1. Laparoscopic Surgery of the Abdomen Bruce V. MacFadyen, Jr.,
MD, et al., Editors Springer
2. Laparoscopic Surgery of the Abdomen
3. Springer New York Berlin Heidelberg Hong Kong London Milan
Paris Tokyo
4. Laparoscopic Surgery of the Abdomen Bruce V. MacFadyen, Jr.,
MD Professor, Department of Surgery, Chief, General Surgery,
Director of Minimally Invasive Surgery, Medical College of Georgia,
Augusta, Georgia Maurice E. Arregui, MD Director of Fellowship in
Advanced Laparoscopy and Endoscopy and Ultrasound, St. Vincents
Hospital and Health Center, Indianapolis, Indiana Steve Eubanks, MD
Associate Professor, Department of Surgery, Director of Surgical
Endoscopy, Duke University Medical Center, Durham, North Carolina
Douglas O. Olsen, MD Attending Surgeon, Centennial Medical Center,
Nashville, Tennessee Jeffrey H. Peters, MD Professor, Department of
Surgery, Chief, General Surgery, University of Southern California
Keck School of Medicine, University of Southern California, Los
Angeles, California Nathaniel J. Soper, MD Professor, Department of
Surgery, Section of Hepatobiliary, Pancreatic, and Gastrointestinal
Surgery, Washington University School of Medicine, St. Louis,
Missouri Lee L. Swanstrm, MD Clinical Professor of Surgery, Oregon
Health & Sciences University, Director, Department of Minimally
Invasive Surgery, Legacy Health System, Portland, Oregon Steven D.
Wexner, MD Chairman, Department of Colorectal Surgery, Chief of
Staff, Cleveland Clinic Florida, Weston, Florida Editors With 252
Illustrations 1 3
5. Maurice E. Arregui, MD Director of Fellowship in Advanced
Laparoscopy and Endoscopy and Ultrasound St. Vincents Hospital and
Health Center Indianapolis, IN 46260, USA Douglas O. Olsen, MD
Attending Surgeon Centennial Medical Center Nashville, TN 37203,
USA Nathaniel J. Soper, MD Professor Department of Surgery Section
of Hepatobiliary, Pancreatic, and Gastrointestinal Surgery
Washington University School of Medicine St. Louis, MO 63110, USA
Steven D. Wexner, MD Chairman Department of Colorectal Surgery
Chief of Staff Cleveland Clinic Florida Weston, FL 33331, USA
Library of Congress Cataloging-in-Publication Data Laparoscopic
surgery of the abdomen / editor, Bruce V. MacFadyen Jr. . . . [et
al.]. p. ; cm. Includes bibliographical references and index. ISBN
0-387-98468-2 (h/c : alk. paper) 1. Digestive organsDiseases. 2.
Laparoscopy. 3. Gastrointestinal systemDiseases. I. MacFadyen,
Bruce V., 1942 [DNLM: 1. Digestive System Diseasessurgery. 2.
Laparoscopymethods. WI 900 L2998 2003] RC816.L37 2003 617.43059dc21
2002029447 ISBN 0-387-98468-2 Printed on acid-free paper. 2004
Springer-Verlag New York, Inc. All rights reserved. This work may
not be translated or copied in whole or in part without the written
per- mission of the publisher (Springer-Verlag New York, Inc., 175
Fifth Avenue, New York, NY 10010, USA), except for brief excerpts
in connection with reviews or scholarly analysis. Use in connection
with any form of information storage and retrieval, electronic
adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed is forbidden. The use
in this publication of trade names, trademarks, service marks, and
similar terms, even if they are not identied as such, is not to be
taken as an expression of opinion as to whether or not they are
subject to proprietary rights. While the advice and information in
this book are believed to be true and accurate at the date of going
to press, neither the authors nor the editors nor the publisher can
accept any legal responsibility for any errors or omissions that
may be made. The publisher makes no warranty, express or implied,
with respect to the material contained herein. Printed in the
United States of America. 9 8 7 6 5 4 3 2 1 SPIN 10664759
www.springer-ny.com Springer-Verlag New York Berlin Heidelberg A
member of BertelsmannSpringer Science+Business Media GmbH Bruce V.
MacFadyen, Jr., MD Professor Department of Surgery Chief, General
Surgery Director of Minimally Invasive Surgery Medical College of
Georgia Augusta, GA 30912, USA Steve Eubanks, MD Associate
Professor Department of Surgery Director of Surgical Endoscopy Duke
University Medical Center Durham, NC 27710, USA Jeffrey H. Peters,
MD Professor, Department of Surgery Chief, General Surgery
University of Southern California Keck School of Medicine
University of Southern California Los Angeles, CA 90033, USA Lee L.
Swanstrm, MD Clinical Professor of Surgery, Oregon Health &
Sciences University Director, Department of Minimally Invasive
Surgery Legacy Health System Portland, OR 97227, USA
6. Preface The use of laparoscopy to remove the gallbladder and
appendix in the 1980s opened the door for the expanded application
of this minimally invasive technique to be applied to abdominal
operations that most surgeons have performed as an open pro-
cedure. Several textbooks have recorded the rapid development of
these techniques in the 1990s. However, longer term data and
experience has led to the development of new techniques,
modications of previous procedures, and changes in patient care.
These changes resulted in the writing of this book, which addresses
new patient man- agement, as well as developments in abdominal and
pelvic operations for the general surgeon. Positive and negative
aspects of patient management, technique, and results are
described. Because the eld of laparoscopy continues to develop and
expand, mod- ication of this data will certainly be necessary. But,
this book is the most up-to-date and comprehensive review in
laparoscopic surgery of the abdomen now available. Each section of
the book is edited by an expert in the eld who, along with the
indi- vidual chapter authors, brings a wealth of experience to the
book. All of the section editors and chapter authors are very busy
clinical surgeons and integrate very well the theoretical and
practical aspects of patient management, not only in the ofce but
also in the operating room and in postoperative care. I want to
particularly thank the section editors for their hard work and
diligence in developing the large number and inclusiveness of each
chapter. Without their help, this book would not have been
possible. This book is the state of the art in laparoscopic
abdominal surgery, and I hope it will stimulate surgeons to push
the envelope and advance the frontiers of this rapidly expanding
eld. Bruce V. MacFadyen, Jr., MD v
12. 56 Avoidance and Treatment of Urological Complications . .
. . . . . . . . . . . . 461 Roland N. Chen 57 Avoidance and
Treatment of Vascular Complications . . . . . . . . . . . . . . . .
464 Mark K. Grove and Mark E. Sesto SECTION VII DIAGNOSTIC
LAPAROSCOPY AND ACUTE ABDOMEN Section Editor: Steve Eubanks 58
Principles of Diagnostic Laparoscopy . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 471 Ross L. McMahon 59 Bedside
Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 481 Leena Khaitan 60 Diagnostic
Laparoscopy for Pelvic Pain . . . . . . . . . . . . . . . . . . . .
. . . . . . . 490 Linda Fetko 61 Diagnostic Laparoscopy for
Suspected Appendicitis . . . . . . . . . . . . . . . . . 497 Aurora
D. Pryor 62 Diagnostic Laparoscopy for Intestinal Disorders . . . .
. . . . . . . . . . . . . . . . 507 James J. Gangemi and Edward G.
Chekan 63 Diagnostic Laparoscopy for Malignancy . . . . . . . . . .
. . . . . . . . . . . . . . . . 513 Rebekah R. White and Douglas S.
Tyler Index . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Contents xi
13. This page intentionally left blank
14. Contributors Peter I. Anderson, MD Department of Emergency
Medicine,Wilford Hall Medical Center,LacklandAir Force Base, TX
78236, USA. Maurice E. Arregui, MD St. Vincents Hospital and Health
Center, Indianapolis, IN 46260, USA. Bruce Belin, MD St. Joseph
Ofce Park, Lexington, KY 40504, USA. George Berci, MD Department of
Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
Sigurdur Blondal, MD Department of Surgery, Landspitali-University
Hospital, IS-101 Reykjavik, Iceland. Luigi Bonavina, MD Division of
General Surgery, University of Milan, Istituto Policlinico San
Donato, Milan, Italy. L. Michael Brunt, MD Department of Surgery,
Washington University School of Medicine, St. Louis, MO 63110, USA.
