Surgical Department at Saint Barnabas Medical Center

Publications - Prayag Barot, MD

Laparoscopic Gastroesophageal Junction Surgery
October 26, 2001 Laparoscopic Conference

Outline

1. Nissen Fundoplication

• The Symptoms
• The Anatomy
• Preoperative evaluation
• The Surgery

2. Heller Myotomy

• The Symptoms
• Preoperative evaluation
• The Surgery

3. Diaphragmatic Hernias

• Hernia types
• The Surgery
  
  

Gastroesophageal Reflux

The Symptoms

• 44% of Americans experience GERD symptoms at least once a month and 18% take some type of OTC medication
• Heartburn, dysphagia, regurgitation, and chest pain are the most common symptoms
• Basic physiologic process is the breakdown of the mechanical anti-reflux mechanism at the cardia of the stomach allowing contents to regurgitate back into the esophagus
• Poor esophageal motility as well as delayed gastric emptying enhances reflux symptoms
• "Shortened esophagus” - strictures and fibrosis of the distal esophagus which results in a “taking up” of the LES into the chest leading to incompetence

The Anatomy

• holds the LES in the abdomen by extrinsic squeeze pressure
  

Preoperative Evaluation

• First trial on medical therapy for 6 to 12 week
• if symptoms recur or are not alleviated, then try endoscopy with biopsy and barium esophagram
• If this is abnormal, do esophageal manometry and 24 hour pH studies
• Only if this is abnormal should they be considered for surgery

Medical Therapy

• Mild esophagitis- weight reduction, elevate head of bed, stop smoking, antacids
• Moderate esophagitis- receptor antagonists, prokinetic agents
• Erosive esophagitis- proton pump inhibitors

Savary-Miller classification of esophagitis

• erythema
• isolated ulcerations
• confluent ulcerations
• fibrosis, strictures, Barretts metaplasia

Biopsy during endoscopy may reveal Helicobacter pylori

Barium Esophogram

• Nature of hiatial hernias can be identified
• Rate of passage can indicate possible esophageal motility disorders
• Spasm or dilations can be identified
• Free reflux of barium into the esophagus is NOT diagnostic of GERD

Esophageal Manometry

• Offers information on motor characteristics of the LES
• 5 water filled balloons are spaced 5cm apart
• Progressively withdrawn from stomach through LES and into the esophagus to measure exact pressures and length of the LES
• Helpful to diagnose esophageal motility disorders which may mimic GERD (achalasia, diffuse esophageal spasm, nutcracker esophagus)

24-hour pH measurement

• Useful for the surgeon to confirm that symptoms are indeed caused by acid reflux, and that a Nissen fundoplication may be therapeuti
• pH probe placed 5cm above the LES
• pH continuously monitored. pH below 4 indicates acid exposure
• Positive test when greater than 5% of the time is recorded with pH below 4
  
  

The Surgery

Three types of repairs commonly done today:
1) The Troupet Procedure... 2)The Hill Repair... 3) The Nissen Fundoplication

	Troupet Repair Popular in Europe 270 degree posterior fundoplication The fundus is attached to the left crus firs The fundus is fixed to the right crus The fundus is now fixed to the left and right sides of the esophagus. This increases the esophageal angle and helps to prevent reflux This repair is best for patients with poor esophageal motility where a 360 degree wrap would be obstructing. Additionally, it does not require a full mobilization of the fundus as it is only a 270 degree wrap.
	Hill Repair A fixation of the cardia to the preaortic fascia along with a lesser curvature gastroplication Produces an elongation of the intraabdominal LES as well as a posterior angulation to the GE junction Requires less dissection since no fundoplication is involved, but is technically challenging to correctly identify the preaortic fascia!

The Nissen Fundoplication

Patient is placed in liithotomy position and in steep reverse Trendelenberg with the surgeon standing between the legs with an assistant on each side.

