Gastrophageal Reflux Disease
And Hiatal Hernia
Jeffrey H. peters ,,m.d., F.A.C.S
A. Indication and preoperative Evaluation
1. Laparodcopic fundoplication is indicated for the treatment of objectively documented, relatively severe gastresophagesl reflux ial (gerd). Care in patient selection and preoperative evaluation are essential for good results .patients with gastroesophageal reflux and any of the following may be considered candidates for the procedure:
a. Esophageal complication such as erosive eaophagitis ,stricture, or barrett’s esophagus
b. Respiratory complications such as recurrent pneumonia or bronchiectasis.
c. Dependence upon proton pump inhibitors (PPIs) for relief of symptoms, particularly if does escalation is required, and in the young
d. Laryngeal and/or respiratory symptoms with a good response to PPI therapy.
2. The therapeutic approach to patients presenting for the first time with symptoms suggestive of gastroesophageal reflux includes an initial trial of PPI Therapy. Many patients will already have sought relief with readily available over the counter agents.
a. Failure of proton pump inhibitors to control the symptoms, suggests either that the diagnosis is incorrect or that the patients has severe disease.
b. Endoscopic examination at this stage of evaluation provides the opportunity for assessing the severity of mucosal damage and the presence of barrett’s esophagus (see part 11, chapter on indication forupper gastrointestinal endoscopy).either finding on initial endoscopy predicts a high risk for medical failure.
3. Appropriate diagnostic evaluation should then be undertaken. The diagnostic approach to patients suspected of having gastroesophageal reflux disease and being considered for antireflux surgery has three important goals. Symptoms thought to be indicative of gastroesophageal reflux disease, such as heartburn or acid regurgitation, are very common in the general population and cannot be used alone to guide therapeutic decision, particularly when one is considering antireflux surgery. These symptoms, even when excessive, are not specific for gastroesophageal reflux and are often caused by other diseases(such as achalasia, diffusespasm, esophageal carcinoma, pyloric stenosis, cholelithiasis gastritis, gastric or duodenal ulcer, and coronary artery disease). A common error is to define the presence of gastroesophageal reflux disease by the endoscopic finding of esophagitis. Limiting the diagnosis to patients with endoscopic esophagitis ignores a large population of patients without mucosal injury who may have severe symptoms of gastroesophageal reflux and could be considered for antireflux surgery. The most precise approach to define gastroesophageal reflux disease is to measure the basic pathophysiologiceased abnormality of the disease, that is, increased exposure of the esophagus to gastric juice. The workup consists of the following stages.
a. 24-hour pH monitoring, to assess the degree and pattern of esophageal exposure to gastric juice. A positive 24-hour ph study is the single most important predictor of a successful outcome.
b. Manometric examination of the lower esophageal sphincter and motor function of the body of the esophagus. this provides insight into the reasons for reflux(sphincter incompetence) as well as the function of the esophageal body.
c. Assessment of esophageal length to exclude esophageal shortening.repetitive. injury causes scarring and fibrosis , and ultimately results in anatomic. Shortening of the esophagus.this compromises the ability to do an adequate repair without any tension and leads to an increased incidence of breakdown or thoracic displacement of the repair.
i. Esophageal length is best assessed using video roentgenographic contrast studies and endoscopic findings.
ii. Endoscopically, hernia size is measuredas the difference between the diapharagmatic crura, identified by having the patient sniff, and the gastroesophageal junction, identified as the loss of gastric rugal folds. Suspect a short esophagus if there is a large(>5 cm) hiatal hernia, particularly if it fails to reduce in the upright position on a video barium esophagram.
Iii. Selection of a partial versus complete fundoplication,and an open or laparoscopic approach is based upon on an assessmentof of esophageal contractility and length.laparoscopic fundoplication is ased in the majority of patients unless a very large(>5-6cm) hiatal hernia or intrathoracic stomach is present, in which case it may be preferable to use an open approach. Recent data would suggest that in the absence of a named motility disorder such as achalasia or scleroderma, most patients with reflux disease will tolerate a properly constructed 360-degree nesses fundoplication without an increased incidence of dysphygia. In addition, the failure rate of partial fundoplication has beenreported to be ashigh as 50% after 2 to 3 years.
B. Patients Position Room Setup
1. Position the patients supine, in a modified lithotomy position. it is important that the knees be only slightly flexed,to avoid limiting mobility of the surgeon and the instruments.
2. The surgeon stands between the legs and work with the both the hands. This allow the right and left handed instrumentsto approach the hiatus from the respective upper abdominal Quadrants.
3. Use 30%to 45% of reverse trendelenburg to displace the transverse colon and small bowel inferiorly, keeping them from obstructing the view of the video camera.
