Laparoscopic anterior valve technique

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摘要

The description of the laparoscopic anterior valve technique covers all aspects of the surgical procedure used for the management of gastroesophageal reflux disease in children.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, mobilization, dissection, hiatal closure, valve creation.
Consequently, this operating technique is well standardized for the management of this condition.

媒體類型

刊物

2002-07

普通的

最愛

音訊

數位出版

WeBSurg.com, Jul 2002;2(07).
URL: http://www.websurg.com/doi-ot02en151a.htm

Laparoscopic anterior valve technique

1. Introduction

The anterior fundoplication was first described by Thal (1968), who used an onlay patch of gastric fundus for the treatment of distal esophageal stricture. The stricture was incised and the serosa of the stomach used to cover the defect.
This method was later promoted by Ashcraft et al. (1978) as an antireflux procedure with success and recurrence rates comparable to that of Nissen’s fundoplication. Further, there were fewer perioperative complications and long-term problems (van der Zee et al., 1994).
The advantages of a laparoscopic approach are:
- less pain and quicker recovery;
- smaller scars;
- fewer complications with adhesion and gas bloat syndrome (van der Zee et al., 1999);
- compatibility with mentally handicapped children.

2. Anatomy

• Local anatomy

1. Lesser omentum
2. Left lobe of the liver
3. Esophagus
4. Diaphragm
5. Pleura
6. Spleen
The normal anatomy of the esophagogastric junction is composed of a 2 to 3 cm segment of esophagus located below the hiatus and fixed to the diaphragm, crura and stomach by attachments. Maintenance of normal relationships between these structures is essential to the integrity and function of antireflux mechanisms.

• Attachments

1. Triangular ligament
2. Phrenoesophageal ligament
3. Gastrophrenic ligament
4. Gastrosplenic ligament
5. Short gastric vessels
6. Left kidney
7. Toldt’s fascia
8. Crura of the diaphragm

• Short gastric vessels

1. Gastrosplenic ligament
2. Splenic artery
The short gastric vessels originate from the splenic artery. They run along the posterior wall of the stomach in the gastrosplenic omentum to end on the fundus.

• Mechanisms

1. Anterior vagus nerve
2. Lesser omentum (reflected)
3. Crura
4. Aorta
5. Esophagogastric junction
6. Cardia of the stomach
Three primary concordant antireflux mechanisms are demonstrable in patients with intact antireflux zone anatomy:
- intra-abdominal position of the distal esophagus;
- restoration of the esophagogastric angle;
- closure of the hiatus with adjoining crura.

3. Indications

Indications
- gastroesophageal reflux refractory to medication, with pathological reflux of pH<4 occurring >5% of the time. It is possible to distinguish between primary and secondary reflux. The former is either idiopathic or involves a hiatal hernia, and the latter usually affects mentally handicapped children (>50% of the pediatric patient population).

Relative contraindications
- motility disturbances of the esophagus;
- antroduodenal dysmotility.

4. Preop period

The day before the procedure, an enema or rectal washout is required. This is important for chronically constipated (often mentally handicapped) children. Otherwise the dilated transverse colon and splenic flexure will obscure the view.
No urinary catheter is needed unless a prolonged procedure is anticipated.

5. Operating room set-up

• Children under 4 years

• Patient

- 20°-30° reverse Trendelenburg;
- positioned at the lower end of the shortened operating table;
- legs covered with drapes and flexed to prevent the patient from slipping;
- knees stabilized by pads to avoid over-extension of the hips.
Adjustment is required in cases of severe scoliosis or flexing contractures of the lower extremities.
Alternative positions may be necessary (van der Zee and Bax, 1995).

• Team

1. The surgeon stands at the lower end of the shortened operating table.
2. The assistant stands on the patient’s right lower side.
3. The scrub nurse stands on the surgeon’s right.
4. Anesthesiologist

• Equipment

1. First monitor
2. Anesthetic unit
3. Second monitor
4. Operating table
5. Electrocautery
6. Instrument table
The first monitor is used by the surgeon and the assistant. The second monitor is used by the scrub nurse and/or anesthesiologist.
The laparoscopic and video units are placed to the patient’s left. All the cables are brought down to the same length and laid out in a semi-circle over the patient. The bundle is tied and fixed to the drape. It should consist of 8 cables: camera, insufflation, suction, rinsing, light, diathermy, external/internal, monopolar/bipolar.

• Children over 5 years

• Patient

- 20°-30° reverse Trendelenburg;
- patient in frog position.
Adjustment is required in cases of severe scoliosis or flexing contractures of the lower extremities.
Alternative positions may be necessary (van der Zee and Bax, 1995).

