Laparoscopic Reduction, Crural Repair, and Fundoplication of Large Hiatal Hernia Alfred Cuschieri, k&y
FRCS, Sami Shimi, MB, ChB, BSC, FRCS, MB, ChB, FRACS, Dundee,Scotland
MD, ChM, FRCS(Edin),
K. Nathanson,
A technique for laparoscopic reduction, crural repair, and total fundoplication for large symptomatic hiatal hernia is described. The procedure entails the mobilization of the esophagogastric junction with crural repair by a continuous suture technique employing a special pre-formed jamming loop knot, followed by total fundoplication that is fixed proximally to the anterior margin of the diaphragmatic hiatus and distally to the esophagogastric junction. The procedure has been performed in eight elderly patients with a good outcome and accelerated recovery to full activity.
From the Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland. Requests for reprints should be addressed to Alfred Cuschieri, MD, ChM. Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee DDf 9SY, Sootland, United Kingdom. Manuscript submitted August 1, 1991, and accepted in revised form January 7,1992.
he scope of minimal access abdominal surgery T through the laparoscope is being expanded and is likely to be applicable to the majority of functional gastrointestinal operations [I]. The technique of laparoscopic mobilization of the abdominal esophagus and esophagogastric junction has enabled successful antireflux surgery with this approach [ZJ. Large hiatal hernias (sliding, paraesophageal, or mixed), often encountered in the elderly, have a propensity to incarceration and strangulation and, for this reason, are treated surgically if the patient is fit [3,4]. For this purpose, the abdominal route is preferred as the vast majority can be reduced without difficulty to the peritoneal cavity. Crural repair is an essential feature of this procedure and is usually accompanied by a total fundoplication, which increases the safety margin against recurrence and corrects any associated reflux. We have developed a laparoscopic technique that reproduces all the essential components of this standard surgical management, and we report our experience in eight patients. OPERATIVE TECHNIQUE The operation is performed with the patient in the supine position and the surgeon on the left side with access to the vacuum-lock telescope holder (First Assistant, Leonard Inc, Philadelphia, PA). Five trocar cannulae are used as shown in Figure 1. The telescope (30” forward-oblique) is inserted through an 11-mm cannula 3 cm to the left and above the umbilicus. The other cannulae are sited as follows: below and to the right of the xiphoid process (5 mm), 4 cm to the right and above the umbilicus (11 to 12 mm), midway between the xiphoid and the umbilicus to the right of the linea alba (5 mm), and at the lower edge of the left subcostal region (5 mm). The laparoscope cannula is introduced blind after the creation of the pneumoperitoneum using a high-flow electronic insufflator, whereas the remaining four are inserted under visual control. The exposure of the hiatal region and the hernia is considerably facilitated by the use of the dipping endoretractor (Karl Storz, Tuttlingen, Germany). This fits on the outside of the telescope and is introduced through the same cannula. In its absence, an expanding threepronged retractor (Karl Storz, Tuttlingen, Germany) or palpating probe is introduced through the xiphoid cannula and used to lift up the left lobe of the liver. The reduction of the hernia is achieved by a “walking” technique using two grasping forceps. As the uppermost reach of the anterior wall of the stomach is grasped and pulled down, the more proximal stomach that appears outside the hiatus is grasped by the second forceps and again pulled down, the process being repeated until the esophagogastric junction and distal esophagus are re-
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 APRIL 1992
425
CUSCHIERI ET AL
