UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

More documents

Recommendations

Info

174 Updated Topics in Minimally Invasive Abdominal Surgery The failure rate of a Nissen fundoplication for paraesophageal hernia is 7-33%, depending whether failure is defined anatomically or symptomatically. Patient satisfaction after laparoscopic Nissen fundoplication with 5-year follow-up is 86-96% (Lafullarde et al., 2001; Smith et al., 2005). Complications associated with laparoscopic hiatal hernia surgery include stenosis, pulmonary complications (pneumonia, pneumothorax, pulmonary edema) and gastrointestinal complications (bleeding, perforation, dysphagia). 4.2.1 Laparoscopic fundoplication technique The patient should be positioned supine on a split leg table with arms out and in a steep reverse Trendelenburg position to help expose the hiatus. After establishing a pneumoperitoneum five trocars are inserted. A liver retractor is used to retract the left liver lobe and expose the anterior surface of the proximal stomach near the gastroesophageal junction. The hepatogastric omentum should be opened over the caudate lobe of the liver, just above the hepatic branch of the vagal nerve, exposing the right crus of the diaphragm. Caution should be taken for an aberrant left hepatic artery in this area, present in approximately 20% of patients. Over left, anteriorly the phrenoesophageal ligament can be divided to its apex on the right. The right and left crus are dissected from its base to the crural arch and the retroesophageal window is gently opened, protecting the posterior vagal nerve. A penrose drain can be used to retract the esophagus during further dissecting, until at least 2-3 cm of distal esophagus can be pulled below the diaphragm without tension. During this dissection caution should be taken not to injure the anterior and posterior vagal nerves, left or right pleura and aorta. The gastric fundus should be mobilized from 10-15 cm inferior to the angle of His, isolating and dividing the short gastric vessels, working back to the gastroesophageal junction. It is important to avoid excessive traction when dividing all posterior gastric arteries and other attachments, to prevent tearing of the short gastric arteries or splenic capsule. In some patients the proximal fundus and upper pole of the spleen are closely attached, making this part of the dissection quite difficult. The mobilized gastric fundus is brought through the retroesophageal window and around the distal esophagus anteriorly to ensure adequate mobilization. If the gastric fundus is released and exits the retroesophageal window, further mobilization is necessary. The fundoplication can be completed around a 50-60 French dilator. The internal diameter of the wrap should exceed the external diameter of the esophagus. Two or three non-absorbable sutures are placed with bites taking full thickness gastric fundus and partial thickness anterior esophageal wall, avoiding the anterior vagal nerve. When completed the wrap should be no greater than 2 cm in length and optimally a bit of distal esophagus should be visible distally to the wrap. Additional sutures from the wrap to the diaphragm can be placed. The crus can be closed using non-absorbable stitches. 4.2.2 Paraesophageal hernia repair Laparoscopic repair of a paraesophageal hernia consists of reduction of the stomach and gastroesophageal junction into the abdominal cavity, complete excision of the peritoneal hernia sac from the mediastinum, and repair of the esophageal hiatus. Following a Nissen fundoplication, the crus should be closed using non-absorbable sutures. In case of a large hiatus, additional anterior or lateral crural stitches can be added. An additional anterior gastropexy can be performed in case of a very large or shortened esophagus. The anterior stomach wall and the antrum should be sutured to the abdominal wall.