• Team

1. The surgeon stands between the legs of the patient.
2. The assistant stands on the patient’s right lower side.
3. The scrub nurse stands on the surgeon’s right.
4. Anesthesiologist

• Equipment

1. First monitor
2. Anesthetic unit
3. Second monitor
4. Operating table
5. Electrocautery
6. Instrument table
As in younger children, the first monitor is used by the surgeon and the assistant. The second monitor is used by the scrub nurse and/or anesthesiologist.
The laparoscopic and video units are placed to the patient’s left. All the cables are brought down to the same length and laid out in a semi-circle over the patient. The bundle is tied and fixed to the drape. It should consist of 8 cables: camera, insufflation, suction, rinsing, light, diathermia external, diathermia internal monopolar, diathermia internal bipolar.

6. Trocar placement

• Pneumoperitoneum

In children, it is generally safer to use an open introduction technique for the first trocar in the subumbilical fold.
Younger children - 2 L/min flow, 5 mm Hg pressure, up to 8 mm Hg for brief periods
Older children - 5 L/min flow, 8 mm Hg pressure

• Trocar placement

1. Trocar A: 5 mm, halfway between the umbilicus and xiphoid process
2. Trocar B: 4-5 mm, in the epigastric region
3. Trocar C: 4-5 mm, in the right midclavicular costal margin
4. Trocar D: 4-5 mm, in the subumbilical fold
5. Trocar E: 4-5 mm, in the left midclavicular costal margin
6. Trocar F: 4-5 mm, in the right costal margin

• Expert opinion

Disposable trocars may be used instead of the standard reusable trocars. Particularly in neonates or small infants, 3 mm expanding trocars may be of advantage because they do not tend to fall out so quickly. As the peritoneum in neonates is very elastic, the Seldinger technique with an expanding trocar allows for an easier entry into the abdomen.
Trocar systems with a movable valve mechanism are easy for needle retrieval.

7. Instrumentation

• Optical devices

Trocar A
1. 0° laparoscope OR
2. 30° laparoscope
The 30° laparoscope is of advantage in children because the abdominal cavity is smaller. It makes it easier to dissect the hiatus and mobilize the fundus from the spleen. If a gastrostomy is already in place, it is easier to work around it (van der Zee et al., 2000a).

• Operating devices

Trocar C
1. Grasping forceps
Trocar E
2. Hook dissector
3. Scissors
4. Suction-irrigation device
5. Needle-holder
Curved instruments are preferred over straight instruments for dissection, because it is easier to see the tip on the monitor.

• Retracting devices

Trocar B
1. Liver retractor
Trocar D
2. Atraumatic grasper
A good instrument for retraction is the flexible retractor, which is adjustable and atraumatic. Alternatively, a grasping forceps with a locking handle may be used. The liver is elevated with the shaft of the instrument, which is attached to the diaphragm by its tip. Retraction of the stomach is performed with a Babcock forceps.

• Optional devices

Trocar F
1. Liver retractor
An alternative trocar for trocar B may be used under the right costal margin. As the left liver lobe is usually still large in small children, an additional liver retractor or grasping forceps with a locking handle may be useful.

8. Major principles

The major principles for reconstruction of an antireflux mechanism are:
- restoration of lower esophageal sphincter pressure by bringing 2 cm to 3 cm of distal esophagus intra-abdominally;
- retention of lower esophageal sphincter pressure by closing the hiatus around the distal esophagus and suturing the fundus against the ventral part of the intra-abdominally located esophagus and diaphragm.

9. Exposure

• Exposure

The hiatal region is located deeply posterior to the xiphoid process. It is covered by the left lobe of the liver. This region is usually easy to expose. Perfect exposure of the hiatal region is indispensable to a safe operative procedure. This exposure is secured through appropriate positioning, gastric clearance and organ retraction.

• Reverse Trendelenburg

The reverse Trendelenburg position causes spontaneous lowering of the abdominal organs, allowing exposure of the operating field.

• Gastric clearance

Depending on the age of the patient, an 8 to 10 mm gastric tube is placed to decompress the stomach and serve as a guiding stent during dissection of the hiatus. The esophageal wall is better defined by the tube and perforation is not likely to occur during the liberation of the left and right crura. During dissection of the posterior wall of the esophagus, it is withdrawn into the mid-esophagus. The tube is reintroduced to secure an adequate diameter for the esophagus when closing the hiatus. It is then removed.

• Retracting the organs

The assistant handles the laparoscope (A) and grasps the cardia of the stomach with a Babcock forceps (D). The left liver lobe is elevated by a liver retractor (B or F) that is fixed to the drape.

10. Mobilization

• Phrenoesophageal ligament

The phrenoesophageal ligament is incised using electrocautery up to the anterior wall of the esophagus and further anteriorly over the left crus. Usually a lymph node on the anterior side of the distal esophagus serves as a landmark above which the dissection can be started.