The mobilization of the esophagus and esophagogastric junction is best started on the left side, exposing the left crus. Unlike reflux cases without a sizable hernia, several bands made up of compressed fibroelastic tissue bind the esophagus to the lower part of the hernial sac and require division before the left margin of the esophagus alongside the left crus is exposed. Some of these bands have veins and require electrocoagulation. A fairly constant arterial branch of the inferior left phrenic artery is encountered at this stage. This is best clipped before exible cannula division. The peritoneum on the margin of the arch of the hiatus and the right crus is then divided. The exposure of e the right crus is completed by division of the transparent * \ 1lmm cannulas window of the lesser omentum close to the esophagogastric junction (pars flaccida). The dissection (scissors and blunt) is continued toward the posterior mediastinum in ( the fibroareolar tissue between the right crus and right U margin of the esophagus and, if kept within the hiatus, is fairly avascular. The posterior vagus is encountered at /\ L this stage loosely adherent to the right posterolateral aspect of the esophagus. Following separation of the vagal F@m l.Thetebscope isinseftedthughan 11-m-ncannula trunk, the esophagus is tented forwards and to the left, 2.5 cm to the left and above the umbilicus.The other cam&e and mobilization of its posterior wall continued until the ares~belowendtotherigMofthexiphddprocess(5mm),4 cm totheright and above the umbilicus(11 to 12 mm), midway medial limit of the left crus is reached. The dissection then moves to the left with division of the gastrophrenic betweenthexiphoidandtheumbilicus~orrigMofthelineaalba (5 mm), and at the lower edge of the left wbcostal region(5 mm). peritoneum and separation of the left posterolateral wall of the esophagus from the left crus. At this stage, the pseudoelastic variable curvature dissecting spatula (Figure 2) is introduced between the left crus and the esophagus near the angle of His and then gently eased behind the esophagus (as its curvature is increased by extrusion) until its end emerges from the right side between the gullet and the posterior vagal trunk [5]. Alternatively, a fixed curved grasper inserted through a flexible cannula is used. A vascular silicon sling introduced percutaneously is then passed round the esophagus (F’iie 3). Traction on the sling then lifts the esophagus forward from the crura and permits completion of the posterior mobilization such that the entire length of the two crura and their insertion are exposed. A traumatic grasper is next introduced behind the esophagus and used to pick the fundus of the stomach held in another grasping forceps introduced from the left side (Figure 4). The fundus is pulled behind and along the right margin of the esophagus. If present, fibrous adhesions between the posterior surface of the stomach and retroperitoneal structures have to be divided to enable the fundus to be brought round without tension. A “walking” technique using two graspers is needed to bring sufficient fundus for a loose fundoplication. The crural repair is conducted first. A 20-cm 2/O Flgure 2. Variable arvatm pseudoelasticdlswcting spatula black silk suture is used on an endoski needle (or half (Karl Stow TuttWw Germany). circle one that has been opened out). A jamming loop knot slipping from the tail is fashioned externally, and the placed with the abdomen. In one of eight patients, adhe- tail is kept long, approximately 2 cm (Figure 5). The sions between the herniated stomach and the hernia sac suture is then inserted into the peritoneal cavity inside a were present. Their division by scissors enabled complete suture applicator. The needle is grasped by the 5-mm reduction of the stomach to be achieved. No attempt is needle holder with the tip pointing to the left. The needle made to dissect the hernia sac, which is left behind in the is passed through the right and left crura near their insertion, and the suture pulled until the jamming loop knot mediastinum.
% /m
426
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 APRIL 1992
LAPAROSCOPY IN THE TREATMENT OF HIATAL HERNIA
FIgwe 4. A traumatic grasper is introduced behind the esophagus
and used to pick the fundus of the stomach held in another gasping forceps introduced from the left side. Fijpre 3. A silicon sling is then railroaded round the esophagus and extemaiized. Traction on the sling lifts the empbgus forward from the crwa and permits completion of the posterior mobilization and complete exposwe of the entire length of the two crwa.
