WebSurg中文版尚未完成，翻譯工作進行中！

Laparoscopic Nissen procedure for hiatal hernia

WebSurg是個虛擬大學，可在世界各地透過網路取得。我們的目標是提供外科醫師、科學協會及醫學產業第一個腹腔鏡及其最新發展之線上持續醫學教育的平台，包括NOTES和機器人手術。

建立帳號

瀏覽全世界

繁體中文 ▼

Google translate

總結
章節
您的意見
詢問專家群

欲觀看此影片請先登入！

Laparoscopic Nissen procedure for hiatal hernia

作者群

關鍵字

stomach,operation,gerd,gastroesophageal reflux disease,hiatal hernia

媒體類型

手術影片

期間

23'00''

刊物

2004-12

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1576.htm

Laparoscopic Nissen procedure for hiatal hernia

1. Trocar placement 00'16''

This is the head of the patient, we have the costal margins on both sides, one important thing is that this woman has a scar on the lower abdomen following a hysterectomy. The umbilicus is just here, I am not using it to introduce the optic port, I am working above the umbilicus for 2 reasons: I am using a 0 degree scope so I need to be quite high on this line; if I am using a 30 degree scope, I can be a little bit lower. This is the xiphoid process and just below it you have another 5mm port used for my left hand; on the right side of the patient, we have the liver retractor, this retractor can be fixed to a mechanical arm on the table. On the left side of the patient, the more active ports can be found, for my left hand here, my right hand just under the costal margin and very laterally another port, which is used to retract the GE junction and is used by the first assistant.

2. Exploration 01'59''

Regarding the anatomy, there is nothing very special, you see the liver retractor here, a very important thing when you are dealing with this type of upper GI surgery. You want a retractor that is adapted to this surgery and not one that divides the liver. Here we have what 60% of the people have to deal with, nothing special, it is a hiatus that has enlarged, with a sliding hiatal hernia, you can see the spleen there, this woman is a little bit fatty but it is not a big deal. Liver retractor a little bit lower; we can see the lesser omentum, the hepatic branches of the vagus trunks, we are used to working above those hepatic branches. We are going to work only in this area; to constrict the fundoplication, we have to use the upper part of the gastric fundus.

3. Hiatus approach 03'28''

Bernard always preserves these hepatic nerves, theoretically there is an increased risk of problems with abduction of gallstones, but it is a question of personal preference and judgement, it gives you slightly less room to manoeuvre in when you preserve them especially in obese patients. I am opening this phreno-esophageal membrane and trying to find the most important landmarks for this type of surgery. My first important landmark is the crura, the first I want to identify is the right crus. Here I have this very important landmark because if I don’t find it, you can go down lower and lower and down there, there is the vena cava. Be sure to find and create your landmarks to be sure that you’re working in the right direction. If you have this right crus, it is very easy to go into the mediastinum and it’s very safe because you know the esophagus is just down there. The first and most important step is to create and identify the different landmarks. I am working on the hiatus with traction placed on the GE junction with a grasper held by the right side assistant. You see it is easy because initially I try to find these marks. In laparoscopy, it is very important to have these tractions and counter-tractions because you don’t have your hand inside so you need other tools to retract and present the different structures. Now I know a little bit more about the hiatus and the position of the esophagus so it makes my work easier inside. Does the patient have a nasogastric tube in? At the start of the anesthesia, of course, we used a nasogastric tube to empty the stomach but as soon as I begin the operation, I take it out because it makes the esophagus too rigid; the risk of injuring the esophagus is more important so I prefer not to have anything in there. A moment ago, you saw the V posteriorly, where the right cruses come round, which he demonstrated beautifully. You see that I am using a lot of blunt dissection and only this device. You have different types of devices this is not the best one but it’s a question of habit.

