umbilicus. Pneumoperitoneum is created and three addi-tional trocars are placed under direct vision. The proce-dure proceeds uneventfully, however the gallbladder contains a large stone that prevents removal of the speci-men from the umbilical port site. The fascial incision at the site is enlarged slightly to allow removal of the gallbladder and stone. At the completion of the case, the umbilical trocar site is closed with a figure- of-eight suture. She is discharged home after a period of observation in the recovery room.
Five days postoperatively the patient presents to the emergency department complaining of persistent nausea and vomiting. In addition she states that she has not had any flatus or bowel movement in the past 2 days. On further questioning, the patient reports that a couple days ago she was lifting one of her children when she felt sudden pain at the umbilicus. On examination her abdomen is distended and tympanitic to percussion. The skin incisions at the trocar sites are all intact, but there is serosanguinous discharge from the umbilical port site.
A nasogastric tube is inserted with return of 800 cc of bilious fluid. A CT scan is performed which demonstrates loops of dilated small bowel with a transition zone at the level of the umbilical trocar site. The patient is taken back to the operating room, access to the abdomen is estab-lished through one of the prior trocar sites, and pneumo-peritoneum is created. The dilated bowel loops are gently pushed aside to allow visualization. A segment of small intestine is seen herniating through the fascial incision at the umbilical trocar site. The figure-of-eight suture is seen to have torn through the fascia. The bowel is gently grasped and reduced back in the abdomen. Upon inspec-tion, the bowel is edematous but pink and viable. The fas-cia at the site is carefully closed again. The patient makes an uneventful recovery, has return of bowel function, and is discharged home.
22
OR Questions
1. Following a laparoscopic cholecystectomy, a patient returns to the hospital with diffuse peritonitis. In the OR she is found to have enteric contents throughout the abdomen.
What is the most likely cause?
An inadvertent enterotomy, caused either during trocar placement or by an unseen cautery injury to the bowel . 2. A patient who needs a right hemicolectomy is requesting it
be performed laparoscopically in order to reduce the risk of anastomotic leak. Is this correct?
While there are many benefits to laparoscopy, the rates of anastomotic leak are the same as in open surgery. It should always be emphasized that while the incisions are smaller, the surgery “on the inside” is still the same size.
3. Toward the end of a laparoscopic appendectomy, the anes-thesiologist reports crepitus around the patient’s neck and face. What has occurred? What is the treatment?
Subcutaneous emphysema occurs when the pressurized gas leaks into the subcutaneous tissues and tracks along the fascial planes. It is generally harmless and resolves within days (Fig. 3.2 ).
4. Durin the course of a long and diffi cult laparoscopic pro-cedure, the anesthesiologist reports that the patient is developing progressively higher end-tidal CO 2 levels. What is the treatment?
The surgeon should consider converting to open surgery.
The patient is likely unable to ventilate effectively due to the prolonged pneumoperitoneum which reduces the func-tional residual capacity and tidal volumes .
5. The morning after a laparoscopic procedure, the patient complains of an aching pain in her shoulder. What is cause of this pain?
Residual pneumoperitoneum irritating the diaphragm causes referred pain to the shoulder. This is normal , and typically resolves within 2 – 3 days as the carbon dioxide is fully reabsorbed .
3. Laparoscopy
6. A patient develops abdominal pain and fever 5 days after a laparoscopic ventral hernia repair. A CT scan demon-strates the presence of free air under the diaphragms. Is this normal?
No , the carbon dioxide from a laparoscopic procedure should be completely resorbed within the 3 days after sur-gery. The presence of significant free air 5 days after a lapa-roscopic procedure should raise the concern for bowel perforation .
Fig. 3.2 CT scan image of a patient with extensive subcutaneous air following a laparoscopic procedure
24
Laparoscopy
Technique
•Establish pneumoperitoneum - Percutaneous (e.g. Veress needle)
- Open (e.g. Hasson trocar)
•Insufflation with CO2to approximately 15 mmHg
•Position patient using gravity to maximize exposure to the area of interest
•Insert other trocars under direct vision
•Position and number of port sites are selected based on procedure Limitations
•Diagnostic laparoscopy can be used immediately prior to laparotomy to confirm intra-abdominal pathology
•Lower rates of wound infection
•Smaller scar size
•Low venous return and decreased tidal volumes secondary to increased intra-abdominal pressures
•Inadvertent enterotomy
Peri-op orders
•General anesthesia is required for sufficient relaxation of abdominal muscles
•Foley catheter should be placed if trocar placement near the bladder is anticipated
•Orders are generally the same as for the corresponding open operation
3. Laparoscopy
Suggested Readings
Jamal MK, Scott-Conner CEH. Patient selection and practical considerations in surgical endoscopy. In: Soper NJ, Swanström LL, Eubanks SW, Leonard ME, editors. Mastery of endoscopic and laparoscopic surgery: indications and techniques. 1st ed.