impinges on the lateral aspect of the right crus. The 3-mm needle holder is then passed through the loop to grasp the suture and pull it through the jamming loop (Figure 6, Top), the tail of which is slipped tightly on the suture that is then pulled to commence the approximation of the crura. Deep continuous bites are taken of the two crura progressing in a cephalad direction until the desired crural approximation is achieved when the suture is locked in a blanket fashion before the direction of the running stitch is reversed (Fii 6, Middle). Further continuous bites are taken down the approximated crura until the tail is reached (FII 6, Bottom). The suture is then tied to the tail using a standard microsurgical knot using the two needle holders. In these large hernias, we use a total wrap (with 35F orogastric tube in situ), and we prefer to perform the fundoplication using a continuous suture technique with 3/O black silk. Again, a 20-cm suture with a long-tailed jamming loop is used. The fust bite picks up the fundus high up to the left of the esophagus, the anterior margin of the hiatus, the anterior esophageal wall, and the uppermost edge of the wrap in that order (Figure 7, Top). After passage of the needle through the jamming loop, the tail is slipped, and the suture is pulled to achieve the approximation of the stomach walls to each other and to the anterior margin of the hiatus. A locking hitch (single throw) is made between the suture and the tail to prevent slipping of the approximated stomach walls from each other and the hiatus during the rest of the suturing. The stomach edges are then approximated to each other over (but not including) the esophagus by running seromuscular bites until the esophagogastric junction is reached. The last bite includes the two edges of the wrap and the underlying esophagogastric junction (to fur the wrap), and the suture is then tied using the Aberdeen knot (Figure 7, Bottom). The silicon sling and orogastric tube are then removed. Alternatively, the fundoplication can be THE AMERICAN
Figue5.Extemalfomdonofjammingloopknotattheendofa 2O-rnm sutve with larat slipping from tail.
performed using interrupted sutures with internal knotting. PATIENTS AND RESULTS Total fundoplication and crural repair have been performed in eight patients (six women, two men), aged 60 to 76 years. The follow-up period ranges from 2 to 19 months (median: 11 months). All the patients were investigated preoperatively with endoscopy and biopsy, barium swallow, 24-hour pH monitoring, esophageal manometry, and isotope esophageal transit studies. Seven patients had a large sliding or mixed hiatal hernia with more than the upper third of the stomach in the chest. All JOURNAL
OF SURGERY
VOLUME
163
APRIL 1992
427
CUSCHIERI ET AL
Figure 7. Fundopkation by continuoussutm technique: Top, The first bite pi& up tha fundus high up to the lefl of ths esophagus,tha anteriormarginof tha hiatus,and the uppermost edge of tha wrap, in that order. Aftsr passaga of the needle throughths jammingloop, the tail is slippedand ths suhre pulled to achieve tha approximationof the stomachwails to each othar and to the hiatus. A locking(doublethrow) is made between ths suture and tha tail to prevent slipping. Bottom, Ths stomach edges are then approximatedto each othar ovar the esophagus by runningssromus~uiarbitesuntiiths esophagogastricjunOtion isreached.Thelastsutureincludesthetw0edges0fthewrapand the underlyii esophagogastk jumtion. Aiternattveiy,the fundopiicationmay be performedusinginterruptedsutms.
these patients had grade 3 esophagitis: two had Barrett’s change; and one had an esophageal stricture. The last patient had a large paraesophageal hernia without reflux but complained of pressure symptoms and dysphagia. This was associated with a step delay on the isotope transit study. Flguo 6. Crud repeir: lop, After the sutwe is raiiroadd through The average operating time was 3 hours (range: 2.5 to thejemningloop,thetaliissilppedtigMlyonthesutve,whichis the approximationof the OrWa.Middle+, 5.5 hours). The postoperative complications encountered thanpulledtoDaapcmtkmusbitesaratekanofthatwoauainacephaled have been transient cervical surgical emphysema (three directionuntilthe da&ad ~nrai approximationis a&Wad whan patients), small left pneumothorax (one patient), and the~eis~edinablanketfashian.Bonom,Furthercontinrc transient dysphagia (one patient). The surgical emphyse ousbitegaretakendowntheapproxlmatedavarrntiithetaiiis ma resolved within a few hours and was due to the CO2 reaOhsd.Thesuhmistfmtiadtothataiiusinga&andafd migrating up the mediastinum during the dissection. The miOroslrgicalknot. 428
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 APRIL 1992
LAPAROSCOPY IN THE TREATMENT OF HIATAL HERNIA
F&o
8. Loft, Reoperative and. Rf@, postoperative barium patient b-sated by lapammp~c WWir of
swallowin a 72-yew&l a mixed hi&l hemii.
