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Chapter 5 Esophageal Surgery |
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above. However, instead of using a 360-degree wrap, a 180–270-degree wrap is used and |
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sutured selectively to the esophagus, leaving one portion of the esophagus free from any |
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wrap. The wrap is not fixed to the crura. This arrangement may prevent early breakdown |
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of the repair. The basic procedures are identical in all respects to the Nissen fundoplica- |
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tion, with a takedown of short gastric vessels, but only six sutures are used to fix the wrap |
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to the esophagus. |
Paraesophageal |
Patient positioning and port placement are the same as Nissen funduplication. The her- |
Hernia |
nia may contain part or all of the stomach, colon, or omentum. The important step is to |
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separate the hernia sac from the pleura and not pull the hernia contents inside the abdo- |
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men, since they will be pulled back to the hernia sac right away. The first step is division |
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of esophago-phrenic membrane. This starts on the right crura, extending superior- |
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anteriorly toward the angle of the His. Then the hernia sac is dissected from the right |
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crura extending toward the chest (Fig.5.20). One should be careful not to open the pleura, |
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which will result in a pneumothorax. The anesthesia team should periodically check for |
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breath sounds and peak inspiratory pressure to make sure there is no tension pneumo- |
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thorax. If that is the case the insufflation should be stopped right away and a chest tube |
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should be placed. |
Paraesophageal hernia
Spleen
X
Stomach
Fig. 5.20 Dissection of hernia sac in paraesophageal hernias. Dotted line shows the line of excision; X the key of the resection of the hernia sac at the angle of His
Paraesophageal Hernia |
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Fig. 5.21 Placement of biologic or biosynthetic patch or mesh as a reinforcement of the crural closure
The dissection continues on the left side; the key to the dissection is the angle of His. If the sac is completely resected there, the stomach will be more easily reduced from the chest. (Fig. 5.20). The short gastric vessels are taken down as previously described. The dissection continues on the left crura until the two planes of dissection reach each other. Then the esophagus is dissected posteriorly from both the right and left crura and a penrose drain is placed around the esophagus. At this point all the contents of the hernia sac should be reduced inside the abdominal cavity.
The crura are closed with intrupted nonabsorbabale sutures. One should be careful as a tight closure may result in dysphagia. Also if the closure is completely performed posterior to the esophagus, it may result in an angled esophagus. In most instances, we reinforce the closure with a piece of absorbable or biological mesh, cut in a U shape, that can be placed around the esophagus on the crura, and fixed in place with sutures or absorbable tacks. (Fig. 5.21).
After this step, a Nissen or Toupet fundoplication is performed based on preoperative studies.
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Fig. 5.22 Esophageal Heller myotomy using the scissors
Fig. 5.23 End of the dissection in esophageal myotomy