Philadelphia: Lippincott Williams & Wilkins; 2009.
Katkhouda N. Advanced laparoscopic surgery: techniques and tips.
2nd ed. Berlin: Springer; 2010. p. 1–20 [Chapter 1, General Concepts].
U. Sarpel, Surgery: An Introductory Guide, 27 DOI 10.1007/978-1-4939-0903-2_4,
© Springer Science+Business Media New York 2014
Introduction
Gastroesophageal reflux disease (GERD) occurs when an incompetent lower esophageal sphincter allows gastric acid to reflux into the esophagus, causing mucosal irritation. The classic symptom of GERD is a substernal burning pain that occurs after meals and is exacerbated by lying supine. Acid reflux can also cause respiratory symptoms such as coughing, laryngitis, and asthma-like wheezing secondary to aspiration.
Because the symptoms of GERD are often nonspecific, the diagnosis may require a complement of tests including upper endoscopy, a barium swallow, esophageal manometry, and a 24-h pH test.
Over time, the persistent irritation caused by severe reflux can lead to the development of Barrett ’ s esophagus , in which the normal squamous epithelium of the distal esophageal mucosa morphs into a glandular columnar epithelium. This process, known as intestinal metaplasia, can progress further into high-grade dysplasia and ultimately adenocarcinoma of the esophagus. Therefore the treatment of GERD serves to both relieve patient symptoms, and to lower the risk of future malignancy.
The treatment of GERD begins with lifestyle modifica-tions such as advising patients to avoid foods that induce reflux, avoid eating before bedtime, elevate the head of the
4
Fundoplication
bed, quit smoking, and lose excess body weight. Medications to treat GERD include H 2-blockers and proton-pump inhibitors. Surgical therapy for GERD is indicated when there is a failure of medical therapy to alleviate the symp-toms, and/or the esophageal injury progresses to Barrett’s esophagus. It is important to realize that in patients who are found to have high-grade dysplasia, invasive carcinoma is often also frequently present. Therefore an esophageal resection should be considered in patients with diffuse high-grade dysplasia.
GERD is sometimes associated with the presence of a hiatal hernia . A hiatal hernia occurs when the esophageal hiatus of the diaphragm is lax, and allows herniation of abdominal contents into the mediastinum. GERD and hiatal hernias are two separate diagnoses, which frequently coexist, although either can occur without the other. A Type I hernia, known as a sliding hiatal hernia, involves migration of only the GE junction into the chest. This change in location of the lower esophageal sphincter from the high pressure of the abdomen to the low pressure of the thorax can allow acid reflux to occur. Type I hernias are by far the most common kind of hiatal hernias, and are often discovered incidentally.
As in other patients with GERD, treatment of individuals with Type I hiatal hernias is with medical therapy first, and surgical fundoplication as needed.
In a Type II —or paraesophageal—hernia, the GE junction remains in the abdomen, but the fundus of the stomach herni-ates up into the thorax. A Type III hernia is a combination of Types I and II, where both the GE junction and the fundus are in the chest (Fig. 4.1 ). Finally, in Type IV hernias, hernia-tion of the stomach is accompanied by other organs such as the colon or the spleen (Fig. 4.2 ). Hernia Types II–IV are distinct from Type I hernias in that the herniated portion of bowel is at risk for becoming acutely incarcerated and stran-gulated. Therefore, all patients who are discovered to have a Type II–IV hernia should undergo surgical repair upon diag-nosis, even if asymptomatic.
Fig. 4.1 Upper GI series demonstrating a Type III hiatal hernia;
note the indentation of the diaphragmatic hiatus on the stomach ( arrow ), and that both the GE junction and the fundus are located in the thoracic cavity
Fig. 4.2 Sagittal CT scan images of a patient with a large Type IV hiatal hernia; note the retrocardiac herniation of small bowel
Surgical Technique
Surgical therapy for GERD aims to decrease reflux by physi-cally reinforcing the lower esophageal sphincter. A fundopli-cation procedure uses the fundus of the stomach to create a wrap around the lower esophagus, thereby increasing the pressure at the sphincter (Fig. 4.3 ). This procedure also alters the angle of the GE junction which may contribute to its anti- reflux effect. A laparoscopic Nissen fundoplication is the most common type of wrap currently performed. It involves using the fundus of the stomach to wrap 360° around the esophagus. Different types of fundoplication vary by the completeness of the wrap, and by whether a transabdominal or transthoracic approach is used.
