has been challenged in recent years and now many asymptomatic hernias are managed expectantly [3]. When a hernia becomes more than mildly symptomatic, it should be repaired in most cases. Typical symptoms related to a paraesophageal hernia can include dysphagia, early satiety, epigastric pain, and even dyspnea.
Some patients may suffer from significant medically refractory gastroesophageal reflux disease necessitating repair. These ulcers may lead to chronic insidious blood loss with resultant anemia or less commonly frank hematemesis.
Operative correction should be considered in these patients, as well. The laparoscopic approach to paraesophageal hernia repair was described first in [4]. Since this time, it has been demonstrated that laparoscopic paraesophageal hernia repair is associated with many of the advantages observed for other laparoscopic procedures when compared to their open counterparts [5, 6].
Some authors have suggested that the recurrence rate following laparoscopic repair is too high [7]. Without prospective randomized trial comparing laparoscopic repair to other techniques and a clear consensus definition of what constitutes a meaningful recurrence, it is difficult to determine if these concerns are justified.
In general, the indications for repair are the same in each. A type I hiatal hernia is often called a sliding hiatal hernia and is the most common of the four types.
Patients with type I hiatal hernias are predisposed to reflux. Most patients with type I hiatal hernias undergoing surgical repair have met indications for antireflux surgery.
In a type I hiatal hernia, the gastroesophageal GE junction migrates through the hiatus. In these hernias, the GE junction maintains its normal intraabdominal position and the fundus herniates through the hiatus. Type II hernias are actually quite uncommon. Type III hiatal hernias occur when the GE junction and the gastric fundus herniate through the hiatus and represent a combination of type I and type II hernias.
These hernias can become quite large Fig. Type IV hernias contain viscera other than the stomach such as spleen, colon, or small intestine. Gastroesophageal junction and fundus herniated through hiatus A sick patient with an incarcerated paraesophageal hernia and gastric ischemia may not require specific evaluation other than an exploratory laparotomy. Patients requiring paraesophageal hernia repair are often 70 years old and older, so proper medical and cardiac clearance can help to define or modify operative risk.
In cases where the primary indication 11 Laparoscopic Paraesophageal Hernia Repair 75 is gastroesophageal reflux disease, evaluation should proceed as described in Chapter The room setup is identical to that of the Nissen fundoplication, as well. Repair of very large hernias can take a significant amount of time 4 or more hours and a bladder catheter as well as other invasive monitoring devices may be a good idea for an older patient or a patient with comorbid medical conditions.
The basic principles of repair are 1 tension-free reduction of stomach and esophagus into the abdomen, 2 re-approximation of the hiatus, and 3 subdiaphragmatic anchoring of the stomach. The hiatal dissection typically begins at the base of either diaphragm crura. It is important not to grab the stomach and try to pull it into the abdomen forcefully.
In some frail patients with large hernias, gastric injury can result from this maneuver. The stomach will gradually come down into the abdominal cavity as the hernial sac is dissected and mobilized.
We prefer to divide the gastrohepatic omentum and to begin the hernia sac dissection at the base of the right crus. The white line of the phrenoesophageal membrane can often be visualized with this maneuver. We prefer the use of an ultrasonic dissector for the hiatal dissection. Hook electrocautery is another option employed by many surgeons. The phrenoesophageal membrane at the base of the right crus is opened and the posterior side of the hernia sac in the mediastinum is then visualized Fig.
The dissection continues anteriorly on the front of the right crus to the apex. It is important not to damage the crural muscle fibers and to leave as much peritoneum on the crus as possible during this dissection.
At the apex, the dissection of the hernial sac is carried down to the base of the left crus, eventually circumferentially dissecting the sac off the hiatal muscle. Excising the hernial sac from the base of the left crus can be difficult in some cases.
Mobilizing the sac from its mediastinal attachments can be helpful. Dividing a few short gastric arteries on the greater curve and getting into the lesser sac on the 76 J. Gould Fig. Once the sac is freed from the diaphragm hiatus, the sac can be separated from its mediastinal attachments Fig. This process typically results in the complete reduction of any stomach still herniated at the beginning of this dissection.
It is important to be careful to avoid injury to the esophagus as well as the vagus nerves and both pleural cavities. Aggressive, circumferential mobilization of the mediastinal esophagus typically results in adequate intraabdominal esophageal length.