one instance of apical pneumothorax was discovered on the postoperative roentgenogram taken in the recovery room. Prompt full expansion was achieved by intercostal underwater seal drainage. One patient developed dysphagia for solids, which lasted 10 days. No other complications were encountered. Postoperative analgesia (omnopon) was required during the first 18 to 24 hours (mean: 15 mg, intramuscularly). The duration of hospital stay averaged 5 days (range: 4 to 9 days). All patients resumed their daily activities within 14 days. The adequacy of the repair was confiied in all patients by a barium swallow performed 4 to 6 weeks later (Fii 8, Left rud R&t). These patients are being assessed prospectively with repeat symptomatic scoring, endoscopy, manometry, and 24-hour pH monitoring at 3 and 12 months. The 3-month assessment has been comTHE AMERICAN
pleted in six. All have no symptoms, absence of acid reflux, and normal endoscopy, except for persistence of the Barrett’s change. The remaining two patients are asymptomatic but have not completed their 3-month assessments, COMMENTS Laparoscopic antireflux surgery was initiated at Ninewells Hospital and Medical School in June 1989. Initially, the experience was limited to patients with documented reflux disease without a sizable hiatal defect and who were not obese. On the basis of these criteria, 6 of 3 1 consecutive patients were electively treated by the open thoracic approach (Belsey mark 4). We still regard gross obesity as a contraindication, but we now undertake laparoscopic treatment of patients with sizable hiatal hernia JOURNAL
OF SURGERY
VOLUME
163 APRIL
1992
429
and large crural defects. The present study considered this subgroup of patients. Although limited, this early experience has confirmed the feasibility and efficacy of laparoscopic treatment of the large hiatal hernia. All the recognized important components of the surgical repair of these hiatal hernias are reproduced by this endoscopic approach. Despite the long duration of these procedures, the recovery of these elderly patients has been most encouraging and exceeds that which we have experienced when the same procedures are conducted by the conventional open techniques. With increasing experience, improved siting of access cannulae, and better instrumentation, the operating time has decreased from 5.5 hours to 2.5 to 3.0 hours. The morbidity encountered has been minor considering our limited experience with these large hernias. The cervical surgical emphysema is of no consequence, and we have often encountered it after laparoscopic vagotomy, partial fundoplication, and cardiomyotomy. However, the pneumothorax may be important especially as we were not aware we had damaged the pleura during the operation. Obviously, a roentgenogram of the chest is necessary in the early postoperative period in all patients after laparoscopic hiatal dissection of the esophagus. The use of the 30” forward oblique telescope is essential. The esophageal dissection is considerably facilitated
430
THE AMERICAN JOURNAL OF SURGERY
by the shape memory pseudoelastic dissector. This prototype instrument is now being produced commercially. In its absence, a rigid curved grasper introduced through a flexible cannula (temporarily replacing the left subcostal) can be used to complete the posterior mobilization and insert a silicon sling around the esophagus. The outcome to date has been encouraging in all respects: the rapid recovery of these elderly patients, the symptomatic relief, and the adequacy of the repair as judged by objective testing. However, the follow-up has been short, and no definite conclusions on the long-term efficacy of the procedure can be made until several years have elapsed. REFERENCES 1. Cuschieri A. The spectrum of laparoscopic surgery. World J Surg (in press). 2. Cuschieri A, Nathanson LK, Shimi S. Laparcscopic ligamenturn teres cardiopexy. Br J Surg; 1991; 78: 947-51. 3. Skinner DB. Symptomatic esophageal reflux. Am J Dig Dis 1966; 11: 771-9. 4. Pearson FC, Cooper JD, Ilves R, Todd TRJ, Jamieson WRE. Massive hiatal hernia with incarceration. A report of 53 cases. Can Ann Thorac Surg 1983; 35: 45-51. 5. Cuschieri A. Variable curvature pseudoelastic shape memory dissecting spatula for laparoscopic surgery. Surg Endosc 1991; 5: 179-81.