• Gastrophrenic ligament

The dissection is continued to the left. Gentle caudal traction of the fundus allows the surgeon to divide the posterior gastrophrenic attachments, anchoring the posterior fundus to the diaphragm.
In children, it is often beneficial to divide the superior short gastric vessels up to the point that the fundus can be moved without pulling the spleen along.
After completing the dissection, there is a clear entrance to the hiatus and right crus.

• Lesser omentum

The cardia is pulled in a caudal direction with the grasping forceps to display the inferior part of the lesser omentum. The inferior part of the lesser omentum is opened.
The hepatic branches of the anterior vagus nerve are preserved.
On completion, the dissection should reveal the esophageal hiatus and the left crus, the caudate lobe of the liver and the right crus.

11. Dissection

• Left crus dissection

1. Liver
2. Esophagus
3. Hiatus
4. Left crus
5. Stomach
6. Spleen
Dissection of the left crus is usually the easiest and can be extended to the left side of the hiatus, leaving only a little to dissect from the right side.

• Right crus dissection

1. Liver
2. Esophagus
3. Hiatus
4. Left crus
5. Right crus
The dissection now begins at the hiatus. When dissection takes place on a plane directly on the esophagus, there is little danger of damaging the pleura. The posterior vagus nerve can be clearly defined and retained using blunt dissection.
The space between the right crus of the hiatus and the esophagus is dissected vertically with a hook dissector. Once a plane close to the esophagus is created, the latter is mobilized with a stent in place and blunt dissection is done to free the right crus.
If the stent is withdrawn, the esophagus can be lifted further and a window can be created at the left crus.
A grasping forceps can be passed behind the esophagus to the left side. A vessel loop is laid around the esophagus for traction during further dissection of the left and right crus.

12. Hiatal closure

• Suture placement

1. Liver
2. Esophagus
3. Hiatus
4. Left crus
5. Right crus
If the esophagus is lifted with the vessel loop, a clear view is obtained of both crura and the dorsal esophagus. Hiatal closure is performed from the right side, using one or two 3x0 braided polyester non-absorbable sutures. A suture is placed from the left crus to the right crus, with a stitch into the dorsal esophagus. This is done under identification of the dorsal vagus nerve.

• Knot-tying

1. Esophagus
2. Spleen
3. Right and left crura
The suture is tied using an intracorporeal knot technique after the gastric tube has been reintroduced to ensure sufficient passage through the hiatus. If necessary, an additional suture is placed. The tube can then be removed.

13. Valve creation

• First layer

1. Diaphragm
2. Liver
3. Spleen
4. Esophagus
5. Stomach
The vessel loop is left loosely in place to mark the gastroesophageal junction.
The first suture is laid from halfway along the dissection line of the phrenogastric ligament to a point halfway along the intra-abdominal distal esophagus.
The second suture is laid from the ventral part of the fundus to halfway along the ventral side of the esophagus under identification of the anterior vagus nerve.
The third suture is laid from the right side of the fundus to halfway along the right side of the esophagus.
As a suitable gutter has now formed, the vessel loop can be removed.

• Second layer

1. Esophagus
2. Second line of stitches
3. Stomach
4. First line of stitches
The first suture runs from a more distal part along the dissection line of the phrenogastric ligament to the proximal part of the intra-abdominal esophagus and the diaphragmatic ridge.
The second suture is laid on the ventral side including the diaphragmatic ridge. The position of the anterior vagus nerve should be noted.
The third suture is laid on the right side, completing the Thal anterior valve technique.

14. Intraop complications

Complications
A recent publication reported a 5.1% rate of intraoperative complications (Esposito et al., 2000). In a personal series of 53 laparoscopic antireflux procedures, intraoperative complications occurred in 1.9% of the cases (van der Zee et al., 1999).

Perforation
Esophageal perforation may occur, particularly during hiatal dissection. A tube, a stent or a flexible endoscope should be introduced into the esophagus and the stomach. The plane between the crura and the esophagus can then be found easily with no risk of dissecting into the esophageal wall.
In the case of redo procedures, adhesion formation may make dissection more difficult. The risk is minimized by atraumatic lifting of the esophagus and the stent.

Hemorrhage
It is a general principle to take note of the left and right gastric arteries or an aberrant left hepatic artery.
Compression of the surrounding tissue with instruments is usually sufficient to stop a hemorrhage. In the event of hemorrhage of the short gastric vessels, compression gives temporary relief. Instruments for suction and rinsing should be readied along with clips. Apply the clips only when the lacerated vessel has been identified and isolated. Otherwise maintain hemostasis with the left grasping forceps and dissect further with the right-handed instrument until the vessel is adequately isolated. With good organization, conversion is seldom necessary.