C. Totcar position and principles of exposure.
1. Uive 10-mm ports are utilized; 5-mmports may be substitutedin the subxiphoid and right sub costal access sites.2. Place the camera above the umbilicus,one third of the distance to the xiphoid process. in most patients if the camera is placed in the umbilicus,it will be too low to allow adequate visualization of the hiatal strictures once dissected.atransrectus location is preferableto midline to minimize the prevalence of port site hernia formation.
3. Place two lateral retracting ports in the right and left anterior axillary lines,respectively. position the trocar for the liver retractor in the right midabdomen,at or slightly below the caamera port. This allows the proper angle towards the left lateral segment of the liver and the ability to push the instrument toward the operating table, lifting the liver. Place the second retraction port at the level of the umbilicus, in the left anterior axillary line.placement of these ports too far lateral or too low on the abdomen will compromise the eccursion of the instruments and thus the ability to retract.
4. The left side operating port( surgeon’s right hand) is placed 1 to 2 in.below the costal margin approximately at the lateral rectus border.this allow triangulation between the camera and the two instruments .
And avoids the difficulty associated with the instruments being in direct line with the camera. The right-sided operating port(surgeon’s left handed(surgeon’s left hand) is placed last after right lateral segment of the liver has been retracted.this prevents”swordfighting” between the liver retractor and the left handed instrument. The falciform ligament hangs low in many patients and provides abarrier around which the left handed instrument must be manipulated.
5. Initial retraction is accomplished with exposure of the esophageal hiatus. A fan retractor is placed into the right anterior axillary port and positioned to hold the left lateral segment of the liver toward theanterior abdominal wall .we prefer to utilize a table retractor to hold this instrument once properly position.trauma to the liver should be meticulously avoided bescause subsequent bleeding will obscure the field. Mobilization of the left lateral segmment by division of the triangular ligament is not necessary. Place a babcock clamp into the left anterior axillary port and retract the stomach toward the patient’s left
D. Technique of nissen fundoplication
1. The critical elements of laparoscopic nissen fundoplication are enumeratedin table21.2 and will be discussed in detail.Crural dissection begins with the identification of the right crus.matzenbaum-type scissors and fine grasping forceps are preferred for dissection. In all except the most obese patients, there is a very thin portion of the gastrohepatic comentum overlying the caudate lobe of the liver.
a. Omentum above and below the hepatic branch of the anterior vagal nerve( which the author routinely spares).
b. A large left hepatic artery arising from the left gastric artery will be present in up to 25% of patients. it should be identified and avoided. A right crural branch will occasionally be seen which can be divided.
c. After the gastrohepatic omentum has been incised, the outside of the right crus with scissors and electrocautery,and dissect the right crus from anterior to posterior as far as possible.
d. The medial portion of the right crus leads into the mediastinum and is entered by blunt dissection with both instruments.
e. At this juncture the esophagus usually becomes evident. Retract the right curs laterally and perform a modest dissection of the tissues posterior to the esophagus.do not attempt to dissect behind thegastroesophageal junction at this time.
f. Meticulous homeostasis is critical. Blood and fluids tend to pool in the hiatus and are difficult to remove. Irregation should be avoided. Take care not to injure the prentice artery and vein as they course above the hitatus. a large hiatal hernia often makes this portion of the procedure easier because it accentuates the diaphragmatic crura.on the other hand,dissection of a large meditational hernia sac can be difficult.
g. Following dissection of the right curs,attention is turned toward the anterior crural confluence. Use the left-handed grasper to holdup the tissues anterior to the esophagus, and sweep the esophagus downward and to the right,separating it from the left curs.
h. Divide the anterior rural tissues and identify the left curs. The anterior magus nerve often”hugs” the left curs and can be injured in this portion of the dissection if not carefully searched for and protected.
i. Dissect the left crus as completely as possible, including taking down the angle of his and the attachments of the fundus to the left diaphragm. A complete dissection of the lateral and inferior aspect of the left crus and fundus of the stomach is the key maneuver allowing circumferential mobilization of the esophagus. Failure to make a complete dissection will result in difficulty in encircling the esophagus,particularly if approached from the right . repositioning of the Babcockretractor toward the fundic side of the stomach facilitates retraction for this portion of the procedure. The posterior vagus nerve may be encountered in the low left crural dissection. it should be looked for and protected.
