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SECTION 2

Esophagus, Stomach and Duodenum

STEP 2

Endoscopy and preparation of the diverticulum

STEP 3

Resection

An endoscopic stapling device is introduced through the operative trocar in the left

upper quadrant and is advanced to the level of the diverticular neck. The stapler jaws

are closed under simultaneous endoscopic control; the endoscope is advanced into the

stomach to prevent too much mucosa being excised, and it is then withdrawn. Once

this is confirmed, the stapler is fired and mucosal closure is verified. Additional stapler

applications may be necessary to completely incise and close the diverticular neck.

The pouch is removed and the staple line is inspected using the endoscope.

Epiphrenic Diverticula

133

STEP 4

Myotomy

A myotomy is performed on the opposite esophageal wall, with longitudinal and circular

muscular fibers divided and the submucosal plane carefully dissected using

the acoustic scalpel. The myotomy is extended proximally above the upper limit of the

diverticulum and distally for almost 1.5cm onto the cardia using either acoustic scalpel

or endo-scissors.

STEP 5

Dor fundoplication

The hiatus is closed posteriorly with two or three interrupted sutures. The anterior wrap

is performed by suturing the gastric fundus to the muscular edges of the myotomy

(Dor type procedure) and the gastric fundus is also sutured to the superior part of the

crura. The fundus is sutured to the right crus and to both the right and left sides of the

esophagus.

Video-Assisted Thoracoscopic Approach

Access

Positioning in a right lateral position as for left posterolateral thoracotomy.

The left lung is deflated using a double lumen endotracheal tube. Ports are inserted

as follows:

■

10mm at the 6th intercostal space posterior axillary line for the camera

■

10mm at the 5th intercostal space at the anterior border of the axillary line for

retraction of the lung

■

10mm at the 3rd intercostal space for working cannula

■

12mm at the mid-axillary line for working cannula

The procedure is as for the open procedure.

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SECTION 2

Esophagus, Stomach and Duodenum

Standard Postoperative Investigations

■

A water-soluble non-ionic contrast swallow is performed on day 5 postoperatively:

– To exclude suture line leak

– To verify the position of the wrap

– To ensure that no significant obstruction has developed

– To provide an impression of gastric emptying

■

Carbonated beverages and very large meals must be avoided in the early post-

operative period

Techniques of Local Esophagoplasty

in Short Esophageal Strictures

Asad Kutup, Emre F. Yekebas, Jakob R. Izbicki

Introduction

Local esophagoplasty is indicated for patients with short esophageal strictures when

endoscopic therapies including bougienage and balloon dilatation are not effective.

Indications and Contraindications

Short peptic stricture

Indications

■

■

Short scarred stenosis

Suspicion of malignancy

Contraindications

■

Indications

■

In patients with documented esophageal achalasia, regardless of the disease’s stage

Not deemed fit for general anesthesia and in those with:

Contraindications

■

■

Significant co-morbidity

■

Short life expectancy in whom pneumatic dilation or botulinum toxin injection

represent a more reasonable therapeutic option

■

Extensive intra-abdominal adhesions from previous upper abdominal surgery can

make the laparoscopic approach hazardous

History and clinical evaluation:

Duration of dysphagia, nutritional status

Chest X-ray:

Atelectasis, fibrosis (s/p aspiration pneumonia)

Barium swallow study:

Degree of esophageal dilatation and lengthening

Esophageal manometry:

Non-relaxing lower esophageal sphincter,

lack of peristalsis

Endoscopy:

Rule out esophageal mucosal lesions, Candida

colonization, associated gastroduodenal disease

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SECTION 2

Esophagus, Stomach and Duodenum

Laparoscopic Procedure

For details on access, see chapter “Laparoscopic Gastrectomy.”

STEP 1

Exposure

Incision of the phrenoesophageal membrane. Dissection is limited to the anterior

surface of the esophagus and of the diaphragmatic crura to prevent postoperative reflux

by preserving the anatomical relationships of the cardia. The cardia is mobilized only in

patients with sigmoid esophagus; in such circumstances, it is preferable to reduce the

redundancy in the abdomen and to close the crura posteriorly.

STEP 2

Heller myotomy

The Heller myotomy is started on the distal esophagus using an L-shaped hook until

identification of the submucosal plane.

The myotomy is extended on the proximal esophagus for about 6cm using insulated

scissors, a Harmonic Scalpel, or Ligasure device.

The myotomy is extended on the gastric side including the oblique fibers for about

2cm using the L-shaped hook.