VOLUME 163 APRIL 1992
FRCS, Sami Shimi, MB, ChB, BSC, FRCS, MB, ChB, FRACS, Dundee,Scotland
MD, ChM, FRCS(Edin),
K. Nathanson,
A technique for laparoscopic reduction, crural repair, and total fundoplication for large symptomatic hiatal hernia is described. The procedure entails the mobilization of the esophagogastric junction with crural repair by a continuous suture technique employing a special pre-formed jamming loop knot, followed by total fundoplication that is fixed proximally to the anterior margin of the diaphragmatic hiatus and distally to the esophagogastric junction. The procedure has been performed in eight elderly patients with a good outcome and accelerated recovery to full activity.
From the Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland. Requests for reprints should be addressed to Alfred Cuschieri, MD, ChM. Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee DDf 9SY, Sootland, United Kingdom. Manuscript submitted August 1, 1991, and accepted in revised form January 7,1992.
he scope of minimal access abdominal surgery T through the laparoscope is being expanded and is likely to be applicable to the majority of functional gastrointestinal operations [I]. The technique of laparoscopic mobilization of the abdominal esophagus and esophagogastric junction has enabled successful antireflux surgery with this approach [ZJ. Large hiatal hernias (sliding, paraesophageal, or mixed), often encountered in the elderly, have a propensity to incarceration and strangulation and, for this reason, are treated surgically if the patient is fit [3,4]. For this purpose, the abdominal route is preferred as the vast majority can be reduced without difficulty to the peritoneal cavity. Crural repair is an essential feature of this procedure and is usually accompanied by a total fundoplication, which increases the safety margin against recurrence and corrects any associated reflux. We have developed a laparoscopic technique that reproduces all the essential components of this standard surgical management, and we report our experience in eight patients. OPERATIVE TECHNIQUE The operation is performed with the patient in the supine position and the surgeon on the left side with access to the vacuum-lock telescope holder (First Assistant, Leonard Inc, Philadelphia, PA). Five trocar cannulae are used as shown in Figure 1. The telescope (30” forward-oblique) is inserted through an 11-mm cannula 3 cm to the left and above the umbilicus. The other cannulae are sited as follows: below and to the right of the xiphoid process (5 mm), 4 cm to the right and above the umbilicus (11 to 12 mm), midway between the xiphoid and the umbilicus to the right of the linea alba (5 mm), and at the lower edge of the left subcostal region (5 mm). The laparoscope cannula is introduced blind after the creation of the pneumoperitoneum using a high-flow electronic insufflator, whereas the remaining four are inserted under visual control. The exposure of the hiatal region and the hernia is considerably facilitated by the use of the dipping endoretractor (Karl Storz, Tuttlingen, Germany). This fits on the outside of the telescope and is introduced through the same cannula. In its absence, an expanding threepronged retractor (Karl Storz, Tuttlingen, Germany) or palpating probe is introduced through the xiphoid cannula and used to lift up the left lobe of the liver. The reduction of the hernia is achieved by a “walking” technique using two grasping forceps. As the uppermost reach of the anterior wall of the stomach is grasped and pulled down, the more proximal stomach that appears outside the hiatus is grasped by the second forceps and again pulled down, the process being repeated until the esophagogastric junction and distal esophagus are re-
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 APRIL 1992
425
CUSCHIERI ET AL