In order to perform a Nissen fundoplication, the esopha-gus and stomach must be fully mobilized to allow for the wrap to reach circumferentially around the esophagus. The lesser sac is entered between the stomach and the greater omentum. This opening is propagated laterally until the short gastric arteries are encountered. These vessels are serially
Diaphragm
Esophagus Left vagus nerve
Body of stomach Right and left crus of diphragm
Fundus of stomach
Litigated short gastric arteries Esophageal hiatus
Esophagus Wrap
Fig. 4.3 Surgical anatomy for Nissen fundoplication: diaphragm, esophageal hiatus, right/left crus, esophagus, gastric fundus, vagus nerve, and short gastric arteries
31 divided along the length of the greater curvature until the GE junction is reached. Excessive traction on the stomach can lead to tearing of these fragile vessels resulting in significant hemorrhage.
Next, the lesser omentum between the liver and the stom-ach is opened, exposing the diaphragmatic crus and the esophageal hiatus . At this point the vagus nerves should be identified and protected. The esophagus is dissected away from the crura and other attachments until the distal portion is brought down into the abdomen. A rubber drain is placed around the esophagus to facilitate its manipulation.
The fully mobilized fundus of the stomach is passed poste-rior to the esophagus, and wrapped around to the front. The wrap should be sufficiently tension-free such that it will remain in this position even before the placement of tacking sutures. Also, it is important to ensure that the wrap sits on the esophagus itself, rather than on the body of the stomach.
Prior to completing the fundoplication, the esophageal hiatus is closed by approximating the diaphragmatic crura with interrupted sutures. Finally, the wrap is sutured into place over a bougie in order to ensure that it is not made too tight.
The technique to repair a Type II–IV hiatal hernia begins with reducing the herniated organs into the abdomen, thus reestablishing normal anatomy. Next, the diaphragmatic defect is closed to prevent recurrence. Depending on the size of the defect, either the diaphragmatic crura can be sutured together as described above, or a piece of synthetic mesh can be used. A fundoplication is typically added to the procedure to treat any accompanying GERD, and to anchor the GE junction and stomach below the diaphragm.
Complications
During dissection around the GE junction, an inadvertent enterotomy into either the esophagus or the stomach can occur. It is crucial to recognize this injury intraoperatively in order to prevent significant morbidity from a leak. If an Complications
injury is identified, the perforation is closed primarily and the fundal wrap is placed over the repair in order to buttress it.
Another potential complication is a pneumothorax , which can occur if the pleural space is entered during dissection of the mediastinum.
Dysphagia is a relatively common occurrence after fundo-plication. Patients may also complain of gas - bloat syndrome which describes the uncomfortable feeling of not being able to burp. Dysphagia and bloating are usually due to edema at the wrap, and typically resolve within a week. However, per-sistent dysphagia may indicate that the wrap is too tight and may warrant surgical revision.
A slipped wrap develops when part of the stomach slides up through the wrap, above the fundoplication. Patients with this complication will complain of a recurrence of their heart-burn. Slippage can occur either immediately in the postop-erative period, or develop gradually over months. Oppostop-erative revision is necessary to correct this complication.
Classic Case
A 46-year-old man presents to his primary care doctor com-plaining of several years of heartburn. He reports that his symptoms have not been effectively relieved despite dietary modifications and medical therapy with a proton-pump inhibitor. He is referred to a gastroenterologist who performs an upper endoscopy that demonstrates Barrett’s esophagus.
Several biopsies of the distal esophagus are taken and do not reveal dysplasia. 24-h pH monitoring confirms acid reflux into the distal esophagus correlating with the patient’s symp-toms. Esophageal manometry confirms normal esophageal motility, and a barium swallow study demonstrates the pres-ence of a Type I hiatal hernia.
Given his persistent symptoms despite medical therapy, he is referred to a surgeon who performs an uncomplicated Nissen fundoplication. On postoperative day #1 a clear liquid diet is started, but the patient reports feeling bloated
33 with difficulty swallowing. The patient is kept NPO with intravenous fluid hydration. Over the next several days, the patient’s symptoms abate and he is able to tolerate liquids.
Ultimately, his diet is advanced and he is discharged home.
OR Questions
1. What dietary modifi cations may be effective in reducing acid refl ux?
Caffeine , spicy foods , and alcohol are all known to exacer-bate GERD symptoms ; avoiding these may provide symp-tom relief .
2. What are the presenting signs and symptoms of a strangu-lated hiatal hernia?
Patients typically complain of sudden chest or abdominal pain that is usually accompanied by nausea and retching.
