Laparoscopic Heller procedure with anterior fundoplication for achalasia

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Laparoscopic Heller procedure with anterior fundoplication for achalasia

Authors

Mots-clés

achalasie,Heller

Type de vidéo

Vidéo chirurgicale

Durée

20'00''

Publication

2004-12

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1687.htm

Laparoscopic Heller procedure with anterior fundoplication for achalasia

1. Trocar placement 00'21''

Regarding port placement, it is exactly the same as for reflux disease. I use this placement for all upper GI surgeries.

2. Esophageal dissection 01'17''

You see that the start of the operation is exactly the same, looking at this landmark, trying to get access to the mediastinum. Here we have to be a little bit more careful because we know that there is an enlargement of the lower esophagus. Again doing this blunt dissection, trying to find a plane carefully, see the esophagus is quite large. We have a view on the esophagus so it’s ok and we continue the dissection of this hiatus. Discussion about the type of valve of anti-reflux mechanism that we will build; if you are doing a Dor anterior fundoplication, you don’t need to dissect the posterior attachments and you focus on the anterior aspect of the esophagus. In general, there are not that many surgeons with experience in this type of disease. If you are doing reflux surgery, you don’t go to this part of the GE junction, but here for the achalasia, you have to open this fat pad in order to get access to the gastric part of the cardia. So now I will try to see where the vagus trunk is, it is here. I am freeing a little the anterior aspect of the esophagus. One of the important things, as it seems to me, is to see the line of the esophagus because it’s important to stay on the anterior aspect or isn’t it when you are doing the myotomy.

3. Gastroesophageal junction dissection 04'20''

Now I am quite careful in order to avoid the vagus trunk. Any thoughts on operating these patients after they have had other treatments such as dilatations or injections? Dilatation is not a big problem but for injections, it is very difficult because I remember the last time I came I did a myotomy just the day before for a woman with previous injections of toxins, the operation went on well but there was a very difficult zone at the site of the injections. The dye test on the first morning was ok, after leaving they called me because she was in pain and in fact there was a perforation at the site of the toxin injections because in this area the mucosa is very thin. Maybe I made a mistake in this patient and did a posterior valve instead of anterior because she also had very severe reflux, and I didn’t cover the myotomy. I would say that if the patient has had previous injections, in all the cases, I would do an anterior valve to cover the myotomy; if there is only a dilatation or things like that, then we can discuss the choice between partial posterior and the anterior valve. Because of laparoscopy, I am trying to do a simple myotomy without an antireflux mechanism and then see if the patient is doing well, it’s ok, but if not, we have to do an esophagectomy. I give them a chance to get back to normality if possible but in most of the cases, they can’t. Stage 3 of achalasia and usually the esophagus doesn’t get back to a normal function. It is important to discuss with these patients what the expectancies are. It is very helpful to clean because we have to have a very precise dissection and if you are using fluids or water to clean, then the sponge is very helpful. What do you perform on your patients the next day? I do a dye test the next morning and if they are doing well, they can have soft food. Part of the work is to try and preserve those branches. We are coming to the gastric part of the cardia, I clean as much as possible. I have a look in the mediastinum to see if it’s ok. I think that I have to clean a little bit more. I am mobilizing a little bit. I am going up into the mediastinum to have the access to the esophagus and make sure that my myotomy is going in the right direction. You see that the mediastinum has much more adhesions than the reflux that we did before. You can find this aspect when you are dealing with very severe esophagitis. What length of myotomy are you aiming to do? It will probably be about 6cm on that part and 2cm there.

4. Myotomy 10'31''

We are going to start the myotomy, the vagus trunk is there, I am not starting there because it is very difficult to find a plane in this area so I am starting on the esophageal part of the cardia. When you are doing this operation, you always know where you are, if you wonder whether or not you are in the right there, you are not. But it is complicated when people have had Botox injections because the things become somewhat fibrotic. It is a little bit more difficult in this area and usually perforations occur in this part, that’s why I am very careful and you see that I have switched from the ultrasonic scissors to the normal shears. What can also be very helpful in this area is the hook with cautery because you can come from the upper part. I think it is looking good. Now we can do an endoscopy to see if we have completed this myotomy.

5. Endoscopic control 15'58''

There you can see now where the mucosa is, where the myotomy starts, stomach there. You see on the endoscopy that we can see the vessels but apparently there are no fibres left. So it looks good and we have desufflated the stomach. The esophagus is very large, it is not a sigmoid but not far off. What is your advice for the length of the myotomy? In general, it is about 6 to 8cm, 6cm on the esophageal part and 2cm at least on the gastric part.

6. Gastric mobilization 18'10''

6cm is the minimum length on the esophagus, is it the same if you have a diverticulum? Yes. I like gastric mobilization because I feel that I can do anything afterwards. You can really tailor your fundoplication without too much traction. Even if I am doing a partial fundoplication, I am mobilizing this upper part of the stomach. We can see this posterior attachment very well. It is a very good method of lifting the posterior wall up, it really exposes it so well. You are sure that you divide what you have to.

7. Anterior fundoplication 19'18''

I think here is enough, so you see the valve is coming very easily and we can do an anterior fundoplication. The advantage of this is to cover the myotomy as compared to the partial posterior approach so I like it this way. Always the same suture, it helps to create the angulation, probably not very helpful but I feel at ease. I like to fix it on the crus, makes it opens. I am always afraid when I do an anterior approach that I am closing the myotomy. By now, we have no traction on the stomach, it’s the normal place of the stitch, you don’t have to make it when you have a big traction on the GE junction because otherwise the esophagus is going up and you will have some tearing on the stitch. It maintains it open. Do you ever close the hiatus? No. With this very large esophagus for reflux or problems like that, we have pills but for any sort of outlet problems, we don’t have anything. I prefer to open it widely in order to avoid any source of dysphagia, because she will still have dysphagia, instead of trying to construct a new external sphincter. For stage 1 achalasia in young patients sometimes with associated with hiatal hernia, I would do a small crura repair, but not in this case. I have to maintain it very widely open. I think that is an important element, it is to have a loose hiatus. Normally this should stay like this, even if I am doing the anti-reflux this way. If I put a stitch between the valve and the myotomy, I have to fix them now on the crus otherwise I close the myotomy. I could put another stitch here on the myotomy and then on the crura but I don’t think it is necessary so I fix it on the crura only. I put this last stitch there and it is finished.