Jo Buyske, MD Department of Surgery, Presbyterian Medical Center,
University of Pennsylvania Health System, Philadelphia, PA 19104,
USA. Margherita O. Cadeddu, MD Department of Surgery, Hamilton
General Hospital, Hamilton, Ontario, L8L 5G4, Canada. W. Keat
Cheah, MBBS Department of Surgery, The National University
Hospital, Singapore 119074. Edward G. Chekan, MD University of
Virginia, Sewickley Valley Hospital, Sewickley, PA 15143. USA.
Roland N. Chen, MD Carson City, NV 89703, USA. xiii
15. xiv Contributors Jonathan A. Cohen, MD Nashville Surgical
Associates, St. Thomas Medical Center, Nashville, TN 37205, USA.
Monty H. Cox, MD Department of General Surgery, Medical University
of South Carolina, Charleston, SC 29425, USA. John R. Craig, MD
Department of Surgery, Deaconess Hospital, Billings MT, 59107, USA
David L. Crawford, MD Department of Surgery, University of Illinois
at Chicago, College of Medicine at Peoria, Peoria, IL 61603, USA.
Ara Darzi, MD Department of Surgical Oncology and Technology,
Imperial College School of Medi- cine, St. Marys Hospital,
Pattington, London W2 1NY, UK. Jose Antonio Diaz-Elizondo, MD
Department of General Surgery, Instituto Tecnolgico y de Estudios
Superiores de Monterrey, Department Hospital San JosTec de
Monterrey, Monterrey, Mxico, C.P. 64718. Urs Diener, MD Department
of Gastrointestinal Surgery, University of California, San
Francisco, San Francisco, CA 94143, USA. Karen Draper-Stepanovich,
MD Department of Surgery, Lexington Clinical, Vanderbilt University
Medical Center, Lexington, KY 40504, USA. Jonathan E. Efron, MD
Department of Colorectal Surgery, Cleveland Clinic Florida, Naples,
FL 34119, USA. Steve Eubanks, MD Department of Surgery, Duke
University Medical Center, Durham, NC 27710, USA. Edward L. Felix,
MD Department of Surgery, University of California, San Francisco,
Fresno, CA 93710, USA. Linda Fetko, MD Department of Obstetrics and
Gynecology, Duke University Medical Center, Durham, NC 27704, USA.
Charles J. Filipi, MD Department of Surgery, Creighton University
School of Medicine, Omaha, NE 68131, USA. Aaron S. Fink, MD
Department of Surgery, Emory University School of Medicine, Atlanta
Veterans Administration Medical Center, Decatur, GA 30033, USA.
Robert J. Fitzgibbons, MD Department of Surgery, Division of
General Surgery, Creighton University School of Medicine,Omaha,NE
68131,USA.
16. Morris E. Franklin, Jr., MD Department of Surgery,
University of Texas at San Antonio, San Antonio, TX 78222, USA.
James J. Gangemi, MD Department of Surgery, University of Virginia
Health System, Charlottesville, VA 22908, USA. Luca Giordano, MD
Department of Minimally Invasive Surgery, Cedars-Sinai Medical
Center, Los Angeles, CA 90048, USA. Peter M.Y. Goh, MD Universitt
zu Kln, II Lehrstuhl fr Chirurgie, Klinikum ChirurgieKln-Merheim,
Germany. Mark K. Grove, MD Department of General and Vascular
Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA. Jeffrey
A. Hagen, MD Department of Surgery, Division of Thoracic and
Foregut Surgery, University of Southern California Keck School of
Medicine, Los Angeles, CA 90033-4612, USA. Matthew F. Hansman, MD
Department of General Surgery, Virginia Mason Medical Center,
Seattle, WA 98101, USA. Kristn H. Haraldsdttir, MD Department of
Surgery, Lunds University Hospital, Lund, Sweden. John E. Hartley,
MD Department of Surgery, University of Hull,Academic Surgical
Unit, Castle Hill Hospi- tal,Cottingham,EastYorkshire,HU16 5JQ,UK.
Michael D. Hellinger, MD Sylvester Comprehensive Cancer Center,
Division of Colorectal Surgery, University of Miami, Miami, FL
33136, USA. Daniel M. Herron, MD Department of Surgery, Division of
Laparoscopic Surgery, Mount Sinai School of Med- icine, New York,
NY 10029, USA. Yik-Hong Ho, MBBS Department of Surgery, James Cook
University / The Townsville Hospital, Mater Mis- ericordiae,Wesley
Park Haven and Cairns Base Hospitals, Queensland 4810,Australia.
George W. Holcomb III, MD Department of Surgery, Childrens Mercy
Hospital, Kansas City, MO 64108, USA. Michael D. Holzman, MD, MPH
Department of Surgery, Vanderbilt University School of Medicine,
St. Thomas Hospi- tal, Nashville, TN 37232, USA. Emina Huang, MD
Department of Surgery, Columbia Presbyterian Hospital, New York, NY
10032, USA. Contributors xv
17. xvi Contributors Haruhiro Inoue, MD First Department of
Surgery, Tokyo Medical and Dental University, Tokyo, Japan. Namir
Katkhouda, MD Department of Surgery, University of Southern
California Keck School of Medicine, Los Angeles, CA 90033, USA.
Leena Khaitan, MD Department of Surgery, Emory University School of
Medicine, Atlanta, GA 30322, USA. Sergio W. Larach, MD Department
of Surgery, University of Florida College of Medicine, Orlando, FL
32806, USA. Demetrius Litwin, MD Department of Surgery, University
of Massachusetts School of Medicine, Worcester, MA 01655, USA.
Anthony Macaluso, Jr., MD Texas Colon and Rectal Surgeons, Medical
City Hospital, Dallas, TX 75230, USA. Bruce V. MacFadyen, Jr., MD
Department of Surgery, Medical College of Georgia, Augusta, GA
30912, USA. Joseph Mamazza, MD Department of Surgery, University of
Toronto, St. Michaels Hospital,Toronto, Ontario M5B 1W8, Canada.
Sharan Manhas, MD Department of Surgery, University of Southern
California Keck School of Medicine, LosAngeles,CA 90033,USA. Peter
W. Marcello, MD Department of Surgery,Tufts University School of
Medicine, Lahey Clinic, Burlington, MA 01805-0001,USA. David W.
McFadden, MD Department of Surgery,West Virginia University,
Morgantown,WV 26506-9238, USA. Ross L. McMahon, MD Department of
Surgery, Duke University Medical Center, Durham, NC 27710, USA.
Brian J. Mehigan, MB Department of Academic Surgery, Trinity
College, Dublin 24, Ireland. Juliane A. Miranda-Rassi, MD
Department of Gastroenterology, Division of Endoscopy, School of
Medicine Universidade Federal de Gois.; Department of Anorectal
Physiology, CDI, Goinia, Goinia GO, 74140-020, Brazil. J.R.T.
Monson, MD Department of Surgery, University of Hull, Academic
Surgical Unit, Castle Hill Hos- pital, Cottingham, East Yorkshire,
HU16 5JQ, UK.
18. Surendra Narne, MD Division of ENT Endoscopic Surgery,
Azienda Ospedaliera, Padova, 35100 Padova, Italy. Juan J. Nogueras,
MD Department of Colorectal Surgery, Cleveland Clinic Florida,
Weston, FL 33331, USA. Lloyd M. Nyhus, MD Department of Surgery,The
Living Institute for Surgical Studies, College of Medicine,
University of Illinois, Chicago, IL 60612-7322, USA. Margret
Oddsdottir, MD Department of Surgery, Landspitali-University
Hospital, IS-101 Reykjavik, Iceland. Lucia Oliveira, MD Department
of Anorectal Physiology, Policlnica Geral do Rio de Janeiro,
Titular Member Brazilian Society of Coloproctology, Titular Member
Brazilian College of Surgeons, Lagoa, Rio de Janeiro, 22470-200,
Brazil. Douglas O. Olsen, MD Centennial Medical Center, Nashville,
TN 37203, USA. Bruce A. Orkin, MD Department of Surgery, George
Washington University Medical Center, Washington, DC 20037,USA.
Marco G. Patti, MD Department of Surgery, University of California,
San Francisco, San Francisco, CA 94143, USA. Carlos A. Pellegrini,
MD Department of Surgery, University of Washington School of
Medicine, Seattle, WA 98195, USA. Alberto Peracchia, MD Department
of Surgical Sciences, University of Milano, 20122 Milano, Italy.
