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The patient position is the same as for Nissen fundoplication. The port positions are also the same.
On starting the esophageal myotomy it is essential to visualize the gastroesophageal junction. This is achieved by division of the phrenoesophageal membrane, the dissection proceeding from right to left. The fat pad indicates the angle of His. At this point the gastroesophageal junction is revealed.
The myotomy is started on the esophagus itself, and should be about 8 cm long. The inferior aspect of the myotomy should be started just at the junction between the esophagus and the stomach, and extend 10–20 mm on the gastric side. First, two graspers are used to grasp the esophagus. A scissor is employed for the myotomy after creating a small groove in the muscular layer of the esophagus to allow its introduction (Fig. 5.22). By combining a spreading motion between the two layers of the esophagus, and dissection with the scissor just dividing the muscular layer, it is possible to see the white, pale esophageal mucosa bulging between the layers (Fig. 5.23). Traction on the layers, with electrocautery by the hook, will allow safe division of the final muscular layers of the diseased esophageal segment.
On completion of the myotomy, the integrity of the mucosa is tested by filling the esophagus with about 300 mL of diluted methylene blue. If a small mucosal perforation is revealed, it is possible to insert a stitch of 3–0 Prolene suture, but it is advisable to add an anterior fundoplication (Dor) to the myotomy as an extra safety measure, and to prevent reflux postoperatively.
Finally,if one believes that measures are needed to prevent postoperative gastroesophageal reflux, it is also possible to add a posterior 180–270-degree Toupet fundoplication.
Esophageal Myotomy for Achalasia
Bilateral Truncal Vagotomy |
Vagotomies |
Truncal vagotomy is not a difficult procedure and should take no more than about 20 min. The patient setup and the surgeon’s position between the patient’s legs, with the assistants on each side, are the same as for all approaches to the hiatus. The landmarks are also the same: the avascular aspect of the lesser sac that,once opened,leads to the caudate lobe of the liver, and the right crus of the diaphragm at the left side of the caudate lobe (Fig. 5.24a).
The right crus of the diaphragm is grasped by the left grasper in the left hand of the surgeon, and the harmonic shears are used to create a small space between the esophagus and the right crus. This space is avascular. With spreading movements of both the shears and the grasper, the space is enlarged, leading to visualization of the left crus of the diaphragm. If the left crus is not immediately recognized, it is possible to follow the right crus down until it connects with the left crus.
The search for the right vagus nerve begins at this point. It usually lies on the back wall of the esophagus, or next to either the right or left crus. The posterior vagus nerve is a big trunk that cannot be missed: it is white, with small veins running on its surface, and it is elastic and resistant to pulling. The posterior vagus is divided between clips, and a piece is sent for pathological examination (Fig. 5.24b).
At this point it is possible to divide the phrenoesophageal membrane that covers most of the branches of the left vagus nerve. The left grasper is used to pull up on the membrane,
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Fig. 5.24 Bilateral truncal vagotomy: (a) landmarks, and (b) divisions of vagus nerves
while the harmonic shears create a dissection plane between the esophagus and the membrane. Clips can be placed as the esophageal membrane is divided to avoid any oozing of blood, or the harmonic shears can be used. Dissection is continued until the angle of His is reached in the area of the fat pad. It should now be possible to recognize one or two trunks of the left vagus nerve, which will be divided in the same manner as the right vagus nerve.
A 30-degree laparoscope should be used to check the posterior aspect of the left border of the esophagus. In this area one should look in particular for the “criminal” nerve branches of Grassi that usually run on the left side of the esophagus. It is crucial to
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Fig. 5.25 Division of the “criminal” nerve branches of Grassi in bilateral truncal vagotomy
divide these to ensure a total vagotomy (Fig. 5.25). If they are missed, the chances of recurrence of an ulcer are greatly increased. If necessary, one should go back and create a small window behind the esophagus to enable division of these “criminal” branches.
Finally, the area is thoroughly rinsed and aspirated, and hemostasis completed as needed.
Highly Selective Vagotomy
This operation proceeds in the same manner as for open surgery. It is important to recognize the landmarks that are part of the operation: the greater gastric nerves of Latarjet, terminal branches of the right and left trunks of vagus nerves, and the crow’s foot at the antrum. Each crow’s foot has between three and five branches. The greater nerves of Latarjet before their ending give rise to several fundic branches that need to be divided to assure a complete highly selective vagotomy (Fig. 5.26).
The beginning of the operation is tedious because one has to create a dissection space in a very narrow angle. This is achieved by dividing a large vessel next to the last branch of the crow’s foot, which will permit division of all the branches together with the vessels, starting from below and moving in a cephalad direction towards the esophagus. It is important to stay close to the lesser curvature of the stomach and avoid the main trunk of the gastric nerve. Indeed, a hematoma may cause compression of the nerve, or even incorrect identification of the nerve and the risk of injury will be greater.
The technique of dissection is to create a window between each vessel and nerve. These windows are created with harmonic shears. Then with a scooping motion each vessel is mobilized and clips are applied (Fig. 5.27). It is important to start with each leaf, of which there are usually three:
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Fig. 5.26 Anatomical landmarks in highly selective vagotomy
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Fig. 5.27 The general technique of division of vessels, applying to highly selective vagotomy, gastrectomy, splenectomy, and Nissen fundoplication. (a) dissection with curved scissors, (b) placement of clips, (c) division of vessels between double clips
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Fig. 5.28 Highly selective vagotomy using clips
An anterior leaf containing all the vessels and nerve branches of the anterior greater nerve of Latarjet
A middle leaf, usually devoid of any vessels
A posterior leaf containing vessels and the branches of the posterior greater nerve of Latarjet
It is imperative to go all the way up to the gastroesophageal junction, and then as in open surgery to continue on the anterior aspect of the esophagus until the angle of His is reached. Then division is started again at the antrum and proceeds in a cephalad manner until the lesser sac is completely opened, which will signify division of all the fundic branches of the two greater nerves of Laterjet. It is important to make sure that at least 3 in. (8 cm) of the esophagus is skeletonized superiorly, but care must be taken not to divide or injure the main trunk of the vagus nerves themselves (Fig. 5.28).
If there is bleeding of a small vessel next to the lesser curvature it is possible to grab the vessel. However, sometimes it is as convenient and more effective to grab the lesser curvature itself with an atraumatic clamp, which should always be available when performing this operation. Subsequently, the general principles apply: pan out the video camera, irrigate and clean the area around the bleeding, and then do selective hemostasis by using either clips or electrocautery.