The hiatal defect is often quite generous in patients with large paraesophageal hernias, and with the use of an angled scope, esophageal mobilization well into the mediastinum is possible. With a transabdominal approach, at about the level of the inferior pulmonary vein continued cephalad dissection becomes increasingly difficult.
Esophageal mobilization should be continued until at least 2—3 cm of intraabdominal esophagus Fig. In our experience and in the experience of others, this length of intraabdominal esophagus is nearly always attainable with a transabdominal laparoscopic approach [8]. Some authors advocate complete sac excision. We believe in removing or dividing as much sac as possible such that the anterior esophagus and GE junction can be clearly identified. It is easy to mistake posterior hernial sac for anterior esophageal muscle.
Anchoring the fundoplication to the posterior sac rather than the esophageal muscle is an obvious setup for a slipped wrap or recurrence. It is also easy to mistake a tubularized stomach for the esophagus. In large hernias, the angle of His may no longer be an identifiable anatomic landmark. Visual identification of longitudinal muscle fibers of the esophagus, identification of the posterior vagus nerve, or even diagnostic endoscopy can be useful for localizing the true gastroesophageal junction in difficult cases.
There is a lot of debate regarding the incidence, importance, and treatment of short esophagus in the literature. A recent review of 94 papers including more than 17, patients revealed an overall incidence of 1. The diagnosis of a short esophagus is always made in the operating room after an earnest attempt at adequate esophageal mobilization.
In patients in whom it is impossible to achieve 2 or more centimeters of intraabdominal esophagus, an esophageal lengthening procedure is an option.
A Collis gastroplasty can be performed laparoscopically. A variety of techniques have been described. We prefer the proximal wedge gastrectomy technique as described by Hunter [11]. In addition to increased potential morbidity related to staple lines and a gastric resection, a Collis gastroplasty leaves acid-producing parietal cells in the neo-esophagus above the intact fundoplication.
We believe that Collis gastroplasties should be used in paraesophageal hernia repair sparingly and only when absolutely necessary, for these reasons. Non-traumatized muscle covered with fascia will close primarily and hold a suture better than damaged and friable muscle fibers.
The hiatus is closed posteriorly with 0-guage, non-absorbable, polyester suture Fig. Many surgeons routinely use pledgets. Erosion of pledgets into the esophageal lumen has 78 J. There is good data to support the routine use of a biologic material to reinforce the crural closure.
In a prospective randomized study, porcine small intestine submucosa derived mesh resulted in a significant decrease in radiographic recurrences after 6 months when compared to non-reinforced hiatal closure in laparoscopic paraesophageal hernia repair [12].
In some cases, primary closure of the hiatus will not be possible and an interposition rather than an onlay technique must be used to achieve hiatal re-approximation. Key -hole or other techniques of hiatus re-approximation with mesh, where the esophagus is encircled by mesh, are associated with a high rate of Fig.
Any permanent, non-biologic prosthetic mesh that comes into contact with the esophagus should be used with caution during hiatal repair as cases of erosion and significant resulting patient morbidity have been reported. A sutured gastropexy, gastropexy via a gastrostomy tube, or a fundoplication can be employed to achieve this goal. For all but the most infirm and elderly patients, gastropexy without fundoplication is potentially associated with an unacceptably high recurrence rate [13].
The most commonly employed technique of subdiaphragmatic anchoring is with a fundoplication. This achieves the dual objective of anchoring the stomach to minimize the chances of recurrence and of correcting reflux in patients who also suffer from gastroesophageal reflux disease.
When creating a fundoplication during paraesophageal hernia repair, division of the short gastric vessels may not be necessary in some patients with extremely mobile stomachs. Solid evidence to support one type of fundoplication over another Nissen vs. Toupet vs. Dor does not currently exist and all types of repairs have been described. At the University of Wisconsin, we typically construct a floppy degree Nissen fundoplication.
If an esophageal bougie is to be passed, this needs to be done very carefully. In patients with a large hiatal defect, the posterior crural repair can result in anterior angulation of the esophagus making esophageal perforation a concern during bougie passage.
As described in Chapter 10, it is important to create a geometrically correct fundoplication. The anterior and posterior fundus should envelop the esophagus.