Jeffrey H. Peters, MD Department of Surgery, University of Southern
California Keck School of Medicine, University of Southern
California, Los Angeles, CA 90033, USA. Johann Pfeifer, MD
Department of Surgery, Karl-Franzens University School of Medicine,
A-8010 Graz, Austria. Edward H. Phillips, MD Department of Surgery,
Center for Minimally Invasive Surgery, Cedars-Sinai Medical Center,
Los Angeles, CA 90048, USA. Alon J. Pikarsky, MD Department of
General Surgery, Hadassah Medical Center, Hadassah University Hos-
pital, Jerusalem 91120, Israel. Eric C. Poulin, MD Department of
Surgery, University of Toronto, St. Michaels Hospital,Toronto,
Ontario M5B 1W8, Canada. Contributors xvii
19. xviii Contributors Aurora D. Pryor, MD Department of
Surgery, Duke University Medical Center, Durham, NC 27710, USA.
Thomas H. Quinn, PhD Department of Biomedical Sciences, Creighton
University School of Medicine, Omaha, NE 68178-0405, USA. Petachia
Reissman, MD Department of Surgery, Shaare-Zedek University Medical
Center, Jerusalem 91031, Israel. William O. Richards, MD Department
of Surgery, Vanderbilt University School of Medicine, Nashville, TN
37232, USA. Yoshihisa Saida, MD The Third Department of Surgery,
School of Medicine, Toho University, Tokyo 153-8515, Japan. Mara R.
Salum, MD Anorectal Physiology Lab, Hospital Srio-Libans;
Universidade Federal de So Paulo, Escola Paulista de Medicina;
Hospital Srio-Libans, So Paulo 01433-010, Brazil. Laurence R.
Sands, MD Department of Surgery, University of Miami School of
Medicine, Miami, FL 33136, USA. T. Cristina Sardinha, MD Department
of Surgery, Long Island Jewish Medical Center, New Hyde Park, NY
11042, USA. Christopher M. Schlachta, MD Department of Surgery,
University of Toronto, St. Michaels Hospital,Toronto, Ontario M5B
1W8, Canada. Mary E. Schultheis, MD Department of Surgery, St.
Agnes Hospital, Baltimore, MD 21229, USA. Anthony J. Senagore, MD,
MS Department of Colorectal Surgery, Cleveland Clinic Foundation,
Cleveland, OH 44195, USA. Francis Seow-Choen, MBBS Department of
Colorectal Surgery, Singapore General Hospital, Nanyang Technolog-
ical University, 169608, Singapore. Pieter A. Seshadri, MD
Department of Surgery, University of Saskatchewan, Saskatoon, SK
S7N 4R5, Canada. Mark E. Sesto, MD Department of General and
Vascular Surgery, Cleveland Clinic Florida, Weston, FL 33331,
USA.
20. Kenneth W. Sharp, MD Department of Surgery, Vanderbilt
University School of Medicine, Nashville, TN 37232, USA. Marc E.
Sher, MD Department of Surgery, Long Island Jewish Medical Center,
New Hyde Park, NY 11042, USA. Jay J. Singh, MD Piedmont Colorectal
Associates, Atlanta, GA 30309, USA. Nathaniel J. Soper, MD
Department of Surgery, Section of Hepatobiliary, Pancreatic, and
Gastrointestinal Surgery, Washington University School of Medicine,
St. Louis, MO 63110, USA. Jonathan D. Spitz, MD Department of
Surgery, DuPage Medical Group, Glen Ellyn, IL 60137, USA. Hubert J.
Stein, MD, PhD Chirurgische Klinik und Poliklinik, Klinikum rechts
der Isar, Technische Universitt Mnchen, D-81677 Munich, Germany.
Lee L. Swanstrm, MD Department of Surgery, Oregon Health &
Sciences University, Department of Mini- mally Invasive Surgery,
Legacy Health System, Portland, OR 97227, USA. Joerg Theisen, MD
Department of Surgery, Klinikum rechts der Isar, Munich, Germany.
Jared Torkington, MB, MS Department of Colorectal Surgery, Cardiff
and Vale NHS Trust, Cardiff, UK. Shirin Towgh, MD Department of
Surgery, University of Southern California Keck School of Medicine,
Los Angeles, CA 90033, USA. Frederick K. Toy, MD Northeastern
Surgical Consultants, P.C., Honesdale, PA 18431, USA. L. William
Traverso, MD Section of General, Thoracic, and Vascular Surgery,
Virginia Mason Medical Center, Seattle, WA 98101, USA. Thadeus L.
Trus, MD Department of General Surgery, Dartmouth-Hitchcock Medical
Center, Lebanon, NH 03756, USA. Douglas S. Tyler, MD Department of
Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
Selman Urans, MD Department of General Surgery, Karl-Franzens
University School of Medicine,A-8010 Graz, Austria. Contributors
xix
21. xx Contributors Guy R. Voeller, MD Department of Surgery,
University of Tennessee, Memphis, TN 38120, USA. Luca A. Vricella,
MD Department of Surgery, George Washington University Medical
Center, Washington, DC 20037, USA. Eric G. Weiss, MD Department of
Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331,
USA. Carl Westcott, MD Department of General Surgery,Wake Forest
University School of Medicine,Winston- Salem, NC 27157, USA. Steven
D. Wexner, MD Department of Colorectal Surgery, Cleveland Clinic
Florida, Weston, FL 33331, USA. R. Larry Whelan, MD Division of
Surgical Specialties, Columbia Presbyterian Hospital, New York, NY
10032, USA. Rebekah R. White, MD Department of Surgery, Duke
University Medical Center, Durham, NC 27710, USA. Eric D. Whitman,
MD Suburban Surgical Associates, St. Louis, MO 63131, USA. Paul E.
Wise, MD Department of Surgery, Vanderbilt University Medical
Center, Nashville, TN 37232, USA. Renee S. Wolfe, MD Department of
Surgery, St. Elizabeth Medical Center, Boston, MA 02135, USA.
Steven M. Yood, MD, MPH Department of Surgery, Yale University
School of Medicine, New Haven, CT 06511, USA. Karl A. Zucker, MD
(deceased) Formerly University of Arizona School of Medicine,
Phoenix, AZ 85004, USA.
22. Section I Minimally Invasive Surgery of the Esophagus and
Stomach Jeffrey H. Peters, MD Section Editor
23. This page intentionally left blank
24. Part I Esophageal Procedures
25. This page intentionally left blank
26. stage lesion is extremely difcult because these charac-
teristics are not visible. Actually, in IIb-type lesions, no
changes can be seen even with meticulous observation using
videoendoscopy. Fortunately, the iodine dye stain- ing method is a
very useful diagnostic technique for the esophagus. Normal
esophageal epithelium, which con- tains glycogen-rich granules,
stains dark brown when sprayed with 2% potassium iodide solution.
In contrast, a cancerous lesion, which has lost glycogen granules
in the epithelial cell layer, is clearly distinguished as an
unstained area with a clear margin to the iodine-stained normal
mucosa. This test is highly specic and sensitive for squamous cell
carcinoma.2 Endoscopic pinch biopsy is essential for histological
conrmation of the disease. Indications for Mucosal Resection The
inltration depth should be no more than m1 or m2, and supercial
spread should be less than half the cir- cumference of the lesion.
According to data from the Japanese national survey for
histological evaluation of surgically resected esophageal cancer
specimens,3 only 4% of mucosal cancer cases that were limited to
the mucosal layer had lymph node involvement. In contrast, 35% of
cases of submucosally invading cancer had lymph node metastasis.
Mucosal cancer without lymph node involvement is considered to be
an appropriate candidate for mucosal resection intending to achieve
permanent cure of the disease. Among mucosal cancers, we have seen
two lymph node-positive cases; these were massively in- vaded
mucosal lesions in which the cancer contacted the muscularis
mucosae over a wide area and supercial spread of the lesion was
more than half its circumference. We restrict the indication to
lesions no deeper than m2 that have spread less than half their
circumference. Even submucosal cancer, if it is lifted by
submucosal saline injection, can be technically resected by this
procedure. Submucosal cancer is then a candidate for 1 Endoscopic
Mucosal Resection in the Esophagus Haruhiro Inoue Backgound and
Historical Development Endoscopic mucosal resection (EMR) is at
present the only endoscopic treatment that provides a complete
specimen for histopathological analysis. In general, a patient with
mucosal cancer with no risk of lymph node metastasis is the best
candidate for this procedure. The author developed the EMRC
procedure (EMR using a transparent plastic cap) in 1992. Utilizing
this technique, any part of the esophageal mucosa from the pharynx
to the gastroesophageal junction, excluding the postlaryn- geal
mucosa, can be easily accessed and safely resected. This chapter
describes the indications and technical details of the procedure,
our clinical results, and the prevention of complications. In
clinical practice, most esophageal cancers are dete- cted in an
advanced stage with complaints of tumor- related symptoms such as
chronic pain, gastrointestinal obstruction, and bleeding. The
prognosis for advanced esophageal cancer is still poor, even when
major surgery with wide-area lymph node dissection is carried out
in combination with multidisciplinary treatments. To improve the
prognosis for esophageal cancer, we must be able to detect the
cancer as an early-stage, mucosal lesion before lymph node
metastasis.1 Preoperature Investigations Detection of Early-Stage
Esophageal Cancer (Squamous Cell Carcinoma) When observed by
endoscopy, normal esophageal mucosa usually appears as a smooth,
at, and whitish lustrous surface. Early-stage esophageal cancer is
char- acterized by changes of color and lusterless and rough
surfaces with marginal stepup or stepdown in mucosal architecture.
