ADVANCED LAPAROSCOPIC FOREGUT SURGERY
B. Salky,Dept. of Surgery, Mount Sinai Medical Center, New York, USA
Surg Treatmt of achalasia
Heller myotomy is the procedure of choice for the surgical management of achalasia. While balloon dilatation has a role in the management of this disease, most physicians interested in esophageal diseases feel that it should be limited to elderly patients who are at high risk to general anesthesia. Bo-tox has very little role in the treatment of achalasia, and its use may make other definitive treatments more risky. Although it still has a role in the elderly patient in whom general anesthesia is dangerous. Surgical myotomy should be performed before the esophagus becomes S shaped. There is a lot of interest in determining if an anti-reflux procedure should be performed at the same time, and if performed, what type should be constructed. A recent randomized-controlled study documented less reflux with the addition of a partial fundoplication (DOR). However, the answer as to the correct fundoplication is unknown at present.
Technique
The patient is placed in modified lithotomy position with the monitor placed in the midline over the head of the patient. The surgeon stands between the legs with one or two assistants on either side. An oral-gastric tube is not placed because of the potential for perforation. For that matter, neither is a temperature probe. Five trocars (each 5 mms) are placed in the same position as hiatal hernia repair. The left lobe of the liver is elevated with a palpation probe or a Nathanson® retractor, and the dissection of the phreno-esophageal ligament is begun after division of the gastro-hepatic ligament. If a large replaced left hepatic artery is present, it is preserved. The anterior 180 degrees of the esophagus is freed from the esophageal hiatus for a distance of 7-8 centimeters. The anterior vagus is identified and preserved. The posterior aspect of the phrenoesopheal ligament is not disturbed. The posterior vagus is not dissected or identified. The gastric fat pad is dissected from the G-E junction until the anterior portion of the stomach wall is clearly identified, including the course of the anterior vagus (which is preserved). I prefer the 5-mm curved, Harmonic Scalpel, but other dissection instruments are usable. A 7-centimeter myotomy is made with at least 5mm onto the gastric wall. This is confirmed with intraoperative endoscopy. A partial fundoplication is performed by suturing the cut end of the left side of the myotomy to the cardia of the stomach. It re-establishes the angle of HIS. Intracorporeal suturing is employed here.
Results
One hundred-thirty nine consecutive patients underwent a laparoscopic Heller myotomy by the author at the Mount Sinai Hospital, New York from 1993 through November 2004. There were no moralities. The mean age was 39 years (range 14-89 years) with 60% males. Forty-one patients had at least one pneumatic dilatation and 21 patients had at least one Bo-Tox injection. The completion rate was 100%. No patient needed transfusion. Ninety-five patients (95%) were very satisfied with the operation, where as five (5%) patients were not. An incomplete myotomy was identified in two patients early in the series. Each was before the routine use of intra-operative endoscopy. They responded to postoperative pneumatic balloon dilatation. Three patients, all with sigmoid esophagus, did not respond well to myotomy in the long term. All three were offered laparoscopic esophagectomy. There have been three mucosal injuries, all recognized and repaired at laparoscopy without adverse affect. All patients with mucosal injury had multiple pneumatic dilatations and multiple Bo-tox® injections. The addition of intraoperative endoscopy (1994) has been very helpful in the identification of mucosal injury, and the gastroesophageal junction, and, thereby, proper placement of the myotomy. Intra-operative manometry was not utilized. Barium study is performed on the first post-operative morning to confirm egress of barium from the esophagus into the stomach. Patients are begun on solid food the first postoperative day. Discharge is on day one. There has been two aspiration pneumonias postoperatively, both significantly prolonging discharge from the hospital. There have been no other significant morbidity.
Conclusion
Laparoscopic Heller myotomy is safe and feasible treatment for achalasia. Intra-operative endoscopy and partial fundoplication are important adjuncts in this surgery. Advanced laparoscopic skills are required (two handed technique, suturing and knot tying). A partial fundoplication is recommended in order to decrease the incidence of acid exposure to the lower end of the esophagus.