A 2—3 cm long wrap should be constructed and anchored to the anterior esophageal muscle. We also suture the wrap to the cruropexy or the mesh posteriorly, as well as the anterior left and right crural pillars. We do not routinely place nasogastric tubes. As long as patients are not suffering from nausea, we begin with a clear liquid meal within the first 24 h of the operation.
Patients rapidly advance to a pureed or soft diet and remain on this diet for 2—8 weeks or until they can swallow without dysphagia. As is the case following Nissen fundoplication, we routinely administer ketorolac as long as age or renal function does not present 80 J. Gould a contraindication and ondansetron empirically to minimize the need for narcotics and to decrease the incidence of postoperative nausea and vomiting.
Long term results with patients. J Thorac Cardiovasc Surg;53 1 —54 2. Hill LD Incarcerated paraesophageal hernia. A surgical emergency. Am J Surg; — 3. Ann Surg; 4 — 4. Am J Surg;—30 5. Am J Surg; 6. Surg Endosc;—8 7. J Am Coll Surg; 5 —60 8. Arch Surg; 7 —40 9. Surg Endosc;12 10 —63 Dis Esophagus;15 2 —31 Am J Surg; 2 —9 Ann Surg; 4 —90 Failure of the lower esophageal sphincter LES to relax results in a functional obstruction that progresses to hypomotility and aperistalsis of the esophagus.
Although the etiology is unclear, the pathophysiologic mechanism involves the destruction of myenteric plexi. Presenting symptoms usually involve dysphagia of liquids and solids, chest pain, and regurgitation of undigested meals [1, 2]. Pharmacologic agents such as calcium channel blockers and nitrates, pneumatic esophageal dilation, and botulinum toxin A Botox injection are temporary solutions that provide no sustained therapeutic benefit in many cases [1].
Laparoscopic Heller myotomy has been found to be an effective, safe, and long-term solution to relief of dysphagia in patients with achalasia.
A swallow study can also identify patients with megaesophagus or a sigmoid esophagus, who may benefit from immediate treatment [2]. Upper endoscopy provides examination of the esophageal mucosa as well as examination of the gastroesophageal GE junction for strictures or distal esophageal tumors that can mimic achalasia pseudoachalasia [3].
Esophageal manometry, considered the gold standard for the diagnosis of achalasia, will demonstrate a poorly or non-relaxing LES in patients determined to have achalasia. Absent peristalsis of the esophageal body is also commonly observed S.
Musunuru and J. Gould on manometry [3, 4]. Multiple sessions of pneumatic dilation or Botox injection can result in submucosal scarring that can complicate the myotomy [5, 6]. Young patients and patients with an acceptable operative risk should be advised to consider surgical myotomy as an initial therapeutic procedure due to this fact.
The patient is well secured before being placed in steep reverse Trendelenburg position. Monitors are placed at eye level at the head of the operating table. Pneumoperitoneum is established to 15 mmHg. A 5-mm optical viewing trocar is placed in this left subcostal position. Under direct vision with a degree laparoscope, a 5-mm port is placed about 10—15 cm below the base of the sternum, superior to the umbilicus, and directly in line with the esophageal hiatus.
This will be the camera port. A 5-mm incision is made in the subxiphoid position for a Nathanson liver retractor for retraction of the left lobe of the liver. As described in the chapter on laparoscopic Nissen fundoplication, the entire operation can be conducted with 5-mm ports depending on the type of needle used for suturing.
If a mm suturing device or a curved needle that must be passed through a mm port is used, the left midclavicular subcostal port can be upsized. The gastrohepatic ligament is divided and the base of the right crural pillar is identified. If a replaced left hepatic artery is encountered, it should be 12 Minimally Invasive Surgical Treatment of Achalasia 83 Fig. At the base of the right crus, the phrenoesophageal ligament is divided. The assistant provides counter-traction by grasping the gastroesophageal junction fat pad and retracting caudally.
The dissection proceeds anteriorly to the apex of the right crus and then the phrenoesophageal membrane on the anterior border of the left crus is gently dissected. If an anterior fundoplication Dor is to be used after the myotomy, an extensive posterior dissection is not necessary.
If a posterior fundoplication is to be employed, a circumferential hiatal dissection should be performed. The anterior vagus nerve is identified and preserved. The anterior vagus nerve often crosses the most optimal anterior esophageal location for the myotomy and may need to be mobilized and reflected during the myotomy to avoid transaction Fig.