The mobilization of the esophagus and esophagogastric junction is best started on the left side, exposing the left crus. Unlike reflux cases without a sizable hernia, several bands made up of compressed fibroelastic tissue bind the esophagus to the lower part of the hernial sac and require division before the left margin of the esophagus alongside the left crus is exposed. Some of these bands have veins and require electrocoagulation. A fairly constant arterial branch of the inferior left phrenic artery is encountered at this stage. This is best clipped before exible cannula division. The peritoneum on the margin of the arch of the hiatus and the right crus is then divided. The exposure of e the right crus is completed by division of the transparent * \ 1lmm cannulas window of the lesser omentum close to the esophagogastric junction (pars flaccida). The dissection (scissors and blunt) is continued toward the posterior mediastinum in ( the fibroareolar tissue between the right crus and right U margin of the esophagus and, if kept within the hiatus, is fairly avascular. The posterior vagus is encountered at /\ L this stage loosely adherent to the right posterolateral aspect of the esophagus. Following separation of the vagal F@m l.Thetebscope isinseftedthughan 11-m-ncannula trunk, the esophagus is tented forwards and to the left, 2.5 cm to the left and above the umbilicus.The other cam&e and mobilization of its posterior wall continued until the ares~belowendtotherigMofthexiphddprocess(5mm),4 cm totheright and above the umbilicus(11 to 12 mm), midway medial limit of the left crus is reached. The dissection then moves to the left with division of the gastrophrenic betweenthexiphoidandtheumbilicus~orrigMofthelineaalba (5 mm), and at the lower edge of the left wbcostal region(5 mm). peritoneum and separation of the left posterolateral wall of the esophagus from the left crus. At this stage, the pseudoelastic variable curvature dissecting spatula (Figure 2) is introduced between the left crus and the esophagus near the angle of His and then gently eased behind the esophagus (as its curvature is increased by extrusion) until its end emerges from the right side between the gullet and the posterior vagal trunk [5]. Alternatively, a fixed curved grasper inserted through a flexible cannula is used. A vascular silicon sling introduced percutaneously is then passed round the esophagus (F’iie 3). Traction on the sling then lifts the esophagus forward from the crura and permits completion of the posterior mobilization such that the entire length of the two crura and their insertion are exposed. A traumatic grasper is next introduced behind the esophagus and used to pick the fundus of the stomach held in another grasping forceps introduced from the left side (Figure 4). The fundus is pulled behind and along the right margin of the esophagus. If present, fibrous adhesions between the posterior surface of the stomach and retroperitoneal structures have to be divided to enable the fundus to be brought round without tension. A “walking” technique using two graspers is needed to bring sufficient fundus for a loose fundoplication. The crural repair is conducted first. A 20-cm 2/O Flgure 2. Variable arvatm pseudoelasticdlswcting spatula black silk suture is used on an endoski needle (or half (Karl Stow TuttWw Germany). circle one that has been opened out). A jamming loop knot slipping from the tail is fashioned externally, and the placed with the abdomen. In one of eight patients, adhe- tail is kept long, approximately 2 cm (Figure 5). The sions between the herniated stomach and the hernia sac suture is then inserted into the peritoneal cavity inside a were present. Their division by scissors enabled complete suture applicator. The needle is grasped by the 5-mm reduction of the stomach to be achieved. No attempt is needle holder with the tip pointing to the left. The needle made to dissect the hernia sac, which is left behind in the is passed through the right and left crura near their insertion, and the suture pulled until the jamming loop knot mediastinum.
% /m
426
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 APRIL 1992
LAPAROSCOPY IN THE TREATMENT OF HIATAL HERNIA
FIgwe 4. A traumatic grasper is introduced behind the esophagus
and used to pick the fundus of the stomach held in another gasping forceps introduced from the left side. Fijpre 3. A silicon sling is then railroaded round the esophagus and extemaiized. Traction on the sling lifts the empbgus forward from the crwa and permits completion of the posterior mobilization and complete exposwe of the entire length of the two crwa.