	Trocar Placement 10 mm port inserted above the umbilicus for the camera 10 mm port placed in upper midline, right subcostal, and two 5 mm ports placed in left subcostal area the liver is retracted through the right subcostal port
	Dissection of the Right Crus The gastrohepatic ligament is divided to gain access to the esophagus The right crus is immediately to the left of the caudate lobe §the anterior edge of the right crus is cut from the subhiatal fat pad, taking care to avoid the anterior vagus nerve
	Dissection of the Left Crus The left crus curves around the esophagus and is dissected free to create a window behind the esophagus The posterior vagus nerve is carefully dissected free and brought posterior to the window §the anterior vagus nerve can remain with the esophagus It is important not to do any blind dissection behind the esophagus as this can lead to gastric perforation
	Approximation of the Crura After a 4-5 cm window is created behind the esophagus and the vagus nerve identified, the crura are approximated using 2-0 non-absorbable suture A 60 F bougie should be passed so that the repair is not too tight
	Mobilization of the Fundus Mobilize the fundus 10 cm distal to the Angle of His to create a tension free fundoplication §the short gastric vessels are clipped. The posterior wall of the fundus is now visible. The section of fundus 5-7 cm distal to the Angle of His should be the most mobile, as this will be pulled around the esophagus
	The Wrap A Babcock clamp is passed behind the esophagus, and grasps the fundus 6-7 cm below the Angle of His This is pulled behind the esophagus and the fundus is approximated so that a contiguous portion of fundus is wrapped around the esophagus The bougie is again advanced to confirm that the wrap is not too tight
	The Completed Fundoplication Vertical U-shaped 2-0 Prolene sutures between pledgets are used to anchor the fundoplication The stitch passes through the full thickness of the stomach, and should include a small part of the esophagus muscle to hold the wrap in place No NGT necessary after surgery §patients may start clear liquids the day after surgery

The Heller Myotomy -

The Symptoms

• Achalasia- lack of peristalsis and lack of complete relaxation of the LES
• Surgical cardiomyotomy and pneumatic dilatation are two ways to improve flow through the LES
• Surgery is able to relieve the obstruction more precisely, but its cost and patient disability make it the second line of treatment after dilatation
• However, with more minimally invasive procedures, its is becoming a more popular method of treatment lcan be done thoracoscopically or laparoscopically

Preoperative Evaluation

• A barium swallow shows the typical “bird’s beak” narrowing seen in achalasia
• Endoscopy should be performed to rule out intraluminal tumors or strictures
• Manometry is used to diagnose motility disorders such as diffuse esophageal spasm or nutcracker esophagus. More specifically, manometry shows the surgeon the area of functional disease

The Anatomy

The esophagus has an outer longitudinal and an inner circular layer of muscle These muscle layers blend in with the musculature of the stomach

	The Heller Myotomy Patient Positioning Steep reverse Trendelenberg Camera inserted above the umbilicus lright costal port for liver retraction Left lateral port for stomach retraction Upper midline and left costal ports for surgical instruments
	Isolating the Esophagus The esophagus is identified by placing an endoscope and following the light Flexing the endoscope serves to stretch the anterior wall of esophagus, facilitating dissection Dissection is carried up from the stomach, preserving the anterior vagus nerve
	The Myotomy The outer longitudinal muscle layer is cut The circular muscle layers are individually divided with a hook cautery Care must be taken not to perforate the mucosa The total length of the myotomy must be about 6 cm, with the lower 2 cm extending onto the cardioesophageal junction At conclusion, the mucosa should protrude freely, with about 40% of its circumference exposed

Diaphragmatic Hernias

Type I (sliding) - the GE junction migrates through the diaphragm

Type II (paraesophageal) - the fundus herniates through the diaphragm with normal GE junction

Type III - a combination of both

Type IV - inclusion of another abdominal organ through the diaphragm

Most hernias are type I, true paraesophageal hernias are seen less than 5% of the time



Hernia Pathophysiology

• Sliding hernias develop because of weakness in the phrenoesophageal ligament
• Paraesophageal hernias occur due to a widening of the hiatus anterior to the esophagus. This may be congenital.
• Iatrogenic paraesophageal herniation may occur after antireflux procedure or Heller Myotomy. Any breakdown of the crural repair will lead to herniation.

The Anatomy

Presentation

• Most patients are asymptomatic or may present with vague chest discomfort.
• Bleeding and strangulation are serious complications, more often seen with paraesophageal hernias
• Volvulus presents with severe pain and associated obstructive symptoms
• Necrosis and perforation lead to septic shock. The mortality rate is 50% at this stage.

Diagnosis

• Lateral CXR reveals a retrocardiac air fluid level - the stomach within the chest
• A retroflexed endoscope will show a second orifice next to the esophagus when looking up from the stomach

Diaphragmatic Hernias

The Surgery

• Hernia Reduction
  • The stomach is reduced into the abdomen
  • The gastrohepatic ligament is divided to gain access to the crura
• Excision of the sac
  • The hernia sac is dissected off the right crura using hook cautery
  • It is essential to excise the hernia sac to prevent recurrence
• Repair of the Crura
  • The esophagus is carefully dissected free and retracted anteriorly
  • Crura are approximated using 2-0 Prolene interrupted sutures
  • A 58 F bougie is passed to make sure the repair is not too tigh
• The Fundoplication
  • floppy Nissen Fundoplication is now done to prevent herniation through the repaired crura

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