Suggested Readings
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MG. Achalasia and Chest Pain: Effect of Laproscopic Heller Myotomy. J Gastrointest Surg. 2003 Apr-Jun;7(5):595-8.
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Paraesophageal
Large hiatal hernias are potentially life-threatening conditions, and surgical repair is indicated unless medical contraindications exist. It is important to classify the types of hernia in order to be able compare results. Type II are those hernias in which the gastroesophageal junction is located below the diaphragm. (True paraesophageal). Type III have components of both sliding and paraesophageal hernias.The esophagogastric junction and more than half of the stomach are located above the diaphragm. This translates to a hiatal opening of 7-8 centimeters. Type IV hernia is a Type III with another organ in the hernia sac (colon, spleen, etc.). Recent advances in therapeutic laparoscopic surgery now allow a minimally invasive approach to these technically difficult problems. Advanced laparoscopic skills, including suturing and knot tying are required for this surgery. The surgeon should be experienced in GERD surgery before embarking on the repair of paraesophageal hernias. There is significant literature detailing the difficulty and learning curve with this disease entity.
Patient Selection
The symptom complex in patients with paraesophageal hernia is different when compared to those patients with GERD. The most common presentations are chest pain, dysphagia, and aspiration. Heartburn is uncommon. The work-up includes endoscopy and barium swallow. I have found barium swallow to be invaluable for helping with an anatomical roadmap preoperatively. If GER is present, manometry and motility are performed; however, this has been required on only one-third of the patients. There is a recent article bringing up the question of what to do in patients who are totally asymptomatic or those with minimal symptoms, detailing benefit in only 20% of all patients. In my experience, only patients with symptoms tend to show up in the surgeons office. Those patients clearly benefit from laparoscopic surgical repair.
Methods
The laparoscopic approach to large hiatal hernias was begun in 1992 at our institution. A review of my prospective database revealed 209 patients who underwent an attempt at laparoscopic repair from June 1992 through November 2004. Two hundred and four patients were completed laparoscopically. This included 31 Type II, 152 Type III, and 26 Type IV hiatal hernias. The mean age was 70(range 43-97 years). All patients had preoperative endoscopy and barium contrast studies. Motility and/or 24 hour pH studies were performed in only those patients with symptoms suggestive of GERD. Fundoplication was performed in all patients with clinical GERD (n=83). Nissen fundoplication was constructed in 74 and Toupet fundoplication in 9 patients. Cardiopexy (without fundoplication) was performed in the rest. Barium swallow was performed on the first postoperative morning. We began to excise the entire hernia sac after the first 25 patients, when an unacceptable early recurrence rate (N=5)(20%) and high conversion rate (20%) were noted.
Results
Since total sac excision in 1993(last 184 patients), there have been no conversions to open. The five patients converted to open (early in the series) were excluded from this study. Fundoplication was performed in the 83 patients with preoperative symptomatic reflux. Seventy-four patients had Nissen fundoplication, and the remaining nine patients underwent partial fundoplication (Toupet). The choice of fundoplication was based on preoperative motility studies performing partial fundoplication on those patients with ineffective esophageal motility. Patients with GERD were the minority of patients, as mechanical symptoms predominated as the symptom complex. Chest pain and dysphagia were the most common presenting symptom. Excision of the sac and Cardiopexy were performed in the rest (N=166). Primary closure of the hiatus with 0 Ethibond suture material loaded with felt pledgets was accomplished in all patients except one using intracorporeal suturing and extracorporeal knotting techniques. One patient early in the series had mesh closure that promptly recurred (pt.#21). Early recurrence occurred in 9 patients, five before sac excision and four after sac excision (Table 1). Three of the four recurrences after sac excision were secondary to vomiting in the immediate postoperative period. These were diagnosed on barium swallow and repair effected on the first postoperative day by repeat laparoscopy. Long-term follow up by telephone survey of 184 patients (15 patients lost to follow up and 10 deaths), revealed 95% of patients remain asymptomatic relative to their preoperative complaints at a mean of 65 months (range 2-122 months). However, documentation with barium swallow has not been possible in all patients. It is common to see a 2-3 centimeter hiatal hernia after one to two years. These patients do not have the same mechanical symptoms they had preoperatively. There were four major in-hospital morbidities including one missed esophageal perforation, two gastroparesis, one deep vein thrombophlebitis, and one perioperative myocardial infarction. There were no mortalities. The mean length of stay was 2 days for the first 12 patients, and one-day for the last 192 patients.
