Minimally Invasive Esophageal Procedures

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Minimally Invasive Esophageal Procedures

from ACS Surgery: Principles & Practice

Posted 04/12/2004

Marco G. Patti, MD, FACS; Piero M. Fisichella, MD

Focuses on minimally invasive techniques for the treatment of abnormal

gastroesophageal reflux and motility disorders of the esophagus; presents a

step-by-step description of laparoscopic Nissen fundoplication, laparoscopic

Heller myotomy with partial fundoplication, left thoracoscopic myotomy, and

right thoracoscopic myotomy; describes preoperative evaluation, operative

planning, operative technique, troubleshooting, complications, and outcome

evaluation.

Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux

In all patients except those with very poor esophageal motility -- for whom

partial fundoplication is preferable -- we advocate performing a 360° wrap

of the gastric fundus around the lower esophagus as described by Nissen, but

we always take down the short gastric vessels to achieve what is called a

floppy fundoplication. This type of wrap is very effective in controlling

gastroesophageal reflux disease (GERD).[1,2] The operation can be divided

into nine key steps as follows: (1) insertion of trocars; (2) division of

gastrohepatic ligament, and identification of right crus of diaphragm and

posterior vagus nerve; (3) division of peritoneum and phrenoesophageal

membrane above esophagus, and identification of left crus of diaphragm and

anterior vagus nerve; (4) creation of a window between the gastric fundus,

the esophagus, and the diaphragmatic crura, and placement of a Penrose drain

around esophagus; (5) division of the short gastric vessels; (6) closure of

the crura; (7) insertion of a bougie into esophagus and through the

esophagogastric junction; (8) wrapping of the gastric fundus around lower

esophagus; and (9) final inspection and removal of instruments and ports

from the abdomen.

In Diagnosing GERD, Symptoms Are Less Sensitive and Specific Than Commonly

Believed

All patients who are candidates for a laparoscopic fundoplication should

undergo a preoperative evaluation that includes the following: (1)

symptomatic evaluation, (2) an upper GI series, (3) endoscopy, (4)

esophageal manometry, and (5) ambulatory pH monitoring.

The presence of both typical symptoms (heartburn, regurgitation, and

dysphagia) and atypical symptoms of GERD (cough, wheezing, chest pain, and

hoarseness) should be investigated, and symptoms should be graded with

respect to their intensity both before and after operation. Nonetheless, a

diagnosis of GERD should never be based solely on symptomatic evaluation.

Many authorities assert that the diagnosis of GERD can be made reliably from

the clinical history, so that a complaint of heartburn should lead to the

presumption that acid reflux is present; however, testing of this diagnostic

strategy has demonstrated that symptoms are far less sensitive and specific

than they are usually believed to be. For instance, our group found that of

822 consecutive patients referred for esophageal function tests with a

clinical diagnosis of GERD (based on symptoms and endoscopic findings), only

70% had abnormal reflux on pH monitoring.[3] Heartburn and regurgitation

were no more frequent in patients who had genuine reflux than in those who

did not; thus, symptomatic evaluation, by itself, could not distinguish

between the two groups.

Mistakes during Trocar Insertion in Nissen Fundoplication

During trocar insertion in Nissen fundoplication, a common mistake is to

place the ports too low in the abdomen, thereby making the operation more

difficult. If port C is too low, the fan retractor will not retract the

lateral segment of the left lobe of the liver well, and the esophagogastric

junction will not be exposed. If port B is too low, the Babcock clamp will

not reach the esophagogastric junction, and when the laparosonic coagulating

shears or the clip applier is placed through the same port, it will not

reach the upper short gastric vessels. If ports D and E are too low, the

dissection at the beginning of the case and the suturing at the end are

problematic.