Laparoscopic Hernia Repair Laparoscopic repair of paraesophageal hernias is superior to open repair, with an associated decreased length of hospital stay, complication rate and recurrence rate (Draaisma et al., 2005). Long-term good functional results are observed in 75% and (symptomatic) recurrences in 15% after large paraesophageal hernia repair (Poncet et al., 2010). Postoperative complications associated with laparoscopic large paraesophageal hernia repair are intrathoracal wrap migration, relative stenosis of the cardia, gastric volvulus or strangulation, pneumothorax, pneumonia and dysphagia. A synthetic mesh can be used to reinforce the hiatal repair, but is still controversial. A mesh might be associated with a decreased recurrence rate, but may give rise to serious complications like prosthetic migration, esophageal perforation, dysphagia and mesh infection. Since the majority of paraesophageal hernias are mixed sliding and paraesophageal hernias, an insufficient LES with GERD-symptoms may remain after surgery and antireflux medication is still required. Esophagus (1) Gastric fundus (2) Splenic capsule (3) Phrenico-esophageal ligament (4) Abberant left hepatic artery (5) Anterior vagus nerve (6) Hepatic branch (7) Posterior vagus nerve (8) Fig. 2. Anatomic landmarks and structures of importance in hiatal hernia repair (Lange & Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002) 175
Page 1 and 2:
UPDATED TOPICS IN MINIMALLY INVASIV
Page 3:
free online editions of InTech Book
Page 6:
VI Contents Chapter 9 Appendicitis
Page 11:
Part 1 Laparoscopic Biliary-Pancrea
Page 14 and 15:
4 Updated Topics in Minimally Invas
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
10 Updated Topics in Minimally Inva
Page 22 and 23:
Page 24 and 25:
14 Fig. 3. Incision of 3,5 cm in le
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
30 4. Patients with sickle cell dis
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
44 5. References Updated Topics in
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 73 and 74:
1. Introduction 5 Laparoscopic Live
Page 75 and 76:
Laparoscopic Liver Resection 2.2.1
Page 77 and 78:
Laparoscopic Liver Resection of 64
Page 79 and 80:
Laparoscopic Liver Resection conver
Page 81 and 82:
Laparoscopic Liver Resection (Bruix
Page 83 and 84:
Laparoscopic Liver Resection (Buell
Page 85 and 86:
Laparoscopic Liver Resection House,
Page 87 and 88:
1. Introduction 6 Hilar Glissonean
Page 89 and 90:
Hilar Glissonean Access in Laparosc
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
1. Introduction 7 Laparoscopic Live
Page 99 and 100:
Laparoscopic Liver Surgery Fig. 1.
Page 101 and 102:
Laparoscopic Liver Surgery speciali
Page 103 and 104:
Laparoscopic Liver Surgery 3. Imagi
Page 105 and 106:
Laparoscopic Liver Surgery 5 mm por
Page 107 and 108:
Laparoscopic Liver Surgery A nylon
Page 109 and 110:
Laparoscopic Liver Surgery Fig. 7a.
Page 111 and 112:
Laparoscopic Liver Surgery or later
Page 113 and 114:
Laparoscopic Liver Surgery non rand
Page 115 and 116:
Laparoscopic Liver Surgery With rap
Page 117 and 118:
Laparoscopic Liver Surgery [19] Tro
Page 119 and 120:
Laparoscopic Liver Surgery [51] Lai
Page 121 and 122:
Laparoscopic Liver Surgery [84] Les
Page 123:
Part 3 Laparoscopic Appendectomy
Page 126 and 127:
116 Updated Topics in Minimally Inv
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135: 124 Updated Topics in Minimally Inv
Page 158 and 159: 148 Fig. 3. Operating room set-up f
Page 167 and 168: 1. Introduction 10 Laparoscopic Her
Page 169 and 170: Laparoscopic Hernia Repair Absorba
Page 171 and 172: Laparoscopic Hernia Repair passes t
Page 173 and 174: Laparoscopic Hernia Repair The cont
Page 175 and 176: Laparoscopic Hernia Repair 2.3.3 TA
Page 177 and 178: Laparoscopic Hernia Repair testicle
Page 179 and 180: Laparoscopic Hernia Repair semicirc
Page 181 and 182: Laparoscopic Hernia Repair fascial
Page 183: Laparoscopic Hernia Repair elastic
Page 187 and 188: Laparoscopic Hernia Repair defect.
Page 189 and 190: Laparoscopic Hernia Repair LeBlanc,
Page 191 and 192: 1. Introduction 11 Laparoscopic Inc
Page 193 and 194: Laparoscopic Incisional Hernia Repa
Page 203: Part 5 Laparoscopic Solid Organ Sur
Page 212 and 213: 202 5. Discussion Updated Topics in
Page 214 and 215: 204 7. References Updated Topics in
Page 224 and 225: 214 8. Surgery Updated Topics in Mi
Page 235 and 236:
14 Laparoscopic Approach to Abdomin
Page 237 and 238:
Laparoscopic Approach to Abdominal
Page 239 and 240:
Page 241 and 242:
Page 243 and 244:
Page 245 and 246:
Page 247 and 248:
1. Introduction 15 Role of Endoscop
Page 249 and 250:
Role of Endoscopy in Laparoscopic P
Page 251 and 252:
Page 253 and 254:
Page 255 and 256:
show all

UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?