Mediastinal mobilization of the esophagus should continue until approximately 6 cm of anterior esophagus is accessible for the myotomy. We prefer to resect the anterior fat pad that lies over the GE junction to better identify this important transition from our intraabdominal extraluminal vantage point.
We prefer to use a monopolar hook electrocautery instrument with the coagulation current set to 20 W and the cutting current set to 0 W. We carefully use a combination of short bursts of electrocautery and blunt dissection with the hook to separate first the longitudinal esophageal muscle fibers and then to hook, elevate, and divide the circular fibers.
The back elbow of the hook is used to create space in the submucosal plane 84 S. Care should be taken to ensure that cautery is not applied to the mucosa. The anterior myotomy is continued cephalad for a length of 4—6 cm.
The myotomy must then be continued onto the anterior gastric wall for a minimum of 2 cm. The orientation of the muscle fibers becomes more random and the myotomy is much more difficult to perform on the stomach, but an adequate gastric myotomy has been shown to be essential for long-term relief of dysphagia [7]. During the course of conducting the myotomy, bleeding from the divided muscle edges may occur.
This is extremely common and typically self-limited. Bleeding can be controlled by gentle pressure with a sponge or an absorbable hemostatic material such as oxidized regenerated cellulose.
Excessive use of cautery to control bleeding should be avoided so as not to damage the mucosa and cause either an immediate or a delayed perforation.
If a mucosal perforation is identified, it should be repaired with fine sutures. We prefer or absorbable interrupted suture.
If the mucosal perforation is on the distal esophagus, consideration should be given to covering this mucosal repair with an anterior fundoplication. If the mucosal perforation is too proximal on the esophagus to be covered by a fundoplication, consideration should be given to closing the esophageal muscle over the mucosal repair. After completion of the myotomy, a diagnostic upper endoscopy is preformed. During passage of the endoscope, the GE junction is evaluated endoscopically and laparoscopically to ensure that the myotomy is complete and that it extends at least 2 cm onto the anterior gastric wall.
The esophagus and stomach are insufflated with the mucosa under water to evaluate for air bubbles, signifying a mucosal perforation. A prospective randomized trial evaluating the outcomes following laparoscopic Heller 12 Minimally Invasive Surgical Treatment of Achalasia 85 with and without an anterior fundoplication determined that the routine addition of a fundoplication is superior to Heller myotomy alone in regards to postoperative gastroesophageal reflux disease [8].
The two most common types of fundoplication following Heller myotomy are the Toupet degree posterior fundoplication and the Dor degree anterior fundoplication. Proponents of the posterior fundoplication believe that the fundus sutured to the divided muscle acts to hold the myotomy apart.
An anterior fundoplication may prevent a delayed mucosal perforation or an unrecognized mucosal perforation from becoming clinically apparent. A Dor fundoplication is also easier and faster to construct than a Toupet. We routinely perform a Dor anterior fundoplication with laparoscopic Heller myotomy. The esophageal hiatus is re-approximated posteriorly with permanent braided sutures. It is important not to impinge or angulate the esophagus with the hiatal closure.
For the Dor fundoplication, dividing the short gastric arteries is not necessary. For the first stitch, the top part of the cardia is sutured to the anterior left crural pillar and to the left side of the myotomy at the most superior aspect Fig. When placing this suture, it is important to place the suture in the portion of the myotomy that naturally sits next to the crural pillar to avoid angulating or kinking the esophagus in this area. The next stitch incorporates the anterior fundal flap, the right edge of the myotomy, and the anterior right crural pillar Fig.
Two more sutures are placed between the anterior fundus and the right edge of the myotomy, essentially covering the entire myotomy with anterior fundus. We use braided, permanent polyester sutures to create the anterior fundoplication. All port sites are infiltrated under direct vision with bupivacaine as local anesthetic. The mm port in the left upper abdomen is closed with an Endoclose. The Nathanson liver retractor and ports are removed under direct vision to evaluate for bleeding.
We typically begin with clear liquids and rapidly advance to a pureed diet for 2 weeks. Following uncomplicated cases, routine esophagrams have been demonstrated to have a poor positive predictive value for leak and are not necessary.
Most patients are discharged on postoperative day 1.
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