PREOPERATIVE DIAGNOSIS: Esophageal achalasia.
POSTOPERATIVE DIAGNOSIS: Esophageal achalasia.
1. Laparoscopic Heller cardiomyotomy.
2. Laparoscopic Toupet fundoplication.
3. Intraoperative esophagogastroduodenoscopy.
John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 50 mL.
DESCRIPTION OF OPERATION: The patient was transported to the operating room and placed supine on the operating table. Following induction of satisfactory general endotracheal anesthesia, the patient was placed in a dorsal lithotomy position using Allen stirrups with appropriate padding of all pressure points. The abdomen was then prepped and draped in the usual fashion using Betadine solution and sterile towels and sheets. A skin incision was made approximately 8 cm inferior to the xiphoid process, superior to the umbilicus and to the left of the midline. The dissection was carried down to the level of the anterior fascia and the abdominal cavity entered under direct vision using an Optiview trocar. Carbon dioxide gas was instilled and a satisfactory pneumoperitoneum was achieved without evidence of respiratory compromise. The 30 degree laparoscope with video camera was threaded through this trocar site and the upper abdomen explored.
Examination of the right upper quadrant revealed a normal-appearing gallbladder and liver without nodularity over the surface. The anterior serosal surface of the stomach was unremarkable and there was no evidence of splenomegaly. Having completed the exploration, a 10 mm trocar was placed along the left costal margin at the midclavicular line and a 5 mm trocar placed on the left costal margin at the anterior axillary line. Two additional 5 mm trocars were placed in the subxiphoid position as well as in the right upper quadrant lateral to the rectus musculature. The 5 mm liver retractor was introduced through the right upper quadrant trocar site and used to elevate the left lobe of the liver. This allowed for complete exposure of the esophageal hiatus. There was no evidence of a sliding axial hiatal hernia and there was a moderate amount of inflammation surrounding the distal esophagus from the patient's prior dilatation.
The gastrohepatic ligament was initially opened over the caudate lobe of the liver using the Harmonic shears. The hepatic branch of the vagus nerve was identified and preserved. The peritoneal incisions were extended over the left and right crus and the mediastinum entered. The esophagus was then circumferentially mobilized and the anterior and posterior vagal nerve trunks identified. The posterior nerve trunk was left in place along the posterior wall of the esophagus and the distal aspect of the anterior trunk completely mobilized. The nerve trunk was encircled with a vessel loop, secured in place with an 0 PDS Endoloop. The posterior aspect of the gastroesophageal junction was fully mobilized as well and a pediatric Penrose drain passed around the esophagus at this level. This was secured in place with an 0 PDS Endoloop. The lesser sac was then entered along the greater curvature of the stomach inferior to the inferior pole of the spleen. The short gastric vessels were divided with the Harmonic shears to the level of the left crus and care was taken to ensure that the entire posterior aspect of the upper fundus of the stomach was completely mobilized.
Next, attention was turned to performing the cardiomyotomy. A site was selected along the anterior wall of the cardia of the stomach, at least 3 cm inferior to the gastroesophageal junction. The serosa and muscular wall of the stomach were then divided using Bovie electrocautery and Harmonic shears, exposing the mucosa of the stomach. Care was taken to ensure that the mucosa was not violated and that all the circular muscle fibers of His were divided. The myotomy was then extended over the anterior wall of the esophagus, carefully dividing the circular and longitudinal muscle fibers. Using the Harmonic shears, the myotomy was extended at least 8 to 10 cm proximally to the dilated area of esophagus where the muscular wall was no longer thickened. Again, care was taken to ensure that the esophageal mucosa was carefully preserved and the muscular wall of the esophagus was widely separated.
Intraoperative esophagogastroduodenoscopy was then performed and confirmed an adequate myotomy extending down onto the wall of the stomach without evidence of injury of the esophageal mucosa. The stomach and esophagus were desufflated and the scope removed. The vessel loop was removed from the anterior vagus nerve and attention turned to reapproximation of the crus posteriorly. This was accomplished using felt pledgets and a single horizontal mattress suture of 0 Ethibond. Care was taken to ensure that there was no narrowing of the esophageal hiatus or anterior angulation of the esophagus. Next, the posterior aspect of the upper fundus of the stomach was passed posteriorly to the esophagus. The esophagus appeared to lie comfortably within the bed of the fundus and there was no evidence of tension. The posterior aspect of the fundus was then secured to the diaphragm using 2-0 Ethibond sutures. The Toupet fundoplication was completed using 2-0 Ethibond sutures as well. The superior sutures were placed at the 10 o'clock and 2 o'clock positions between the muscular wall of the esophagus, the fundus of the stomach, and the diaphragm. Two additional sutures were placed on either side between the muscular wall of the esophagus and the fundus of the stomach.
At the completion of the fundoplication, it measured approximately 2.5 cm in length and there was no evidence of tension. There was wide distraction of the myotomy exposing the esophageal mucosa and the area of dissection was thoroughly irrigated with Kantrex solution. After assuring satisfactory hemostasis, any remaining fluid was evacuated and the suction irrigator used to remove as much carbon dioxide gas as possible. The trocars were removed and the incisions irrigated with Kantrex solution. The fascial opening at the 10 mm trocar sites were closed with 0 Vicryl sutures and 0.5% Marcaine instilled into the incisions. The skin was closed with 4-0 Vicryl subcuticular suture and benzoin and Steri-Strips, as well as a Tegaderm dressing placed across the incisions. The patient was then awakened and transported back to the recovery room in satisfactory condition with sponge and needle counts reported as correct at the end of the procedure.