clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer
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256 SECTION 2 Esophagus, Stomach and Duodenum
Standard Postoperative Investigations
■ Patients who report unusual abdominal or chest discomfort, GERD related symptoms, or dysphagia should undergo testing (endoscopic, radiological and/or physiologic evaluation).
Postoperative Complications
■Dysphagia
■Recurrent GERD symptoms and/or esophagitis
■Wrap disruption/migration or acute paraesophageal hernia
■Gas-bloat syndrome
Tricks of the Senior Surgeon
■Securing the patient to the table using a beanbag will allow steep reverse Trendelenburg positioning for gravity displacement of the bowel and maximum exposure of the gastroesophageal junction.
■Dividing the short gastric vessels will freely mobilize the fundus.
■Adequacy of fundic mobilization is checked by releasing the fundus and watching whether the fundus rests in place or recoils under tension.
■Care should be taken not to create a hypomochlion when performing posterior hiatoplasty.
■A short, floppy wrap £2cm in length is ideal.
■A 360-degree wrap is too tight if a 10-mm Babcock clamp does not easily pass under the wrap.
Operation for GERD: Laparoscopic Approach |
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Laparoscopic Partial Fundoplication (Table1)
Indications and Contraindications
See “Laparoscopic Nissen Fundoplication.”
■Procedure of choice for GERD patients with abnormal proximal esophageal motility in order to prevent excessive postoperative dysphagia or gas bloating symptoms (Table2).
Table1. Partial fundoplication techniques
Thal |
90degree anterior wrap |
Watson |
120degree anterolateral wrap |
Dor |
150–200degree anterior wrap |
Toupet |
270degree posterior wrap |
Belsey Mark IV |
270degree transthoracic anterolateral wrap |
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Table2. Indications for partial fundoplications
Primary esophageal motility disorders
Achalasia (after myotomy)
Scleroderma
Secondary esophageal motility disorders
Poor motility secondary to chronic reflux/Barrett’s esophagus
Inability to tolerate complete fundoplication
Dysphagia
Gas bloating
Chronic nausea
Aerophagia
Revision of obstructing 360degree wrap
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Esophagus, Stomach and Duodenum |
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Laparoscopic Toupet Fundoplication |
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Procedure |
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■ Initial operating room/patient setup, port placement, exposure, dissection, and |
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closure of hiatal defect identical to the procedure outlined in “Laparoscopic Nissen |
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Fundoplication.” |
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Fundoplication |
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STEP 1 |
Fixation of the fundus to the left crus |
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After the leading edge of the fundus is pulled posterior and to the right of the |
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esophagus, the fundus is sutured to the left crus and to the right side of the esophagus |
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over a length of 2–3cm (A, B). |
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A
B
Operation for GERD: Laparoscopic Approach |
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STEP 2 |
Fixation of the fundus to the esophagus and the right crus |
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The anterior fundus is sutured to the left side of the esophagus over a length of 2cm (A). The 270-degree fundoplication is secured to the right crus with separate gastrocrural
sutures (B).
A
B
Operation for GERD: Conventional Approach
Karim A. Gawad, Christoph Busch
Introduction
The laparoscopic approach to gastroesophageal reflux (GERD) has become the “gold standard” over the past decade. Nevertheless, an open approach may be preferable in patients who have undergone previous open upper abdominal surgery or in cases of recurrent or re-recurrent GERD when revisional laparoscopy may not seem sufficient to definitely treat the disease.
Indications and Contraindications
Indications |
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Significant gastroesophageal reflux |
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“When a laparoscopic approach is not indicated” |
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Recurrent disease following previous open or laparoscopic surgery |
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Status postconventional upper abdominal surgery with massive adhesions |
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Failure of conservative treatment |
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General contraindications for surgery under general anesthesia |
Contraindications |
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Preoperative Investigations/Preparation for the Procedure
See chapter on “Operation for GERD: Laparoscopic Approach.”
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Esophagus, Stomach and Duodenum |
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Procedures |
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Access |
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Transverse upper abdominal incision, if required with additional upper midline incision; |
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alternatively, left subcostal or upper midline incision |
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Division of the triangular ligament with ligation (cave: accessory bile duct) to expose |
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the esophagogastric junction |
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Choice of Procedure |
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Simple reflux disease (esophagitis up to III): |
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– Fundoplication |
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– Ligamentum teres (round ligament) plasty |
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Complicated reflux disease (esophagitis IV): |
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– Fundoplication + dilatation (of florid esophagitis) |
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– Fundoplication + parietal cell vagotomy (in gastric hyperacidity) + if necessary |
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dilatation (of florid esophagitis) |
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– Fundoplication + parietal cell vagotomy + stricturoplasty (of scarred strictures) |
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– Limited resection of the gastroesophageal junction |
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STEP 1 |
Mobilization of the distal esophagus and fundus |
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The distal esophagus is completely dissected and armed with a vessel loop. The gastric |
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fundus is completely mobilized by division of the short gastric vessels in order to form |
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a loose,“floppy” fundoplication. |
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If ligamentum teres plasty is planned, there is no need for fundic mobilization. |
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Special attention has to be paid to thoroughly preserving the ligament at laparotomy. |
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In the presence of a hiatal hernia, a posterior hiatoplasty is performed using |
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non-absorbable suture material. |
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Operation for GERD: Conventional Approach |
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Total (“Nissen”) Fundoplication |
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STEP 2 |
Passage of the fundus |
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The mobilized fundus is passed behind the esophagus to the right side so far that |
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it can be easily united with the remaining fundic frontwall in front of the esophagus. |
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STEP 3 |
Formation of the wrap |
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The two cuff-folds are fixed with three, maximally four, non-absorbable sutures. One |
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suture should partially grab the esophageal wall to prevent a telescope phenomenon. |
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Esophagus, Stomach and Duodenum |
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STEP 4 |
Anchoring of the wrap |
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Finally the fundic cuff is again tested. Two fingers should easily pass the loose wrap around the distal esophagus (“floppy Nissen”).
One or two additional sutures can fix the left cuff-fold to the anterior gastric wall in order to prevent slippage (telescope phenomenon).
Operation for GERD: Conventional Approach |
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Ligamentum Teres (Round Ligament) Plasty
STEP 1
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See above. |
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STEP 2 |
Dissection of the round ligament |
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The round ligament is carefully dissected from the abdominal wall and from the liver, |
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respectively. The free end of the ligament is transposed dorsally around the esophagus |
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coming from the right side. |
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Esophagus, Stomach and Duodenum |
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STEP 3 |
Fixation to the anterior gastric wall |
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The round ligament is then attached to the anterior gastric wall under relative tension using three or four non-absorbable sutures. Fixation to the anterior aspect of the gastric corpus is performed.