Other mistakes of positioning must be avoided as well. It is important not

to place port C too medially, because the fan retractor may clash with the

left-hand instrument; the gallbladder fossa is a good landmark for

positioning this port. Port A must be placed with extreme caution in the

supraumbilical area: its insertion site is just above the aorta, before its

bifurcation. Accordingly, we recommend initially inflating the abdomen to a

pressure of 18 mm Hg just for placement of port A, because increasing the

distance between the abdominal wall and the aorta reduces the risk of aortic

injury. We also recommend directing the port toward the coccyx. After

insertion of this port, the intraperitoneal pressure is decreased to 15 mm

Hg. A Hasson cannula can be used in this location, particularly if the

patient has already had one or more midline incisions. Maintaining the

proper angle (60° to 120°) between the axes of the two suturing instruments

inserted through ports D and E is also important: if the angle is smaller,

the instruments will cover part of the operating field, whereas if it is

larger, depth perception may be impaired. Finally, if a trocar is not in the

ideal position, it is better to insert another one than to operate through

an inconveniently placed port.

If the surgeon spears the epigastric vessels with a trocar, bleeding will

occur, in which case there are two options. The first option is to pull the

port out, insert a 24 French Foley catheter with a 30 ml balloon through the

site, inflate the balloon, and apply traction with a clamp. The advantage of

this maneuver is that the vessel need not be sutured; the disadvantage is

that the surgeon must then choose another insertion site. At the end of the

case, the balloon is deflated. If some bleeding is still present, it must be

controlled with sutures placed from outside under direct vision. The second

option is to use a long needle with a suture, with which one can rapidly

place two U-shaped stitches, one above the clamp and one below. The suture

is tied outside over a sponge and left in place for 2 or 3 days.

Complications of Nissen Fundoplication

A feared complication of laparoscopic Nissen fundoplication is an esophageal

or a gastric perforation. This complication is caused by traction applied

with the Babcock clamp or a grasper to the esophagus or the stomach

(particularly when the stomach is pulled under the esophagus) or by

inadvertent electrocautery burns during any part of the dissection. A leak

will manifest itself during the first 48 hours. Peritoneal signs will be

noted if the spillage is limited to the abdomen; shortness of breath and a

pleural effusion will be noted if spillage also occurs in the chest. The

site of the leak should always be confirmed by a contrast study with barium

or a water-soluble contrast agent. Perforation is best handled by means of

laparotomy and direct repair. If a perforation is detected intraoperatively,

it may be closed laparoscopically.

About 50% of patients experience mild dysphagia postoperatively. This

problem usually resolves after 4 to 6 weeks, during which period patients

receive pain medications in an elixir form and are advised to avoid eating

meat and bread. If, however, dysphagia persists beyond this period, one or

more of the following causes is responsible.

1. A wrap that is too tight or too long. The wrap should be performed

without tension over a 56 French bougie. The total length of the wrap should

not exceed 2.5 cm.

2. Lateral torsion with corkscrew effect. If the wrap rotates toward the

right (either because of tension from intact short gastric vessels or

because the fundus is small), a corkscrew effect is created.

3. A wrap made with the body of the stomach rather than the fundus. The

relaxation of the lower esophageal sphincter (LES) and the gastric fundus is

controlled by vasoactive intestinal polypeptide and nitric oxide; after

fundoplication, the two structures relax simultaneously with swallowing. If

part of the body of the stomach rather than the fundus is used for the wrap,

it will not relax as the LES does on arrival of the food bolus.

4. Choice of the wrong procedure. In patients who have severely abnormal

esophageal peristalsis (as in end-stage connective tissue disorders), a

partial wrap should be performed. A 360° wrap will control reflux, but it

may cause postoperative dysphagia and gas bloat syndrome.

If the wrap slips into the chest, the patient becomes unable to eat and

prone to vomiting. A chest radiograph shows a gastric bubble above the

diaphragm, and the diagnosis is confirmed by means of a barium swallow. This

problem can be prevented by using coronal sutures and by ensuring that the

crura are closed securely.

Paraesophageal hernia may occur if the crura have not been closed or if the

closure is too loose. In our view, closure of the crura not only is

essential for preventing paraesophageal hernia but also is important from a

physiologic point of view, in that it acts synergistically with the LES

against stress reflux. Sometimes, it is possible to reduce the stomach and

close the crura laparoscopically. More often, however, because the crural

opening is very tight and the gastric wall is edematous, laparoscopic repair

is impossible and laparotomy is preferable.