However, detection of a minute or early- 5
27. 6 H. Inoue mucosal resection if the patient has refused
surgery or is a poor surgical risk. Treatment of Barretts Esophagus
EMR appears promising in the treatment of Barretts mucosa. So far,
few studies that discuss it directly have appeared in the
literature. The rst application of EMR for adenocarcinoma on
short-segment Barretts esopha- gus was reported in 1990 by the
author.4 Histopatholog- ical analysis of the endoscopically
resected specimen showed that esophageal glands in the submucosa
were totally resected. Therefore, this procedure is theoretically
appropriate for eradication of Barretts esophagus. In our
experience of EMR for squamous cell carcinoma, however, totally
circumferential mucosal resection often causes severe stenosis.
Therefore, the division of the EMR session into a few sessions
seems to be preferable. In the future, the author considers that
major part resec- tion of Barretts mucosa by EMR will be preferred
to obtain a histological specimen to analyze for cancer dif-
ferentiation, inltration depth, and vessel involvement. For
residual parts, repeated EMR or other ablative therapy should be
applied to completely eradicate Barretts mucosa. Endoscopic Mucosal
Resection for Early-Stage Cancer in the Esophagus Various local
treatments such as laser ablation, argon plasma coagulator, and
irradiation have been applied to treat mucosal cancer, but EMR is
the only procedure that provides a complete resected specimen for
histopatho- logical analysis. We originally developed the EMRC pro-
cedure as a technique of mucosal resection. We believe it to be the
simplest and safest technique to perform muco- sectomy in any part
of the gastrointestinal tract. Principles The gastrointestinal (GI)
tract consists of two layers: the mucosal layer and the muscle
layer. Embryologically, the mucosa is derived from the endodermal
cell layer and the muscle layer from the middle germ layer of
vivipar- ity. The mucosal and the muscle layers are attached each
other by loose connective tissue in the submucosa and can be
separated by external force. For this reason, we can safely resect
just mucosa from inside the cavity, leaving the muscle layer
intact. However, the gastrointestinal wall is less than 4mm thick,
so that special care to avoid perforation is ex- tremely important
during the procedure. Injection of saline solution into the
submucosal layer is a simple and effective technique to avoid
muscle involvement. Lifting of the mucosa is always exhibited
during submucosal saline injection in any part of the GI tract,
without excep- tion. After injection of a sufcient volume of
saline, the mucosa, including the target lesion, can be safely
captured in the cap, strangulated by a snare wire, and resected by
electrocauterization. History In 1955, in the era of the rigid
scope, Rosenberg5 reported the importance of submucosal saline
injection during polypectomy of rectal and sigmoidal polyps.
Mucosal resection for supercial cancer using the berscope was rst
performed for early gastric cancer around 1983 in Japan. The
original strip-off biopsy technique advo- cated by Tada et al.6 was
injection and snaring (Table 1.1). Submucosal saline injection was
used to create a bleb; then, this bleb was cut by snare
strangulation. This procedure had already been reported by Dehle et
al. in 19737 as a technique for sessile colonic polyp resection.
Another EMR technique recommended by Takekoshi et al.8 was grasping
and snaring (see Table 1.1), that is, retracting the mucosa by a
grasper and then strangulat- ing it by snare wire. Martin et al. in
19769 had also reported this technique. Now, these two procedures
are combined and integrated as strip biopsy, that is, sub- mucosal
saline injection to create a bleb, mucosal retrac- tion by grasper,
and capture of the mucosal lesion by a snare loop. Hirao et al.10
reported an injection, pre- cutting, and snaring technique, which
means that after submucosal injection the target mucosa was cut by
an electrocautery needle knife and the isolated mucosa was then
captured by snare wire (see Table 1.1). Table 1.1. Classication of
endoscopic mucosal resection (EMR) techniques. Without-suction
techniques 1. Strip-off biopsy (injection and snaring)6,7 2. Lift
and cut biopsy double-snare polypectomy (grasping and snaring)8,9
3. ERHSE (injection, precutting, and snaring)10 4. EMRT (grasping
and snaring using overtube)4a With-suction techniques 1. EEMR tube
method (injection and snaring using overtube)13a 2. np-EEM
(injection and snaring using overtube)14a 3. EMRC (injection and
snaring using cap)1518 4. EMRL (EVL and snaring)20,21 5.
Simple-suction technique (snaring using stiff snare)22a ERHSE,
endoscopic resection with hypertonic saline-epinephrine solu- tion;
EMRT, EMR using a transparent overtube; EEMR, endoscopic esophageal
mucosal resection; np-EEM, endoscopic esophageal muco- sectomy
under negative-pressure control; EMRC, endoscopic mucosal resection
using a transparent plastic cap; EMRL, endoscopic mucosal resection
using a ligating device. a These techniques are only available for
the esophagus.
28. Momma et al. and Makuuchi et al. reported the rst
application of EMR in the esophagus utilizing the strip- biopsy
technique in 1989 (injection, lift, and snaring).11,12 At the same
time, the author reported the EMRT pro- cedure, which uses a lift
and cut method utilizing a specially designed EMRT tube4 (Table
1.1). In the same paper,4 the rst application of EMR for
adenocarcinoma on a short segment of Barretts esophagus was
reported. Makuuchi developed the endoscopic esophageal mucosal
resection (EEMR) tube method13 (Table 1.1). By this method, a
larger specimen can be obtained than by other techniques. A modied
Makuuchi tube is utilized in Kawanos technique.14 This modied tube
has a lateral window for mucosal trapping. We rened our EMRT pro-
cedure4 to an EMR cap (EMRC) procedure1518 (see Table 1.1). EMRC
made the surgical technique simpler and easier and made it possible
to apply the procedure to any part of the GI tract from pharynx to
anus, pre- cluding the postlaryngeal mucosa and the small
intestine. The principle of the EMRC procedure is based upon the
endoscopic variceal ligating (EVL) technique developed by
Stiegmann.19 EMR utilizing a variceal ligating device (EMRL) is a
technically simple and safe procedure (see Table 1.1). Masuda et
al. in Japan, Chaves et al.,20 and Freischer et al.21 reported
experience utilizing the EVL device. This method is basically
similar to the EMRC procedure but divides it into two steps. This
method is appropriate to resect a relatively small lesion, less
than 10mm, because the size of the specimen is limited by the small
capacity of the ligation cap. Soehendra et al. introduced the
extremely simple suction technique of mucosectomy.22 In their
method, no accessory device is necessary to perform the proce- dure
except a specially designed snare, which is made of monolament
stainless steel wire with a diameter of 0.4mm. A large-channel
endoscope (Olympus GIF-1T) is utilized in combination with the
special snare because that endoscope provides adequate suction
alongside an inserted snare. The size of the resected specimen
seems to be smaller than that with other techniques, but the
simplicity of this procedure is potentially interesting. EMRC
Surgical Technique In preparation for the EMRC procedure, a cap
made from transparent plastic is attached to the tip of the
forward-view endoscope and is xed tightly with adhe- sive tape. A
cap is commercially available from Olympus as the Distal attachment
and is approved by the FDA in the United States. For the initial
session of EMR in the esophagus and stomach, an oblique-cut
large-capacity cap with rim (MAJ297; Olympus, Tokyo, Japan) is xed
on the tip of the standard-size endoscope (Q240, Q140; Olympus) to
obtain a larger sample. For trimming a residual lesion, a
straight-cut medium-size cap with rim (MH595; Olympus) is
appropriate. Supercial extension of mucosal cancer is often dif-
cult to recognize accurately in routine endoscopic obser- vation
but is clearly delineated by chromoendoscopy. For squamous cell
carcinoma of the esophagus, iodine (2% iodine potassium solution)
is the most promising dye, showing the lesion clearly as an
unstained area. Spraying indigocarmine solution emphasizes surface
relief in the stomach. The tip of the snare wire carefully marks
the mucosal surface that surrounds the margin of the lesion.