impinges on the lateral aspect of the right crus. The 3-mm needle holder is then passed through the loop to grasp the suture and pull it through the jamming loop (Figure 6, Top), the tail of which is slipped tightly on the suture that is then pulled to commence the approximation of the crura. Deep continuous bites are taken of the two crura progressing in a cephalad direction until the desired crural approximation is achieved when the suture is locked in a blanket fashion before the direction of the running stitch is reversed (Fii 6, Middle). Further continuous bites are taken down the approximated crura until the tail is reached (FII 6, Bottom). The suture is then tied to the tail using a standard microsurgical knot using the two needle holders. In these large hernias, we use a total wrap (with 35F orogastric tube in situ), and we prefer to perform the fundoplication using a continuous suture technique with 3/O black silk. Again, a 20-cm suture with a long-tailed jamming loop is used. The fust bite picks up the fundus high up to the left of the esophagus, the anterior margin of the hiatus, the anterior esophageal wall, and the uppermost edge of the wrap in that order (Figure 7, Top). After passage of the needle through the jamming loop, the tail is slipped, and the suture is pulled to achieve the approximation of the stomach walls to each other and to the anterior margin of the hiatus. A locking hitch (single throw) is made between the suture and the tail to prevent slipping of the approximated stomach walls from each other and the hiatus during the rest of the suturing. The stomach edges are then approximated to each other over (but not including) the esophagus by running seromuscular bites until the esophagogastric junction is reached. The last bite includes the two edges of the wrap and the underlying esophagogastric junction (to fur the wrap), and the suture is then tied using the Aberdeen knot (Figure 7, Bottom). The silicon sling and orogastric tube are then removed. Alternatively, the fundoplication can be THE AMERICAN
Figue5.Extemalfomdonofjammingloopknotattheendofa 2O-rnm sutve with larat slipping from tail.
performed using interrupted sutures with internal knotting. PATIENTS AND RESULTS Total fundoplication and crural repair have been performed in eight patients (six women, two men), aged 60 to 76 years. The follow-up period ranges from 2 to 19 months (median: 11 months). All the patients were investigated preoperatively with endoscopy and biopsy, barium swallow, 24-hour pH monitoring, esophageal manometry, and isotope esophageal transit studies. Seven patients had a large sliding or mixed hiatal hernia with more than the upper third of the stomach in the chest. All JOURNAL
OF SURGERY
VOLUME
163
APRIL 1992
427
CUSCHIERI ET AL
Figure 7. Fundopkation by continuoussutm technique: Top, The first bite pi& up tha fundus high up to the lefl of ths esophagus,tha anteriormarginof tha hiatus,and the uppermost edge of tha wrap, in that order. Aftsr passaga of the needle throughths jammingloop, the tail is slippedand ths suhre pulled to achieve tha approximationof the stomachwails to each othar and to the hiatus. A locking(doublethrow) is made between ths suture and tha tail to prevent slipping. Bottom, Ths stomach edges are then approximatedto each othar ovar the esophagus by runningssromus~uiarbitesuntiiths esophagogastricjunOtion isreached.Thelastsutureincludesthetw0edges0fthewrapand the underlyii esophagogastk jumtion. Aiternattveiy,the fundopiicationmay be performedusinginterruptedsutms.
these patients had grade 3 esophagitis: two had Barrett’s change; and one had an esophageal stricture. The last patient had a large paraesophageal hernia without reflux but complained of pressure symptoms and dysphagia. This was associated with a step delay on the isotope transit study. Flguo 6. Crud repeir: lop, After the sutwe is raiiroadd through The average operating time was 3 hours (range: 2.5 to thejemningloop,thetaliissilppedtigMlyonthesutve,whichis the approximationof the OrWa.Middle+, 5.5 hours). The postoperative complications encountered thanpulledtoDaapcmtkmusbitesaratekanofthatwoauainacephaled have been transient cervical surgical emphysema (three directionuntilthe da&ad ~nrai approximationis a&Wad whan patients), small left pneumothorax (one patient), and the~eis~edinablanketfashian.Bonom,Furthercontinrc transient dysphagia (one patient). The surgical emphyse ousbitegaretakendowntheapproxlmatedavarrntiithetaiiis ma resolved within a few hours and was due to the CO2 reaOhsd.Thesuhmistfmtiadtothataiiusinga&andafd migrating up the mediastinum during the dissection. The miOroslrgicalknot. 428
THE AMERICAN JOURNAL OF SURGERY
VOLUME 163 APRIL 1992
LAPAROSCOPY IN THE TREATMENT OF HIATAL HERNIA
F&o
8. Loft, Reoperative and. Rf@, postoperative barium patient b-sated by lapammp~c WWir of
swallowin a 72-yew&l a mixed hi&l hemii.
