clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

A 1-cm stab incision is made in the center of the triangle created by the three sutures which are held under tension. Under laparoscopic vision the anterior stomach wall is punctured by an 18-gauge needle exactly in the center of the triangle. Through the needle a guidewire is inserted into the stomach and a 26-Fr. dilatator with a peel-away sheath is pushed over the guidewire into the stomach percutaneously.

At the end of the procedure the correct placement of the tube is confirmed radiographically.

The inner dilatator is removed and a regular 24-Fr. urinary catheter is placed through the remaining peel-away sheath into the stomach. The peel-away sheath is removed. After the balloon of the catheter is inflated, the stomach is pulled against the abdominal wall and the sutures are subcutaneously secured under traction and progressive reduction of the pneumoperitoneum. The catheter is then put under traction for 24h.

See chapter “Conventional Gastrostomy: Temporary or Permanent Gastric Fistula” for postoperative investigations and complications.

■Exchange the 24-Fr. urinary catheter for a special gastrostomy button device 14days postoperatively (see Figure).

■To avoid dietary deficiencies, patients should be under the supervision of a nutritional specialist.

■In case of contraindications for general anesthesia, the procedure can also be performed under local or regional anesthesia.

Operation for GERD: Laparoscopic Approach

Ketan M. Desai, Nathaniel J. Soper

Introduction

Laparoscopic antireflux surgery (LARS) has assumed a major role in the treatment of gastroesophageal reflux disease (GERD). The advancement in laparoscopic techniques and instrumentation over the past decade has led to an increase in the number of antireflux operations. Although the operation is fundamentally similar to open antireflux procedures, clear benefits to the laparoscopic approach have been described.

In 1955, Rudolf Nissen reported the efficacy of a 360° gastric wrap through an upper abdominal incision to control reflux symptoms. It was not until 1991 that the first laparoscopic Nissen fundoplication was reported. From that point, acceptance on the part of patients and physicians to proceed with surgical treatment began to grow. Although the minimally invasive approach follows the same surgical principles as the open operation, LARS reduces postoperative pain, shortens the hospital stay and recovery period, and achieves a functional outcome that is similar to that of the open operation.

Indications and Contraindications

Relative Contraindications

■Previous upper abdominal surgery

■Morbid obesity

■Short esophagus

Preoperative Investigation/Preparation for Procedure

The operating room personnel and equipment are arranged with the surgeon between the patient’s legs, the assistant surgeon on the patient’s right, and the camera holder to the left.

Video monitors are placed at either side of the head of the table and should be viewed easily by all members of the operating team.

Irrigation, suction, and electrocautery connections come at the head of the table on the patient’s right side. Special instruments include endoscopic Babcock graspers, cautery scissors, curved dissectors, clip applier, atraumatic liver retractor, 5-mm needle holders, and ultrasonic coagulating shears.

Port arrangement should allow easy access to the hiatus and permit comfortable suturing by placing the optics between the surgeon’s hands. Access to the abdominal cavity is achieved by either a closed or open technique superior to the umbilicus.

The initial port is placed in the left mid-rectus muscle approximately 12–15cm below the xiphoid process. Four additional ports are placed under direct vision of the laparoscope. Ports are typically placed in the following locations to optimize visualization and tissue manipulation, and to facilitate suturing: right subcostal, 15cm from the xiphoid process; a point midway between the first two ports in the right mid-rectus region; in the left subcostal region 10cm from the xiphoid; and in the right paramedian location at the same horizontal level as the left subcostal trocar (usually 5cm inferior to the xiphoid process).

The gastroesophageal junction is usually deep to the xiphoid, and from a point 15cm distant, only half of the laparoscopic instrument must be introduced to reach the hiatus. This distance establishes the fulcrum at the midpoint of the instrument and maximizes its range of motion during tissue manipulation.

With current 5-mm equipment and optics, we generally use only one 10–12 port, for the surgeon’s right hand, to allow insertion of an SH needle through the valve mechanism.

Exposure of the esophageal hiatus is facilitated by gravity and maintained by an assistant. Positioning the patient in the reverse Trendelenburg position displaces the bowel and stomach from the diaphragm.

A skilled camera holder and the use of an angled laparoscope (30° or 45° ) are important.

The assistant introduces a self-retaining liver retractor through the right subcostal port, and a Babcock grasper is introduced through the right mid-rectus port to pull the stomach and epiphrenic fat pad inferiorly and allow division of the gastrohepatic ligament using the ultrasonic shears. Division of the gastrohepatic ligament is done with preservation of the hepatic branch of the anterior vagus.

The left triangular ligament is not divided but is left to aid in retraction of the liver anteriorly. Next, both the crura and anterior vagus nerve are identified after opening the phrenoesophageal membrane.

The esophagus is serially dilated, and a 50–60Fr. Maloney dilator is left in place during the creation of the wrap. The dilator calibrates the wrap and prevents excessive narrowing of the esophagus during the actual fundoplication. Dilation must be performed cautiously if the patient has esophageal stricture or severe inflammation. The surgeon should watch the bougie pass smoothly through the gastroesophageal junction. If the bougie appears to be hung up at the gastroesophageal junction, the surgeon can sometimes improve the angulation by retracting the stomach anteriorly or caudally.

With the dilator in the esophagus, the fundus is positioned, and a “short, floppy” Nissen fundoplication is constructed using three interrupted, braided O- or 2-O polyester sutures. Seromuscular bites of fundus to the left of the esophagus, the anterior esophageal wall away from the anterior vagus nerve, and the fundus to the right are all incorporated in the 360-degree fundoplication. The esophageal wall should be incorporated in at least one of the sutures to inhibit slippage of the wrap around the body of the stomach or into the thoracic cavity.

Our practice has been to use extracorporeal knotting techniques, tying square knots and pushing them into position, whereas other surgeons prefer intracorporeal suturing. Regardless, the surgeon should take generous tissue bites and appose the gastric wall without strangulating tissue. Ideally, the wrap should be £2cm in length.

After three sutures secure the fundoplication, additional sutures may be placed from the wrap to the crura for stabilization, although we currently do not perform this step. The esophageal dilator is withdrawn by the anesthesiologist. At this point the Nissen fundoplication is complete.