Markings are positioned 2mm from the actual lesion margin. Visual
enhancement during chromoendoscopy disappears within a couple of
minutes, and therefore the markings by electrocoagulation become
essential, especially to the at lesion. Epinephrine saline solution
diluted 500,000 times (0.1% epinephrine solution 0.2ml plus normal
saline 100ml) is injected into the submucosa with an injection
needle (23 gauge, 4mm tip length). Controlling the position of a
needle tip in the submucosal layer is not technically difcult. The
most important key to avoiding transmural penetration of the needle
is to puncture the mucosa at a sharp angle. The total volume of
injected saline depends on the size of the lesion, but it is neces-
sary to inject enough saline to lift up the whole lesion. Usually
more than 20ml is injected. In principle, normal mucosa distal to
the lesion is punctured rst (Fig. 1.1). When saline is accurately
injected into the submucosal layer in any part of the
gastrointestinal tract, lifting of the mucosa or bulging of the
mucosal surface is always observed. The injected area is also
recognizable as a whitish swelling. With the injection of a
sufcient volume of submucosal saline, any type of EMR procedure can
be performed quite safely. 1. Endoscopic Mucosal Resection in the
Esophagus 7 Figure 1.1. Submucosal saline injection. Puncture the
distal part of the lesion rst. Puncturing the mucosa at a sharp
angle avoids transmural penetration.
29. 8 H. Inoue A specially designed small-diameter snare SD-7P
(1.8 mm outer diameter; Olympus) is essential to the preloop- ing
process. The snare wire is xed along the rim of the EMRC cap. To
start the prelooping process, moderate suction is applied to the
normal mucosa to seal the outlet of the cap (Fig. 1.2A), and then
the snare wire that passes through the instrumental channel of the
endoscope is opened (Fig. 1.2B). The opened snare wire is xed along
the rim of the cap, and the outer sheath of the snare extends up to
the rim of the cap (Fig. 1.2B). This step completes the prelooping
process of the snare wire. When the endoscope approaches, the
target mucosa, including the lesion, is fully sucked inside the cap
(Fig. 1.3) and is strangulated by simple closing of the prelooped
snare wire. At this moment, the strangulated mucosa looks like a
snared polypoid lesion. The pseudopolyp of the strangulated mucosa
is cut by blend current electrocautery. The resected specimen can
be easily taken out by keeping it inside the cap without using any
grasping forceps. The smooth surface of the muscle layer is
observed at the bottom of the articial ulcer. In this case, a large
vessel was observed at the center of the articial ulcer; a
hemostatic clip was applied to it to prevent bleeding.23 Bleeding
is usually nonexistent or minor and stops spontaneously with
compression of the lateral wall of the transparent cap. To conrm
complete resection of the lesion, iodine dye spraying is useful. If
additional resection is necessary to completely re- move residual
lesion, all procedures, including saline injection, should be
repeated step by step. Injected saline usually inltrates and
disappears from the injection site within around 5min, ending its
role as a cushion between the mucosa and the muscle layer. Repeated
saline injection, therefore, becomes necessary to reduce the risk
of muscle involvement during the procedure. Our only experience of
perforation of the esophagus hap- Seal outlet of EMRC cap Normal
mucosa A. B. Open snare wire to rim Figure 1.2. The endoscopic
mucosal resection cap (EMRC) prelooping process. A. Suction the
normal mucosa and seal the outlet of the EMRC cap. B. Open the
snare wire; it then goes along the rim of the cap. The prelooping
condition is created. The outer sheath of the snare wire is pushed
up to the distal end of the cap, and the snare wire is xed along
the rim of the EMRC cap. A. B. Prelooped snare wire Figure 1.3. The
EMRC procedure. A. After creating the prelooping condition, target
mucosa is drawn inside the cap. B. The strangulated mucosa.
30. pened during the second strangulation,with no additional
saline injection. Histopathological Assessment The resected
specimen should be stretched and xed on a rubber plate using ne
needles and then bathed in 10% formalin solution. The xated
specimen is divided into 2-mm columns. Histopathological analysis
of semiserial sections makes it possible to reconstruct the
supercial extension of the cancer. Postoperative Care Three days
after EMR, the articial ulcer is covered by a white coating. Twelve
days after EMR, the articial ulcer is almost recovered with thin
but normal squamous epithelium. Almost all patients complain of
mild post- sternal pain and mild throat pain, which will disappear
within a couple of days using medication. Just after EMR, a mucosal
protective agent (for example, Marlox) is prescribed four times a
day. Anti- biotics are also administered intravenously for the rst
2 days, followed by 7 days of oral antibiotics. In our expe-
rience, one patient who received near-total circumfer- ential
resection in the esophagus, with only 2 days of antibiotics
followed by no medication, suffered a severe stricture. That
stricture was considered to have been caused by chronic, persistent
inammation. A few hours after treatment, the patient can start to
drink cold water. On the following day, the patient re- ceives a
soft meal. On the second day after treatment, the patient receives
a normal diet. In almost all cases of mucosal resection, quality of
life can be maintained,24 so we believe that early detection of
cancerous lesions and treatment by endoscopic mucosal resection is
an ideal means of cancer treatment. Results In our institute, more
than 180 cases of early-stage esophageal cancer underwent mucosal
resection, mainly by two techniques.25 Of these cases, 72% were
absolute indications for mucosal resection according to our crite-
ria. The other cases were only relatively indicated be- cause of
poor risk for surgery or refusal of surgery. In absolutely
indicated cases, no local or no distant metas- tasis occurred
during the follow-up period. The 5-year survival rate was 95%,
including other causes of death. All patients who died during the
5-year follow-up period suffered from other fatal diseases such as
myocardial infarction, liver cirrhosis, and stroke. As a major
complication in the esophagus, one patient in our early series
suffered perforation during the second cauterization. That patient
recovered by conser- vative treatments such as intravenous
hyperalimentation and antibiotic administration, resulting in no
con- comitant problems. Eight years later, she is healthy with no
surgery-related complaints. Another patient who received near-total
circumferential mucosal resection developed persistent stenosis
that could not be controlled by repeated forceful balloon
dilatation. He was nally treated by surgical esophagectomy. Five
years after esophagectomy, he is in good health. In this case,
anti- biotics were administered for only 2 days, which may have
allowed chronic inammation to develop, resulting in stenosis.
Complications Mechanism of Perforation When the EMR procedure is
performed without saline injection, the muscle layer beneath the
surface mucosa is also drawn inside the cap, together with the
covering mucosa, which risks muscle involvement at the moment of
closure of the snare loop. A small-volume saline injec- tion is not
sufcient to avoid muscle involvement because this creates only a
small bleb (Fig. 1.4A). Full suction for a small bleb causes muscle
entrapment in the cap, result- ing in muscle strangulation with the
mucosa (Fig. 1.4B,C). An extra-large-volume saline injection
creates a large bleb (Fig. 1.4D). This large cushion mechanically
pre- vents muscle involvement during snare strangulation (Fig.
1.4D,E). In the other words, snaring of the mucosa should never be
done at the base of the lifted mucosa (Fig. 1.4B) but rather should
always be done at the middle part of the lifted mucosa (Fig.
1.4E,F). To prevent perforation, a large-volume saline injec- tion
is important. In the esophagus, about 20ml saline causes more than
half-circumferential mucosal dissec- tion, keeping the mucosal
surface about 1cm apart from the muscle layer. When saline is
accurately injected into the submucosa in any part of the
gastrointestinal tract, lifting or bulging of mucosa can be always
observed. The with suction techniques listed in Table 1.1 have a
potentially greater risk of muscle involvement than the without
suction techniques, and therefore injecting a larger volume of
saline into the submucosa is highly rec- ommended. The author
usually injects at least 10ml for each snaring. Large-volume saline
injection is in itself a safe procedure. In our experience of
removal of a creep- ing tumor in the rectum, a total of about 100ml
saline was injected, and the whole lesion was safely removed with
inducing a half-circumferential ulceration. In this case,
posttherapeutic treatment was uneventful, and therefore 1.