The diagnosis is confirmed by a CT scan which will demon-strate the herniation. A high degree of suspicion is required to make this diagnosis promptly since the signs and symp-toms can be non - specific , and most patients are unaware that they have a hiatal hernia .
3. On POD#1 following a Nissen fundoplication a patient becomes tachycardic to 105 bpm and has a fever of 38.8 °C.
What is the clinical concern?
The patient may have a leak from an inadvertent injury to the stomach. An emergent UGI with gastrograffin may be used to determine if a leak is present. If the clinical suspicion is sufficiently high , the surgeon may choose to re explore the patient without any imaging .
4. A patient with long-standing GERD is taken for a Nissen fundoplication. During the dissection of the distal esopha-gus the surgeon notices billowing of the left diaphragm and the anesthesiologist reports that she is suddenly having diffi culty maintaining the patient’s oxygen saturation.
What is the diagnosis and treatment?
Auscultation will confirm the presence of a pneumothorax.
The surgeon should desufflate the abdomen and observe for OR Questions
resolution of the hypoxia. Any hemodynamic instability should prompt the immediate placement of a chest tube . 5. A patient involved in a motor vehicle collision complains
of shortness of breath. Decreased breath sounds are noted on auscultation of the left chest. In addition to pneumo-thorax, what should be included in the differential diagnosis?
Significant blunt force impact can lead to diaphragmatic rupture with resultant herniation of abdominal contents into the thoracic cavity.
Fundoplication
Hiatal hernia
•Occurs when structures herniate through a lax esophageal hiatus up into the mediastinum
•Type I: herniation of only GE junction
•Type II: herniation of the fundus of the stomach
•Type III: a combination of Type I and Type II
•Type IV: herniation of other organs (e.g. spleen, colon)
•Non-operative therapy is used for type I hernias
•Hiatal hernia repair is usually recommended for types II-IV, since incarceration and strangulation of hernia contents can occur Gastroesophageal reflux
disease (GERD)
•Decreased pressure at the lower esophageal sphincter allows reflux of acidic gastric contents into the distal esophagus
•Often asymptomatic, or may present with heartburn, regurgitation, dysphagia, laryngitis, hoarseness, cough
•Barrett’s esophagus: change in the esophageal mucosa from its usual squamous to a columnar epithelium, increases the risk of
adenocarcinoma
•Evaluation involves endoscopy, manometry, pH monitoring, and upper GI imaging
35
Peri-op orders
•Antiemetic agents
•Consider post-op upper GI study
•Clear liquids on POD#1
•Advance diet as tolerated Technique
•Usually performed laparoscopically
•Nissen fundoplication is most common technique
•Dissection of the esophageal hiatus
•Ligation of short gastric arteries and mobilization of the stomach fundus
•Approximation of diaphragmatic crura to tighten esophageal hiatus
•Fundus is wrapped around the esophagus and sutured in place
•May be performed with hiatal hernia repair as needed
Complications
•Enterotomy
•Pneumothorax
•Dysphagia
•Gas-bloat syndrome
•Slipped wrap
Suggested Reading
Linden PA. Overview: esophageal reflux disorders. In: Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L, editors. Adult chest surgery. 1st ed. New York: McGraw-Hill Professional Publishing; 2009.
Suggested Reading
U. Sarpel, Surgery: An Introductory Guide, 37 DOI 10.1007/978-1-4939-0903-2_5,
© Springer Science+Business Media New York 2014
Introduction
Resection of the esophagus is most commonly performed for the treatment of esophageal carcinoma. Two histologic sub-types of this cancer exist, each with their own distinctive features. Worldwide, by far the most common type of esopha-geal cancer is squamous cell carcinoma (SCC). This tumor type is associated with smoking and alcohol intake, which are individual risk factors for SCC and also have a synergistic effect when combined. While rates of SCC in other countries remain high, over the past few decades the incidence in the USA has been steadily dropping—a change attributed to lower rates of tobacco and alcohol use.
At the same time, there has been a dramatic rise in the incidence of esophageal adenocarcinoma , such that adeno-carcinoma has recently surpassed squamous cell adeno-carcinoma as the most common type of esophageal cancer in the USA.
Esophageal adenocarcinoma is thought to occur as the end result of a sequence of events that culminate in carcinogen-esis. The first step in this process is the development of gastroesophageal reflux disease (GERD), in which a lax lower esophageal sphincter allows acidic contents of the
Esophageal adenocarcinoma is thought to occur as the end result of a sequence of events that culminate in carcinogen-esis. The first step in this process is the development of gastroesophageal reflux disease (GERD), in which a lax lower esophageal sphincter allows acidic contents of the