one instance of apical pneumothorax was discovered on the postoperative roentgenogram taken in the recovery room. Prompt full expansion was achieved by intercostal underwater seal drainage. One patient developed dysphagia for solids, which lasted 10 days. No other complications were encountered. Postoperative analgesia (omnopon) was required during the first 18 to 24 hours (mean: 15 mg, intramuscularly). The duration of hospital stay averaged 5 days (range: 4 to 9 days). All patients resumed their daily activities within 14 days. The adequacy of the repair was confiied in all patients by a barium swallow performed 4 to 6 weeks later (Fii 8, Left rud R&t). These patients are being assessed prospectively with repeat symptomatic scoring, endoscopy, manometry, and 24-hour pH monitoring at 3 and 12 months. The 3-month assessment has been comTHE AMERICAN
pleted in six. All have no symptoms, absence of acid reflux, and normal endoscopy, except for persistence of the Barrett’s change. The remaining two patients are asymptomatic but have not completed their 3-month assessments, COMMENTS Laparoscopic antireflux surgery was initiated at Ninewells Hospital and Medical School in June 1989. Initially, the experience was limited to patients with documented reflux disease without a sizable hiatal defect and who were not obese. On the basis of these criteria, 6 of 3 1 consecutive patients were electively treated by the open thoracic approach (Belsey mark 4). We still regard gross obesity as a contraindication, but we now undertake laparoscopic treatment of patients with sizable hiatal hernia JOURNAL
OF SURGERY
VOLUME
163 APRIL
1992
429
and large crural defects. The present study considered this subgroup of patients. Although limited, this early experience has confirmed the feasibility and efficacy of laparoscopic treatment of the large hiatal hernia. All the recognized important components of the surgical repair of these hiatal hernias are reproduced by this endoscopic approach. Despite the long duration of these procedures, the recovery of these elderly patients has been most encouraging and exceeds that which we have experienced when the same procedures are conducted by the conventional open techniques. With increasing experience, improved siting of access cannulae, and better instrumentation, the operating time has decreased from 5.5 hours to 2.5 to 3.0 hours. The morbidity encountered has been minor considering our limited experience with these large hernias. The cervical surgical emphysema is of no consequence, and we have often encountered it after laparoscopic vagotomy, partial fundoplication, and cardiomyotomy. However, the pneumothorax may be important especially as we were not aware we had damaged the pleura during the operation. Obviously, a roentgenogram of the chest is necessary in the early postoperative period in all patients after laparoscopic hiatal dissection of the esophagus. The use of the 30” forward oblique telescope is essential. The esophageal dissection is considerably facilitated
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THE AMERICAN JOURNAL OF SURGERY
by the shape memory pseudoelastic dissector. This prototype instrument is now being produced commercially. In its absence, a rigid curved grasper introduced through a flexible cannula (temporarily replacing the left subcostal) can be used to complete the posterior mobilization and insert a silicon sling around the esophagus. The outcome to date has been encouraging in all respects: the rapid recovery of these elderly patients, the symptomatic relief, and the adequacy of the repair as judged by objective testing. However, the follow-up has been short, and no definite conclusions on the long-term efficacy of the procedure can be made until several years have elapsed. REFERENCES 1. Cuschieri A. The spectrum of laparoscopic surgery. World J Surg (in press). 2. Cuschieri A, Nathanson LK, Shimi S. Laparcscopic ligamenturn teres cardiopexy. Br J Surg; 1991; 78: 947-51. 3. Skinner DB. Symptomatic esophageal reflux. Am J Dig Dis 1966; 11: 771-9. 4. Pearson FC, Cooper JD, Ilves R, Todd TRJ, Jamieson WRE. Massive hiatal hernia with incarceration. A report of 53 cases. Can Ann Thorac Surg 1983; 35: 45-51. 5. Cuschieri A. Variable curvature pseudoelastic shape memory dissecting spatula for laparoscopic surgery. Surg Endosc 1991; 5: 179-81.
VOLUME 163 APRIL 1992