Endoscopic Mucosal Resection in the Esophagus 9
31. 10 H. Inoue large-volume saline injection is considered a
safe proce- dure in itself. Control of Bleeding from the Ulcer Bed
Low-concentration epinephrine saline solution (epineph- rine saline
solution diluted 500,000 fold) is denitely effective to control
bleeding during EMR. In the esoph- agus, submucosal injection of
this solution results in almost complete hemostasis, but in the
stomach bleeding from an articial ulcer sometimes cannot be
controlled by the solution.At present,the hemostatic clip is the
most reliable therapeutic modality to control spurting bleed- ing
from the ulcer bed.23 Consequently, bleeding from the ulcer bed can
be relatively easily controlled. Conclusion Mucosal cancer in the
esophagus generally has no risk of
lymphnodemetastasis.ItiscuredbyEMR,whichprovides a resected
specimen for histopathological analysis. References 1. Lambert R.
Endoscopic detection and treatment of early esophageal cancer: a
critical analysis. Endoscopy 1995;27: 1218. 2. Endo M,Takeshita
K,Yoshida M. How can we diagnose the early stage of esophageal
cancer? Endoscopic diagnosis. Endoscopy 1986;18:1118. 3. Endo M,
Kawano T. Analysis of 1125 cases of early esophageal carcinoma in
Japan. Dis Esoph 1991;4:7176. 4. Inoue H, Endo M. Endoscopic
esophageal mucosal re- section using a transparent tube. Surg
Endosc 1990;4:198 201. 5. Rosenberg N. Submucosal saline wheal as
safety factor in fulguration of rectal and sigmoidal polypi. Arch
Surg 1955; 70:120122. 6. Tada M, Murakamai A, Karita M, et al.
Endoscopic rese- ction of early gastric cancer. Endoscopy
1993;25:445450. 7. Dehle P, Largiader F, Jenny S, et al. A method
for endo- scopic electroresection of sessile colonic polyps.
Endoscopy 1973;5:3840. 8. Takekoshi T, Baba Y, Ota H, et al.
Endoscopic resection of early gastric carcinomas: results of a
retrospective analysis of 308 cases. Endoscopy 1994;26:352358. A.
D. B. E. C. F. Insufficient Sufficient Figure 1.4. Submucosal
saline injec- tion. A. Small-volume injection of saline creates a
small bleb. B. During suction of the target mucosa, the muscle
layer is also sucked into the cap. C. Muscle layer entrapment at
closure of the snare wire. D. Large-volume saline injection creates
a large bleb. E. Even during full suction, only the top of the bleb
is captured inside the cap. F. The mucosa is strangulated at the
middle part of the bleb. This step makes the procedure safe.
32. 9. Martin TR, Onstad GR, Silvis SE, et al. Life and cut
biopsy technique for submucosal samplings. Gastrointest Endosc
1976;23:2930. 10. Hirao M, Masuda K, Asanuma T, et al. Endoscopic
resec- tion of early gastric cancer and other tumors with local
injection of hypertonic saline-epinephrine. Gastrointest Endosc
1988;34:264269. 11. Monma K, Sakaki N,Yoshida M. Endoscopic
mucosectomy for precise evaluation and treatment of esophageal
intra- epithelial cancer (in Japanese). Endosc Dig 1990;2:501 506.
12. Makuuchi H, Machimura T, Sugihara T, et al. Endoscopic
diagnosis and treatment of mucosal cancer of the esopha- gus (in
Japanese). Endosc Dig 1990;2:447452. 13. Makuuchi H. Endoscopic
mucosal resection for early esophageal cancer. Dig Endosc
1996;8:175179. 14. Kawano T, Miyake S, Yasuno M, et al. A new
technique for endoscopic esophageal mucosectomy using a transparent
overtube with intraluminal negative pressure (np-EEM). Dig Endosc
1991;3:159167. 15. Inoue H, Takeshita K, Hori H, et al. Endoscopic
mucosal resection with a cap-tted panendoscope for esophagus,
stomach, and colon mucosal lesions. Gastrointest Endosc 1993:5862.
16. Inoue H, Noguchi O, Saito N, et al. Endoscopic mucosec- tomy
for early cancer using a pre-looped plastic cap. Gastrointest
Endosc 1994;40:263264. 17. Tada M, Inoue H, Endo M. Colonic mucosal
resection using a transparent cap-tted endoscope. Gastrointest
Endosc 1996;44:6365. 18. Izumi Y, Teramoto K, Ohshima M, et al.
Endoscopic resec- tion of duodenal ampulla with a transparent
plastic cap. Surgery (St. Louis) 1998;123:109110. 19. Stiegmann GV.
Endoscopic ligation: now and the future. Gastrointest Endosc
1993;39:203205. 20. Chaves DM, Sakai P, Mester M, et al. A new
endoscopic technique for the resection of at polypoid lesions. Gas-
trointest Endosc 1994;40:224226. 21. Freischer DE, Dawsey S, Tio
TL, et al. Tissue band ligation followed by snare resection (band
and snare): a new tech- nique for tissue acquisition in the
esophagus. Gastrointest Endosc 1996;44:6872. 22. Soehendra N,
Binmoeller KF, Bohnacker S, et al. Endo- scopic snare mucosectomy
in the esophagus without any additional equipment: a simple
technique for resection of at early cancer. Endoscopy
1997;29:380383. 23. Hachisu T, Yamada H, Satoh S, Kouzu T.
Endoscopic clip- ping with a new rotatable clip device and a long
clip. Dig Endosc 1996;8:172173. 24. Takeshita K, Tani M, Inoue H,
et al. Endoscopic treatment of early oesophageal or gastric cancer.
Gut 1997;40:123127. 25. Inoue H. Endoscopic mucosal resection for
esophageal and gastric mucosal cancers. Can J Gastroenterol
1998;12:355 359. 1. Endoscopic Mucosal Resection in the Esophagus
11
33. Background and Historical Development of Endoscopic
Treatment Toward the end of the nineteenth century, Zenker and von
Ziemssen formulated the hypothesis that a pharyn- goesophageal
diverticulum is caused by increased hypopharyngeal pressure
producing herniation through an area of structural weakness, that
is, the junction of the inferior pharyngeal constrictor and the
cricopharyngeus muscle, also known as Killians triangle. It is
currently believed that inadequate opening of the upper esophageal
sphincter, resulting from brosis of the cricopharyngeal muscle,
considerably increases hypo- pharyngeal intrabolus pressure.1,2 For
this reason, when surgical resection or suspension of the
diverticulum is performed without a concomitant myotomy, the proce-
dure may fail to relieve dysphagia and to prevent com- plications
or recurrence of the pouch.3,4 Unlike the traditional surgical
approach, which varies depending on the preference of the
individual surgeon, the endoscopic approach is by principle
centered on the upper esophageal sphincter. First proposed early in
the twentieth century by Mosher, it consists of division of the
septum interposed between the pouch and the cervi- cal esophagus,
thus allowing the creation of a common cavity with simultaneous
section of the upper esophageal sphincter. This procedure has been
performed in some institutions using electrocoagulation or laser;
although the results appear satisfactory, complications such as
bleeding, perforation, and the need for repeated treat- ment have
been reported. Moreover, postoperative pain is quite common,
especially after electrocoagulation.5,6 During the last decade,
interest in the transoral treat- ment of Zenkers diverticulum has
been renewed by the introduction of endostaplers.79 In fact, it has
been shown that division of the septum can be safely and
effectively performed through an endosurgical approach under gen-
eral anesthesia. Indications for Endoscopic Therapy Treatment of
Zenkers diverticulum is indicated to relieve symptoms such as
dysphagia and pharyngo-oral regurgitation and to prevent the
life-threatening compli- cation of aspiration pneumonia. The
tendency of the pouch to progressively enlarge and the possible,
although rare, development of a squamous cell carcinoma repre- sent
additional arguments in favor of early treatment. Myotomy is
regarded today as an essential component of the operation. It has
been shown that myotomy and virtual elimination of the pouch may be
achieved via an endosurgical approach. The principle of this video-
assisted operation is to establish a common cavity between the
hypopharyngeal pouch and the adjacent esophageal lumen by means of
a linear endostapler. Division of the common wall by stapling is a
one-stage operation, requires a few minutes, and appears simpler
and safer than using electrocoagulation or laser. Compared to the
conventional surgical operation, the advantages of endostapling
include absence of skin inci- sion, shorter operative time, minimal
or no postoperative pain, quicker resumption of oral feeding, and
shorter hos- pital stay. An additional advantage of this approach
is expected in patients who present with recurrent divertic- ulum
after conventional operation or in those who have undergone surgery
in the left side of the neck. In such cir- cumstances,the
conventional operation may pose a major technical challenge to the
surgeon and may be associated with a high risk of leakage or
recurrent nerve palsy. Diverticula smaller than 2cm represent a
formal con- traindication to the endosurgical approach because the
common wall is too short to accommodate one cartridge of staples
and to allow complete division of the sphinc- ter. The result would
be an incomplete myotomy, causing persistent dysphagia. Although
the postoperative outcome of these patients, who often are elderly
and compromised, suggests greater comfort and a quicker recovery
compared to the con- 2 Minimally Invasive Treatment of Zenkers
Diverticulum Luigi Bonavina, Surendra Narne, and Alberto Peracchia
12
34. ventional operation, it should be taken into account that
the endosurgical approach requires general anesthesia. Therefore,in
patients with excessive operative risk,a con- ventional operation
carried out under simple local anes- thesia still remains the
procedure of choice. Preoperative Assessment and Preparation A
barium swallow study and upper gastrointestinal endoscopy are
routinely performed before operation. The diverticulum is carefully
entered with the endoscope, and the mucosa is examined to rule out
carcinoma. The length of the diverticulum is measured from the
upper esophageal sphincter to the bottom of the pouch. The
remaining esophagus is examined for the presence of hiatal hernia
or esophagitis. A thin guidewire inserted at the end of the
endoscopic examination may assist in positioning the manometric
catheter within the esoph- ageal lumen if a motility study is
planned. The patients are kept on a liquid diet the day before the
operation. Intravenous antibiotics and intensive res- piratory
physiotherapy are recommended for a few days before surgery in
patients admitted on an emergency basis for aspiration pneumonia.
