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Laparoscopic esophageal diverticulectomy and myotomy

Open trans-thoracic surgery represents the traditional approach for the treatment of symptomatic esophageal diverticula. However, it should be noted that minimally invasive techniques, including the laparoscopic trans-hiatal approach has been reported with success. We present the case of a patient suffering from dysphagia and regurgitation due to an esophageal diverticulum, successfully treated through a laparoscopic approach.

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Laparoscopic esophageal diverticulectomy and myotomy

作者群

B Dallemagne, S Perretta, J Marescaux

摘要

Open trans-thoracic surgery represents the traditional approach for the treatment of symptomatic esophageal diverticula. However, it should be noted that minimally invasive techniques, including the laparoscopic trans-hiatal approach has been reported with success.
We present the case of a patient suffering from dysphagia and regurgitation due to an esophageal diverticulum, successfully treated through a laparoscopic approach.

分類

complex cases

關鍵字

esophageal diverticula, diverticulectomy, myotomy

媒體類型

手術影片

期間

10'00''

刊物

2009-01

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2517.htm

Laparoscopic esophageal diverticulectomy and myotomy

1. Clinical case presentation 00'18''

This patient has some regurgitation and dysphagia. We want to show you the endoscopy just to better understand the mechanism that leads to symptoms. The assistant is in the esophagus. In the lower part of the screen, we can see the normal esophagus with the Z-line and the GE junction, and in the upper part of the screen, we can see this big diverticulum with still some food remnant inside. My main concern is that it is a very large neck for the diverticulum so I hope we will be able to treat all the diverticulum and neck from the abdomen and through the hiatus.

2. Trocar placement 01'40''

Regarding placement of the port, it’s quite a typical placement of upper GI surgery and surgery of the hiatal area. You see the umbilicus of the patient and the placement of the 5 trocars in the upper part of the abdomen. On the right side of the patient, you have the liver retractor. In the middle, above the umbilicus, you have the optic, then in the subxiphoid area, you have one port and I’m going to use this with my left hand, then on the left side of the patient under the costal margin, you have my right hand so I’m working with these 2 trocars and laterally you have the final trocar, which is held by the assistant standing on the left side of the patient. That’s the same positioning of the trocars that we are using for hiatal surgery. Here we are using a 30 degree scope within the abdomen. So we did not touch the left part as you can see and what we did is to open the liver suspensor to introduce the liver retractor. Will you leave the flexible endoscope inside too? We will leave it inside because if I can do it from here, when I’m stapling the diverticulum, it’s very important to have some control from inside in order to avoid closing the lumen of the esophagus totally.

3. GE junction dissection-crura identification 03'22''

Usually for reflux surgery, we try to preserve those fibres but here it’s not really the objective. I prefer to have a very large view. Here’s the right crus, which is an important landmark for the surgery of the GE junction. My first goal is to identify the right crus, this landmark as much as possible and doing so by blunt dissection, I can get quite an easy access to the mediastinum. I’m just trying to find my cleavage plane alongside the crus. My left hand is lifting the crus a little bit. And now I’m about the position of the esophagus, and I’m a little bit freer. This diverticulum is on the left side strangely enough. Usually we find it on the right side. I’ll probably need some traction on the esophagus so I think that I’ll dissect the posterior aspect of the esophagus in order to get this good traction because I don’t like the graspers on the esophagus. So I’ll do the classical dissection as for anti-reflux surgery. The angulated scope in this area is very helpful. Another thing that is important is to have a good assistance when using an angulated scope. You can see that I’m not trying to make any blind maneuver when getting my passage behind the esophagus and that’s very important because we know that a lot of complications come from this posterior dissection. You are demonstrating that “no touch” technique now not grasping anything only the fat. Through this system, I have a good grasping of the esophagus.

