PREOPERATIVE DIAGNOSIS:
Esophageal achalasia.
POSTOPERATIVE DIAGNOSIS:
Esophageal achalasia.
OPERATIONS PERFORMED:
1. Laparoscopic
Heller cardiomyotomy.
2. Laparoscopic
Toupet fundoplication.
3. Intraoperative
esophagogastroduodenoscopy.
SURGEON: John Doe , MD
ANESTHESIA: General
endotracheal.
ESTIMATED BLOOD LOSS: 50 mL.
COMPLICATIONS: None.
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.