In some circumstances, especially in elderly individuals,
preoperative nutritional support may be necessary. Short-term
antibiotic prophy- laxis is given before induction of anesthesia.
Surgical Technique The operation is performed under general
anesthesia with nasotracheal intubation. The patient is placed
supine on the operating table, with a small pillow below the upper
back and the head hyperextended. The surgeon is sitting behind the
patients head. A modied Weerda endoscope (Karl Storz,Tuttlingen,
Germany) is introduced into the hypopharynx under direct vision and
gently pushed behind the endotracheal tube. The two self-retracting
valves, which can be approx- imated and angulated to t the patients
hypopharyngeal anatomy, are then allowed to enter the diverticulum
and the esophageal lumen, respectively (Fig. 2.1). After
visualization of the septum interposed between the diverticulum and
the esophagus, the diverticuloscope is xed and held in place by
means of a chest support (Fig. 2.2). A 5-mm wide-angle 0 telescope
is inserted through the diverticuloscope and connected to a
cold-light source and to a video camera to obtain a magnied vision
of the operative eld on a television screen. The depth of the
diverticulum can be checked using a graduated rod. This maneuver
also allows the surgeon to straighten the pouch and to elongate the
common wall (Fig. 2.3). The diverticulum esophagostomy is performed
using a disposable linear endostapler (EndoGIA 30, Tyco, or ETS 35,
Ethicon Endo-surgery) with a shorter anvil, thus allowing tissue
stapling and sectioning down to the bottom of the septum. The anvil
is placed in the lumen of the diverticulum and the cartridge of
staples into the lumen of the cervical esophagus (Fig. 2.4). The
instru- ment jaws are placed across the septum along the midline
before ring. With a single application of the endostapler, the
posterior esophageal wall is sutured to the wall of the
diverticulum, and the tissue is transected between three rows of
staples on each side. Multiple stapler applications may be
necessary according to the size of the diverticu- 2. Minimally
Invasive Treatment of Zenkers Diverticulum 13 Figure 2.1. Weerda
diverticuloscope. Figure 2.2. Position of the diverticuloscope. The
lower valve is inserted into the Zenker diverticulum and the upper
valve into the esophageal lumen.
35. 14 L. Bonavina et al. Postoperative Care A nasogastric tube
is generally not required. A gastro- graphin swallow study is
performed on the rst postop- erative day. The patient is then
allowed to drink and eat and is discharged from the hospital. A
soft diet is recom- Diverticulum Sphincter Upper blade Scope Septum
Lower blade Diverticulum Figure 2.3. Visualization of the septum.
The telescope is inserted through the instrument. Ethicon 35mm
cartridge A Endo-GIAB Figure 2.4. Endoscopic linear staplers. A.
The Ethicon device has a shorter staple head and a 35- mm
cartridge; this does not require any mechanical modication, making
the instrument more suitable for the operation. B. The endo-GIA
instrument required sawing off the anvil to avoid a residual spur.
The shorter anvil allows tissue stapling and sectioning down to the
bottom of the diverticulum. lum. Using the tip of the anvil, the
bottom of the diver- ticulum can be pushed gently downward to
lengthen the common wall and to minimize the size of the residual
spur. Electrocoagulating endosurgical scissors may be used to
complete the section at the distal end of the staple line (Fig.
2.5). After removal of the stapler, the two wound edges retract
laterally because of the division of the cricopha- ryngeal muscle
(Fig. 2.6). Finally, the suture line is checked for hemostasis, and
the hypopharynx is irrigated with saline solution. Figure 2.5.
Suture section of the septum interposed between esophagus and
diverticulum. Figure 2.6. Frontal view of the stapled and divided
septum. A common cavity has been created.
36. mended during the rst postoperative month. A barium swallow
study is performed after 6 to 12 months. Results Conversion to open
surgery was required in 3% of cases in a recent series8 ; the
reason was a difcult exposure of the common wall in two cases and a
mucosal tear in another. In these individuals, introduction of the
endo- scope and stapler manipulation were difcult due to limited
mouth opening or reduced neck extension. No postoperative morbidity
or mortality was recorded. In most patients, two applications of
linear endostapler with a modied anvil were used. Before modication
of the anvil of the endo-GIA stapler, ve patient complained of
persistent postoperative symptoms; three patients under- went
repeat endosurgical operation, one underwent laser treatment by
means of exible endoscopy, and one even- tually required open
surgery. Overall, this procedure has proven safe and effective.
Radiologic, manometric, and scintigraphic studies over a follow-up
period up to 5 years consistently show decreased outow resistance
at the pharyngoesophageal junction. The short hospital stay, lack
of morbidity, minimal patient discomfort, and complete symptom
relief associated with this operation have prompted us to change
the approach to Zenkers diverticulum in our institution during the
past decade. References 1. Cook I, Dodds W, Dantas R. Opening
mechanisms of the human upper esophageal sphincter. Am J Physiol
1989;257: G748G759. 2. Mason R, Bremner C, DeMeester T, et al.