Pneumothorax
Pneumothorax is an infrequent complication in children. When blunt dissection is performed close to the esophagus, little risk exists.
If pneumothorax does occur it usually has no detrimental effects on ventilation if CO2 pressure does not exceed 5 mm Hg to 8 mm Hg. At the end of the procedure, the pneumothorax can simply be drained by percutaneous thoracic puncture with an intravenous catheter under positive end-expiratory pressure of 4 cm H2O ventilation.

Emphysema
In children, the mediastinum is a resistant structure and mediastinal emphysema is an infrequent and self-limiting event.
Subcutaneous emphysema around the trocar site may occur if the fascia at the trocar site is not closed at the end of the procedure and if CO2 is not adequately evacuated from the abdominal cavity. Subcutaneous emphysema may be a first indication for later trocar site hernia.

Vagus nerve trauma
Vagus nerve trauma may induce dysphagia or delayed gastric emptying. Symptoms subside in due course. The trauma can be avoided by active identification of both the anterior and posterior branches of the vagus nerve during dissection.

15. Postop management

Postoperative management
Oral intake or gastrostomy feeding can start the same day or the following morning.
The patient usually leaves hospital on the second postoperative day.
In order to prevent pain, nausea and vomiting, the following is prescribed:
- 0.25 mg/kg/d morphine IV 12h postop, and 60 to 90 mg/kg/d paracetamol suppository in 3 doses;
- 0.1 mg/kg/d Ondansetron IV 12h postop.

Postoperative complications
In a multicenter review (Fonkalsrud et al., 1998) of 7467 pediatric antireflux procedures, major complications occurred in 4.2% of neurologically normal children (NN) and in 12.8% of neurologically impaired children (NI).
The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory failure (4.4%), gas bloat syndrome (3.6%), and intestinal obstruction (2.6%).
Death rates were 0.07% and 0.8% in NN and NI respectively. Reoperations were performed in 3.6% and 11.8% of NN and NI respectively.
For pediatric laparoscopic antireflux procedures, Esposito et al. (2000) recorded postoperative complications in 3.4% and recurrence in 2.1% of cases.

Recurrence of symptoms
Recurrence of gastroesophageal reflux disease is often related to a disruption of the fundoplication, herniation of the wrap into the posterior mediastinum, or a combination of both (Kimber et al., 1998). Two therapeutic attitudes may be justified:
- resuming long-term proton pump inhibitor medical treatment (wrap disruption);
- repeat surgery (wrap herniation or a combination).
Laparoscopic redo procedures are complex, but feasible in the hands of experienced surgeons (van der Zee et al., 2000b).

16. Conclusion

The anterior valve technique according to Thal can be performed laparoscopically in children. Children have a quick recovery. At follow-up, we found no difference between NN and NI children. None of the children with a follow-up of more than 5 years have any symptoms anymore.
In children with gastroesophageal reflux following esophageal atresia repair or neurologically impaired children with a gastrostomy, surgeons prefer a 360° Nissen fundoplication.

17. Reference

Ashcraft KW, Goodwin CD, Amoury RW, McGill CW, Holder TM. Thal fundoplication: a simple and safe
operative treatment for gastroesophageal reflux. J Pediatr Surg 1978;13:643-7.
Esposito C, Montupet P, Amici G, Desruelle P. Complications of laparoscopic antireflux surgery in
childhood. Surg Endosc 2000;14:622-4.
Fonkalsrud EW, Ashcraft KW, Coran AG, Ellis DG, Grosfeld JL, Tunell WP, et al. Surgical treatment of
gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics 1998;101:419-
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Kimber C, Kiely EM, Spitz L. The failure rate of surgery for gastro-oesophageal reflux. J Pediatr Surg
1998;33:64-6.
Thal AP. A unified approach to surgical problems of the esophagogastric junction. Ann Surg
1968;168:542-50.
van der Zee DC, Bax NM, Ure BM. Laparoscopic secondary antireflux procedure after PEG placement in
children. Percutaneous endoscopic gastrostomy. Surg Endosc 2000a;14:1105-6.
van der Zee DC, Bax NM, Ure BM. Laparoscopic refundoplication in children. Surg Endosc
2000b;14:1103-4.
van der Zee DC, Arends NJ, Bax NM. The value of 24-h pH study in evaluating the results of laparoscopic
antireflux surgery in children. Surg Endosc 1999;13:918-21.
van der Zee DC, Bax NM. Laparoscopic Thal fundoplication in severely scoliotic children. Surg Endosc
1995;9:1197-8.
van der Zee DC, Rövekamp MH, Pull ter Gunne AJ, Bax NMA. Surgical treatment of reflux esophagitis:
nissen versus Thal procedure. Pediatr Surg Int 1994;9:334-7.

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