4. Esophageal mobilization 08'12''

As you have seen, we have opened the lesser omentum just to show you that we can get access to the crura easily through both ways, upper and lower way. We saw the posterior vagus too. You can see that quite easily, it is more difficult to see the anterior vagus. You have seen this view with the vagus trunk, you can’t work without this landmark because without it you work in this direction and you open the left pleura; if you go too low you go into the posterior gastric fundus and you can get a perforation of the stomach so don’t do anything before having this view of the back of the esophagus. Then you have all the structures of the vagus trunks, just take the trunks with you and clear a little bit more the landmarks, and then you can progressively work on the left crus, which is here. Don’t force your way when you are on the right side, just go back to the left crus, clear a bit more, identify the different structures, and then by going back to your position, you will find your way. If you have some oozing, just by cleaning on the left crus, I did open the way. Nothing is done using force or in a blind way. We know from the start that a lot of problems came from the posterior dissection of the esophagus. I use the umbilical tape for traction on the GE junction without a grasper so it is quite helpful. I am using a tissue tape, I can do a knot and don’t need clips or anything. I am now working as you can see in the upper mediastinum to try and free the esophagus and get more length back into the abdomen. This woman bleeds quite easily, even with gentle dissection, there is some oozing; this oozing can be very difficult when you are in some parts of the mediastinum. You asked for the anterior vagus trunk. Just by changing the position of the assistant’s grasper, we can change the direction of the traction and the side that we are working on. We have no grasper on the esophagus, nothing very dangerous for it, it is just blunt retraction. In this part, we have to be very careful because the posterior vagus trunk lies somewhere there. You always do a 360 degree Nissen through choice. That is probably the simplest one and the one that gives the best results in my opinion, you don’t have too many sutures to do it. I have mobilized and now I check the length of the esophagus back into the abdomen because I have to release the traction and be sure that this junction is lying down in the abdomen without any tension. That is what we are testing now, I think it is ok. I am still preparing the crura for the next part of the operation, which is the crura repair, which is also very systematic. In this area, what can be annoying is sometimes a small left diaphragmatic crural artery coming here, so you have to be aware of it because you can get bleeding in this part of the diaphragm, which is sometimes difficult to control. With this type of Ultracision system, we don’t have this type of trouble anymore.

5. Gastric fundus mobilization 13'53''

We now move to the next part of the operation, which is the gastric mobilization that I do in all the patients. The first thing is to find the place where to start the gastric mobilization, we don’t have to do a full gastric mobilization but just a fundic mobilization. Usually, if you release this fatty tissue here, you have this part of the stomach and there is a small fat pad in this area that I am trying to find. Here it is, it’s really the upper part of the gastrosplenic ligament. We are working in the upper part of the gastric fundus and not on the body of the stomach, you see this fat pad here, and then we are starting there. Even in very slim patients, you have this fat. You see we are entering the rear cavity. What I am doing with the Ultracision system, you can do with clips or bipolar forceps or whatever you want. We are still using the same instruments as at the beginning. I am used to working with a 0 degree scope, some people prefer to use angulated scopes; in this area, it is true that the angulated scope is sometimes more efficient but it is a question of habit. This is the posterior aspect of the stomach, I will retract this posterior aspect with the grasper. I am opening the posterior aspect of the stomach and all these posterior attachments, which are very important. I think it is also important to have a large posterior window because if you create a small posterior window with a huge stomach, you will create conditions to have dysphagia as well. We don’t mention that enough but the size of the posterior window is also important in terms of the outcome of the operation.

6. Hiatus repair 16'30''

I have introduced my suture through the umbilical port. What type of suture do you use? I favour non-absorbable ones, at home in Belgium I use Mersuture, here I am using Ethibond. I believe that silk is absorbable so I don’t recommend it, I was always using it in my open experiences to do this type of operation, but having a large experience of redos, in people with previous fundoplications with silk, I cannot find any sutures anymore. The important thing is to get used to one type of suture, in terms of its manipulation. One without too much memory, one you can see easily. I am not that used to that type of suture, but I think that Ethibond is good. I think that we have a very large hiatal hernia; in these conditions, I am used to dividing these fibers and I’ll show you that the view can be a little bit different. There is a question of the number of movements within and outside the abdomen so I try to reduce as much as possible the amount of movements through the trocars.

7. Fundoplication 19'18''

Now the next step is the fundoplication, I am going to grab my mobilized gastric fundus, anterior aspect, I have the posterior aspect, I just put my fundus down there. I am supposed to grab the posterior aspect and this is the way. Here is the posterior aspect of the stomach. Now again if you want to be sure in your early experiences, you can calibrate but I know that in this valve I can use a 200 French bougie. It is important to make your own visual assessment initially. You don’t put a stitch through the esophagus? Not the first one, I’ll show you why. I like to have the shape of the fundoplication before fixing it to the esophagus to be sure that I have got the good part of the stomach, that I don’t have any twists or anything like it. I have the esophagus, I have my valve so I can check the fundus, no torsion or nothing, now I can fix it to the esophagus. So now I am fixing the valve. Everything is staying very floppy. It is important to create a 1.5cm long valve, it doesn’t have to be very long. I am still with the same suture as in the beginning of the repair, this valve is quite regular, it is fixed by one stitch on the anterior aspect of the esophagus, I like to put another stitch here, you can see the membrane, which is here. It is a little bit stronger so my assistant will release the traction on the junction. We are coming to the end, you see this crura repair, you see the valve with the posterior aspect of the fundus, the valve is symmetrical, this is the anterior wall, posterior wall, the valve is quite floppy, the drain is on the GE junction there, I have put the valve a little higher than the anatomical GE junction because the Z line is here, not there.