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Redo partial fundoplication for dysphagia

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Redo   partial   fundoplication   for   dysphagia

作者群
D Mutter, F Jamali
關鍵字
gerd,operation,gastroesophageal reflux disease,hiatal hernia,repeat procedure,stomach
媒體類型
期間
09'00''
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-vd01en1002e.htm

Redo   partial   fundoplication   for   dysphagia

1. Case presentation 00'17''
In this video, we will illustrate the case of a 50-year-old patient who 6 months ago underwent an operation for symptomatic gastroesophageal reflux disease. This was complicated by the onset of severe dysphagia for solid and liquids. Six attempts at pneumatic dilatation have failed. The preoperative contrast swallow that you see demonstrates esophageal dilatation with a bird beak deformity and very scant passage of contrast into the stomach. The patient is approached laparoscopically. The dissection is started by mobilization of the attachments of the wrap and the stomach to the left lobe of the liver. The dissection is then carried out at the level of the diaphragmatic hiatus. Fibrous adhesions are divided at this level. Here we can see the esophagus with the right and left crura being identified and dissected. The anterior portion of the wrap is examined and seems to be intact. Dissection of the right crus is then undertaken. Special care is taken to avoid esophageal injury at this phase of the dissection. The dissection is carried out along the junction and the adhesions between the right crus and the esophagus. This allows for complete mobilization of the wrap from the right crus. The remainder of the attachments between the wrap and the right crus are hereby visualized and dissection will be continued in this plane to completely free a significant intra-abdominal portion of the esophagus. Significant fibrous adhesions between the stomach and the right crus of the diaphragm are identified. Those are divided using sharp dissection and electrocautery. The dissection is then again taken further north along the plane between the right crus and the esophagus to completely free the distal esophagus from any fibrous adhesions. Small vessels that are encountered are clipped and divided. Now we can see the posterior portion of the wrap completely free from its attachments to the right crus. These are the sutures that were probably placed to anchor the wrap to the right crus of the diaphragm. At the level of the GE junction and the esophageal hiatus, we can see this tight fibrous band compressing the esophagus. This band is divided using sharp dissection. The fibrous capsule wrapping the distal esophagus is identified and the split opened to release any compression of the distal esophagus at the level of the diaphragmatic hiatus. Now we can see the retrogastric window developed with the left and right crus and the left crus is being held. The next step will consist of division of the wrap using a 3.5mm Endo-GIA tool stapler. Once the wrap is divided, the divided end of the wrap quickly recoils to the left upper quadrant. This step here recreates for you the anatomy of the wrap before it was divided. We can see that there is a significant roll and twist on the stomach as a result of the wrap that was in place. With this division now complete, the stomach remains in place and is ready for the continuation of the procedure. We will transform this Nissen fundoplication into a Toupet partial fundoplication. Several anchoring sutures will be placed between the retroesophageal part of the wrap and the right crus of the diaphragm. Intracorporeal suturing techniques are used. A 2nd suture is now being placed between the retroesophageal portion of the wrap and the right crus. A 3rd suture is placed cephalad to complete the anchorage. On the left-hand side, we will recreate the angle of His by anchoring the stomach to the left crus and the distal esophagus. Once again, several sutures will be placed until the satisfactory partial 270 degree posterior fundoplication is completed. This is the final image demonstrating the Toupet fundoplication as well as the torsion that existed on the stomach as a result of the previous Nissen fundoplication. The distal esophagus has been freed. Postoperatively, the patient does well and this is an image of this postoperative contrast swallow demonstrating free passage into the stomach with absence of reflux and absence of esophageal dilatation.