4. Intramediastinal dissection 06'01''

So we’re going to work into the mediastinum so I’m working quite close to the esophagus. We redo sometimes when we have a big opening of the pleura; that doesn’t have any consequence. I will ask my assistant to retract the endoscope a bit otherwise it is too rigid. In some of the recordings of the HD manometry, we had some sort of spasm. What was the limit of the diverticulum? You can see I have changed the angle of the scope so I can have a better view. My assistant is measuring 5cm from the junction. Usually when you have this sort of diverticulum, the mediastinum is quite inflammatory. Is there a use for a flexible scope instead of a laparoscope to go inside? Maybe to do NOTES through the hiatus but it’s not a natural orifice so… Sorry for the picture but it’s very difficult to work with 2 instruments plus the laparoscope within a very small place that’s why we have some conflict of the instruments and that’s why the image is not very stable. But I like to have this superior dissection. I need it to see the upper part of the neck of the diverticulum. The question was whether putting a flexible retractor in the mediastinum would help. We use that for a trans-hiatal esophagectomy. I’m using the same retractor than the one for the liver retraction and I put it in the diaphragm. But usually for the trans-hiatal, this one is quite large but we can open the diaphragm a little bit. Now I’ll try to work on the side. This is the pleura. I’m using a lot of blunt dissection because here I have the pleura. If I cut straight, I’d open the pleura. So blunt dissection is very important. We move back. You see that the esophagus is moving progressively so probably we’ll be able to get it from the abdomen. As you know, diverticulum is only mucosa. I don’t know if this is the vagus trunk. Actually, it is there. Here we see the muscle of the esophagus and the diverticulum so I’ll progressively try to retract. The thing is to find the right dissection plane between the diverticulum. I like to have a very precise view so I’m using sponges instead of water or suction. The most difficult part is always to get the upper part of the neck. If you retract on the esophagus on the GE junction, what happens? Does it open below the diaphragm now? I don’t know. Probably but I’ll still have the same problem to retract the vagus trunk. My concern is that the vagus trunk is very fixed. I think that’s the vagus trunk there. Probably that fixes the diverticulum in the upper part. I think the trunk is there. It’s a clear demonstration that laparoscopy can give you a very precise view on the different structures. Probably we are respecting more the structures than we were used to doing in open surgery. Maybe you could pull on the GE junction one more time so that we could see what happens. I’m coming to the upper part as you can see. The pleura is there. Here is the esophagus and there is the vagus trunk.

5. Diverticulum’s neck identification 13'59''

So now probably I’m coming to the upper part of the neck. I have the lower part here. I’ll clear it a little bit more just to see the limits between the fibres and the mucosa. But really I think that I’m almost done here. Now I just have to clear the junction between the mucosa and the muscle. In a few seconds I will ask my assistant to check the lower part and see if we are not retracting all the mucosa of the esophagus. When this is inflated, I’ll try to see. Can you flush the stuff out? I like to insufflate the diverticulum because this way you can see the junction. Usually the risk is to get all the mucosa from the esophagus so that’s why it’s very important to have some sort of control inside of the esophagus either with a bougie or the endoscope. These are the fibres. It’s a very nice dissection, almost done now.

6. Division of diverticulum and myotomy 17'56''

Now we’re ready to staple. We’ll keep the endoscope inside. It is now passed all the way and it’s going to calibrate the lumen. Just to be sure that when you place traction on the mucosa, it’s not that you’re getting all the mucosa of the esophagus. It’s hard to put everything into the mediastinum. There’s no mucosa left. Now we will close the muscle above the staple line. Do you put a nasogastric tube down afterwards postoperatively? No I don’t think it’s necessary. Will you do a gastrograffin swallow tomorrow? Yes I will on the first postoperative day and then if it’s OK, the patient is allowed to drink, semi-liquids, and then normal diet. So it’s quite a typical and a similar outcome as for a myotomy. And then when I have finished that, we’ll do a myotomy. Will you close the crura? I will see the size; if it’s too large, maybe I’ll place one posterior stitch. Do you staple it longitudinally in the line of the esophagus? Yes, transversely. It’d be very difficult from the abdomen. When I encounter some problems during surgery when getting the neck of the sac, when the vision is not as clear as the one that I have, then I leave a mediastinal drain. But here I’m quite confident since I have a good endoscopic control so I’d say that drainage is not really necessary. But this really depends on the surgeon. There are probably no rules about that. No perforation. Here’s what I’ve done. You left at the time when I was suturing the staple line, then we’ve made a myotomy on the other side and we control it with the endoscope. Here’s the vagus trunk still alive crossing the zone of the myotomy. This is a very long myotomy. I know this guy has a very small fundus and we’re just mobilizing the upper part of the gastric fundus to do a Dor fundoplication.

7. Fundoplication and closure of the crura 27'20''

Let’s see the wrap. I’m not pleased about it because this guy has a very small fundus and even when we have mobilized the upper part, I don’t like the way this valve is crossing the esophagus because everything is twisted and so I put one stay stitch there as for a Dor but usually with a Dor you complete with that. The fact is that I put my myotomy laterally on the other side as for the diverticulectomy. I prefer not to do this sort of anti-reflux. I will stop here.