2. Circumferential dissection of the esophagus is achieved by careful dissection of the anterior and posterior soft tissues within the hiatus.if the crura have been completely dissected then dissection posterior to the esophagus to create a window will not be difficult.
a. From the patient’s right side, use the left-handed instrument to retract the esophagus anteriorly. This allow the right hand to perform the dissection behind the esophagus. reverse thismaneuver for the left-sided dissection.
b. Leave the posterior vagus nerve on the esophagus.
c. Identify the left crus and keep dissection caudad to it. thereis a tendency to dissecect into the mediastinum and left pleura .
d. In the presence of severe esophagitis, transmural inflammation, esophageal shortening, and a large posterior fat pad, this dissection may be particularly difficult. if unduly difficult, abandon this route of dissection and approach the hiatus from the left side by dividing the short gastric vessels(see later) at this point in the procedure rather than the later.
e. After completing the poster dissection, pass a grasper (via the surgeon’s left-handed port) behind the esophagus and over the left crus. Pass a penrose drain around the esophagus and use this as an esophageal retractor for the remainder of the procedure.
3. Fundic mobilization. Complete fundic mobilization allow construction of a tension-free fundoplication.
a. Suspend the gastrosplenicomentum anteroposteriorly, in a clothesline fashion via two Babcock forceps, and inter the lesser sac approximately one third of the distance down the greater curvature of the stomach. Sequentially dissect and divide the short gastric vessels with the aid of ultrasonic shears (Ethicon endo-surgery, Cincinnati ,oh). An anterior-posterior rather than medial-to-lateral oriention of the vessels is preferred , with the exception of those close to the spleen. The dissection includes pancreaticogastric branches posterior to the upper stomach and continues until the right crus and caudate lobe can be seen from the left side. with caution and meticulous dissection, the fundus can be completely mobilized in virtually all patients.although generally possible via the right-and left-handedsurgeon’s access ports, occasionally this dissection will require removal of the liver retractor and placement of a second babcock forceps through the right anterior axillary port to facilitate retraction during the division of the short gastric vessels.
4. Esophageal mobilization. The esophagus is mobilized into the posterior mediastinum fo several centimeters to provide maximal intraabominal esophageal length. Posterior and right lateral mobilization is readily accomplished. Take care during the anterior and left lateral mobilization not to injure the anterior vagusnerve. gentle traction on the penrose drain around the gastroesophageal junction facilitates exposure. The right and left pleural reflections often come into view and should be avoided.
5. Crural closer. Continue the crural dissection to enlarge the space behind the gastroesophageal junction as much as possible.
a. Holding the esophagus anterior and to the left , approximate the crure with two to four interruptrd figure-of –eight 0-gauge ethibond sutures ,starting just above the aortic decussation and worhing anterior.
b. The auther prefers a large needle(CTI) passed down the left upper 10-mm port to facilitate a durable crural closure.
c. Because space is limited, it is often necessary to use the surgeon’s left-handed (nondominant) instrument as a retractor, facilitating placement of singlebites through each crus with the surgeon’s right hand.the aorta might be punctured while suturing the left crus. Identification of its antherior surface and often retracting the left crus away from theasrta via the left handed grasper will help avoid inadvertent aortic puncture.
d. The author prefers extracorporeal hnot tying using a standard knot pusher or a “tie knot” device, although tying within the abdomen is perfectly appropriate.
6. Create short, loose fundoplication with particular attention to the geometry of the wrap.
a. Grasp the posterior fundus and pass it left to right rather then pulling right to left. This assures that the posterior fundus is used for the posterior aspect of the fundoplication. this is accomplished by placing a babcock clamp through the left lower port, and grasping the midportion of the posterior fundus. gently bring the posterior fundus behind the esophagus to the right side with an upward, rightward, and clockwise twisting motion . this maneuver can be difficult particularly for the novice.ifso,placement of a 0silk suturein the midposterior fundus andgrasping it from the right side facilitates brining the posterior fundus around to create the fundoplication.
b. Bring the anterior wall of the fundus anterior to the esophagus above the supportingpenrose drain.
c. Manipulation both the posterior and antheriorfundic lips to allow the fundus to envelope the esophagus without twisting.laparoscopic visualization has a tendency to exaggerate the size of the posterior opening that has been dissected. Consequently,the space for the passage of the fundus behind the esophagus may be tighter than thought and the fundus relatively ischemic when brought around. If the right lip of the fundoplication has abluish discoloration, the stomach should be returned to its original position and the posterior dissection enlarged.
d. Pass a60-french bougie to properly size the fundoplication, and suture it utilizing a single U-stitch of 2-0 prolene buttressed with felt pledgets. The most commonerror is an attempt to grasp the anterior portion of the stomach to construct the right lip of the fundoplication rather than the posterior fundus .the esophagus should comfortably lie in the untwisted fundus prior to suturing.
e. Place two anchoring sutures of 2-0 silk above and below theU-stitch to complete the fundoplication. When finished , the suture line of the fundoplication should be facing in a right anterior direction.
f. Irrigate the abdomen ,assure hemostasis, and remove the bougie and penrose drain.