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Laparoscopic Toupet fundoplication 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。

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Laparoscopic   Toupet   fundoplication   for   hiatal   hernia

作者群
GB Cadière
關鍵字
gerd,operation,gastroesophageal reflux disease,hiatal hernia,laparoscopy
媒體類型
期間
11'00''
刊物
2004-09
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1279e.htm

Laparoscopic   Toupet   fundoplication   for   hiatal   hernia

1. Case presentation 00'23''
The working trocars for my right hand and for my left hand make an angle of 90 degrees over the pathology. My optical system with the camera then bisects this angle. These are the perfect positions for the trocars to perform any kind of tasks inside of the abdomen. The other trocar is used to place the retractor for the adjacent organs, thus providing the exposure of the operative field. The hiatal hernia is here. It’s easy to reduce and you see here the nerve of Latarget. The crow’s foot is here. The extragastric branches of the nerve are here. The right crus is here. The left crus is here. And here is the phrenogastric ligament. I will put this ligament under tension to show it better. The anterior peritoneal sheath of the phrenogastric ligament above the left crus is here. The 1st step is to ask your assistant to grasp the esophageal junction and pull down toward the left side of the patient. You can see here the bulge of the right crus, which is a good landmark to know that I have to come from here to this point and I’ll cut the extra branches of the nerve. You see in fact, we have 2 layers of peritoneum. If there is a big artery here, then you have to use clips to divide it. Now I will show the anterior peritoneal layer and the posterior peritoneal layer. The posterior peritoneal layer makes a reflection here and goes here. I just take the anterior peritoneal layer in order to avoid injury of the esophagus. We will continue to divide the peritoneal sheath to the left side of the esophagus. This is the anterior peritoneal sheath of the phrenogastric ligament and now I will come back to the posterior peritoneal sheath, which makes a reflection along the right crus. You can see here the edge of the right crus and probably the esophagus is here. And you can take the entire thickness of the esophageal ligament safely and without any difficulty. The next step is to locate the left crus, which is just here. You have to be careful in this area because you can make a hole in the pleura. If you see here, here I can make a hole and I will probably be on the other side. This is the left crus here and the right crus. We are through to the other side as you can see. And now I can dissect a little bit in the mediastinum because we can see all the structures very well. And now I perform the dissection from the esophagus to the upper part of the crus. And I have to be careful to avoid injury to the anterior vagus nerve. This is the left crus here and this finishes up the dissection. The next step is the mobilization of the greater curvature of the stomach. The starting point for me is you can see these vessels going in the direction of the colon and here these vessels go in the direction of the spleen. This is my landmark to start the dissection. First I open the lesser sac. Once the lesser sac is opened, I just take the anterior peritoneal sheath. Progressively here we’re making distance in coming around the greater curvature. Each of the short gastric vessels is cauterized on its length prior to dividing it. And now I introduce an umbilical tape, which is helpful because we can use it for traction. And as you can see, the fundoplication is immediately ready. Now we have to perform a closure of the crus. I have severed all the attachments first. This is the Endo-stitch device. Figure of eight sutures are placed interrupted and you can see how I form a knot with the Endo-stitch device. You have to be very careful here because the vena cava is just below us. So the next step is to take the wrap at the top and fix it to the crus. I take the posterior wall, the crus and then tie an endo-knot. Then you can see the wrap sits comfortably inside the abdomen without tension. And now look because I have made this exposure. I have a perfect view of my wrap. Take the esophagus here, the wrap here, to tie an endo-knot, I don’t move my left hand, I use only the needle driver to form an intracorporeal instrument tie. Now regarding the results and efficacy between the Nissen fundoplication and the Toupet as you know Lundell has performed an amazing study with 10-year follow-up and the efficacy in his study seems to be about the same. Why? Probably because the most effective mechanism of the anti-reflux is the posterior part of the wrap. If you want to allow the patient to have the ability to belch and/or vomit, the best is to have a short and anterior wrap to avoid gas bloating. It’s the reason why here what I do is to try to make it very close here and after I try to enlarge it a little bit. The superior aspect, the 2 edges of the stomach are closer together on the anterior surface of the esophagus than they are distally. The wrap has a posterior length of about 3cm. The crus is repaired and we have fixed the posterior wall of the wrap to the crus. And you can see the running sutures here. We don’t want this too tight to avoid edema but I think it’s enough to fix the wrap so this is the end of the procedure.