Short Esophagus
There is conflicting data on the incidence of short esophagus in this disease. In fact, there is considerable debate as to whether it exists or not. In my experience, unless there is a documented stricture of the esophagus, a true short esophagus does not exist. Total sac excision with mobilization of the esophagus high into the mediastinum coupled with posterior closure of the crura fibers will allow adequate intra-abdominal length of the esophagus. However, if adequate length cannot be obtained, laparoscopic Collis-Nissen gastroplasty is indicated. However, keep in mind that the long-term results of Collis-Nissen are not great either. And there is a short-term incidence of leak and potential mortality from the procedure itself.
Postoperative course
The patients are encouraged to ambulate the first postoperative night, and they are allowed clear fluids. Pain control is adequate with Toradol®. Routine barium esophagram is performed the morning after surgery in order to document the presence of the stomach below the diagphram. Patients are re-laparoscoped if the stomach is not below the diaphragm or if there is a question of the stomach’s location. Resuturing of the hiatus is performed if an early recurrence is documented. In my experience, if the patient vomits postoperatively, the incidence of recurrence has been 100%. Therefore, all patients are pre-treated with anitemtics.
Controversy
There has been recent interest in using synthetic mesh as an on-lay graft over closure of the diaphragmatic crus. There is data to support a low recurrence rate in the short term. There is one randomized, prospective trial on the use of posterior closure and fundoplication with on-lay DualMeash® (PTFE)showing no recurrence at 2.5 years. However, there are numerous isolated reports of erosion of mesh into the gastrointestinal tract. The exact incidence of this is unknown, but it usually takes years for erosion to occur. It seems prudent to express caution in the routine use of a synthetic mesh next to the gastrointestinal tract, including the esophagogstric junction. If mesh is required, omentum should be interposed between mesh and gastrointestinal tract. There has been some early interest in bio-degradable mesh, but there are no long term level 1 data as of yet to support it.
Conclusions
Laparoscopic repair of Type II, III, and IV hiatal hernia is feasible. Long term follow up at a mean of 65 months demonstrates 95% clinical success relative to the preoperative symptoms. Total sac excision and primary closure of the diaphragm are the most important technical elements needed to effect proper repair. These results compare favorably to open surgery. The use of prosthetic mesh as a routine is probably not justified. Laparoscopic surgery is the procedure of choice in the repair of Type II, III, and IV hiatal hernia.
TABLE I
NO SAC EXCISION
PATIENT # / RECURRENCE / PROCEDURE / TYPE / RE-OPERATION / RESULT2 / Pexy / Weeks / III / Open Surgery / Poor
5 / Pexy / Weeks / III / Open Surgery / Good
21 / Nissen / Weeks / III / Open Surgery / Good
22 / Nissen / Weeks / III / No Surgery / Good
25 / Nissen / Weeks / III / No Surgery / Poor
SAC EXCISION
74 / Pexy / POD 1 / IV / Lap Surg POD 1 / Good83 / Nissen / Months / III / Lap Surgery / Good
84 / Pexy / POD 1 / III / Lap Surg POD 1 / Good
91 / Pexy / POD 1 / III / Lap Surg POD 1 / Good
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