Pharyngeal swal- lowing disorders. Selection for and outcome after
myotomy. Ann Surg 1998;228:598608. 3. Bonavina L, Khan N, DeMeester
T. Pharyngoesophageal dysfunctions. Arch Surg 1985;120:541549. 4.
Shaw D, Jamieson G, Gabb M, Simula M, Dent J. Inuence of surgery on
deglutitive upper oesophageal sphincter mechanics in Zenkers
diverticulum. Gut 1996;38:806811. 5. Dohlman G, Mattson O. The
endoscopic operation for hypopharyngeal diverticula. Arch
Otolaryngol 1960;71: 744752. 6. Van Overbeek J, Hoeksema P, Edens
E. Microendoscopic surgery of the hypopharyngeal diverticulum using
electro- coagulation of carbon dioxide laser. Ann Otol Rhinol
Laryngol 1984;93:3436. 7. Collard J, Otte J, Kestens P. Endoscopic
stapling technique of esophagodiverticulostomy for Zenkers
diverticulum. Ann Thorac Surg 1993;56:573576. 8. Narne S, Bonavina
L, Guido E, Peracchia A. Treatment of Zenkers diverticulum by
endoscopic stapling. Endosurgery 1993;1:118120. 9. Peracchia A,
Bonavina L, Narne S, Segalin A, Antoniazzi L, Marotta G. Minimally
invasive surgery for Zenker diver- ticulum. Analysis of results in
95 consecutive patients. Arch Surg 1998;133:695700. 2. Minimally
Invasive Treatment of Zenkers Diverticulum 15
37. Background and Historical Development Gastroesophageal reux
disease (GERD) is arguably one of the most common disorders in
Western civiliza- tion. For reasons that are not clear, it appears
to be increasing in prevalence. Historically, the treatment of GERD
has included dietary modication, weight loss, and intermittent
antacid therapy. These measures were often ineffective, however,
and surgical therapy has been applied to those who failed. In the
early days of surgical antireux therapy, these were usually
patients with refractory ulcers and severe brotic strictures. With
the introduction of specic medical therapy with H2 receptor
antagonists and, more recently, proton pump inhibitors, the number
of patients with these acid-pepsin-related complications of reux
disease has declined. In their place, patients with malignant
complications of reux disease have emerged as a larger problem,
with the recognition of the relationship between GERD and Barretts
esophagus. Because cancer of the esophagus is frequently fatal, and
because patients with Barretts esophagus are often relatively
asymptomatic, formal investigation of patients with a history of
signicant reux symptoms and institution of effective therapy has
become important. Historically, two problems have prevented the
wide- spread acceptance of antireux surgery. The rst was the
observation that a fundoplication was frequently compli- cated by
dysphagia and gas bloat, complications related to an overly
competent lower esophageal high-pressure zone. Second was the
perioperative morbidity and mor- tality associated with antireux
surgery. Hospital stays were routinely a week or more, with up to 6
or 8 weeks of additional disability from work. The development of
more potent acid suppression medications further restricted the
application of antireux surgery, to the point where referral to
surgery was limited to patients with complicated reux disease who
proved refractory to medical therapy.1 Two major developments over
the past several decades have dramatically changed both the outcome
and ac- ceptance of antireux surgery. The rst was the appreci-
ation that a shorter, loose, fundoplication markedly reduced the
postoperative sequelae associated with antireux surgery.25 With
these modications in tech- nique, most patients are able to belch
normally and eat without long-term dysphagia, without sacricing
efcacy in controlling reux of gastric contents into the esopha-
gus. The second development that has revolutionized antireux
surgery was the introduction of the laparo- scopic Nissen
fundoplication. Bernard Dallemagne rst recreated the procedure that
Nissen had serendipitously discovered in 1936.6,7 Because of the
diminished morbidity of these minimally invasive antireux
procedures, the threshold for referral to surgery for patients with
GERD rapidly decreased. As a result, the laparoscopic Nissen
fundoplication has become one of the most commonly performed
laparo- scopic procedures in everyday surgical practice. The
explosion of laparoscopic antireux surgery worldwide has stimulated
a new interest in the study of surgical treatment of GERD. Through
this experience, much has been learned, but signicant controversies
remain. Nonetheless, in the setting of relatively early GERD,
laparoscopic antireux procedures have been established as safe,
highly effective, and long-lasting alternatives to lifelong medical
therapy. Clinical Features GERD is a syndrome that includes a
variety of clinical manifestations including symptoms and tissue
injury patterns associated with abnormal esophageal exposure to
gastric contents. The presenting symptoms can vary widely, but they
can conveniently be grouped into three 3 Laparoscopic Complete and
Partial Fundoplication Jeffrey A. Hagen and Jeffrey H. Peters
16
38. categories: typical symptoms, atypical symptoms, and
complications. The indications for antireux surgery and the results
to be expected vary in these three groups, and as such they warrant
separate consideration. Heartburn and regurgitation are the most
common typical symptoms of GERD. Heartburn is most often described
as a substernal burning sensation that may radiate up into the
throat. It may occur following meals, or with physical activity
such as bending or stooping, and in some patients it occurs
predominately at night. It has been estimated that 10% of the
population experiences heartburn daily, with up to one-third
experiencing heart- burn at least once a month.8 Patients with
heartburn also frequently complain of regurgitation, which is
described as the appearance of acid or bitter uid, without warning,
into the back of the throat. Regurgitation is particularly likely
to occur after meals and when the patient lies down at night. The
patient or their spouse may describe episodes of awakening from
sleep coughing or choking. In addition to heartburn and
regurgitation, the patient with typical symptoms of GERD may
experience dys- phagia. It is more common in patients with
complicated reux disease and stricture formation, but dysphagia may
occur in the absence of segmental narrowing, as a result of either
a large hiatal hernia9 or the presence of reux-induced esophageal
peristaltic dysfunction. When present, the symptom of dysphagia
warrants particular attention to exclude the possibility of cancer.
Atypical symptoms of reux disease include chest pain, hoarseness,
and pulmonary symptoms such as asthma,chronic cough,and aspiration
pneumonia. Rarely, patients may present with protracted hiccups,
night sweats, and erosions of their dental enamel. It has been
shown, in patients with angina-like chest pain who have a negative
cardiac evaluation, that abnormal gastroe- sophageal reux will
occur in up to 50%.10 Thus, GERD is the most common abnormality in
these patients. Chronic hoarseness or reux laryngitis is associated
with abnormal esophageal acid exposure in as many as 75% of
patients studied by prolonged pH monitoring.11 Ambulatory
monitoring of pH in the cervical esophagus may be particularly
helpful in these patients. Respiratory symptoms occasionally
associated with GERD include repeated episodes of aspiration
pneumonia, chronic cough, and, more commonly, nonallergic asthma.
Recent studies have shown that as many as 20% of patients with
chronic cough have abnormal reux,12 with reux being documented in
up to 80% of patients with chronic asthma.13 Complications of GERD
include the development of esophageal ulcers or strictures, as well
as the malignant complications of GERD, including the development
of Barretts esophagus and esophageal adenocarcinoma. It has been
estimated that approximately 10% of unse- lected patients with reux
symptoms have evidence of Barretts esophagus on endoscopy,14 making
endoscopic evaluation an important part of the evaluation of any
patient presenting with chronic reux symptoms. Preoperative
Investigations To document that gastroesophageal reux is
responsible for symptoms, and to maximize the chances of success
with antireux surgery, patients suspected of having GERD should be
carefully investigated before consider- ing antireux surgery. It
has been shown that success in antireux surgery is largely
determined by two objectives: to achieve the long-term relief of
reux symptoms, and to do so without the development of
complications or complaints induced by the operation. In practice,
achiev- ing these two deceptively simple goals is difcult. Both
depend heavily upon establishing that the symptoms for which the
operation is being performed are caused by excess esophageal
exposure to gastric juice. In addition, it is critical that the
appropriate antireux procedure be performed in the proper fashion.
Success can be expected in most patients if these two criteria are
met. To achieve these goals, the evaluation of patients suspected
of having GERD who are being considered for antireux surgery has
four important components: 1. Establishing that GERD is the
underlying cause of the patients symptoms 2. Estimating the risk of
progressive disease 3. Determining the presence or absence of
esophageal shortening 4. Evaluating esophageal body function and,
occasion- ally, gastric emptying function Objective Documentation
of GERD In the past, patients referred for antireux surgery had
more advanced disease, usually associated with severe esophagitis,
and often with stricture formation. Estab- lishing reux as the
cause was generally not difcult. However, as the threshold for
surgical referral has decreased, increasing numbers of patients
without endo- scopic esophagitis or other objective evidence of the
presence of reux are now considered for laparoscopic antireux
surgery.15,16 In these patients, formal diagnostic testing is
required to document the presence of abnormal esophageal exposure
to gastric contents, the hallmark of GERD. The gold standard for
diagnosing GERD is the use of ambulatory 24-h pH testing.17
Estimating the Risk of Progressive Disease Identication of patients
likely to develop progressive reux disease in spite of medical
therapy would allow us 3. Laparoscopic Complete and Partial
Fundoplication 17
39. 18 J.A. Hagen and J.H. Peters to prevent complications of
GERD such as strictures or Barretts esophagus by early application
of antieux surgery. Although absolute predictors do not as yet
exist, a combination of 24-h pH testing, detection of abnormal
esophageal exposure to duodenal contents (Bilitec mon- itoring),
and the use of esophageal motility studies have provided us with
some useful guidance. Patients with very high degrees of acid
exposure, particularly at night, are at particular risk for the
development of complicated reux disease.18 Thus, careful review of
both the pattern and severity of acid reux is important.
Complications of reux disease have also been shown to correlate
with the presence of abnormal esophageal exposure to bilirubin.19
As a result, before instituting long-term medical therapy in
patients with GERD, consideration should be given to Bilitec
monitoring. Finally, complicated reux disease has also been shown
to be more common in patients with a defective lower esophageal
sphincter (LES),20 and in those with impaired esophageal body
function.21 In patients with one or more of these risk factors for
com- plications of reux disease, early surgical therapy should be
considered. Detection of Esophageal Shortening In a manner
analogous to stricture formation, esophageal shortening can occur
as a consequence of scarring and brosis associated with repetitive
esophageal injury.22,23 Recognition of anatomic shortening of the
esophagus is important because it can compromise the ability to
perform an adequate tension-free antireux repair. In our
experience,24 and the experience of others,25 un- recognized
esophageal shortening is a major cause of recurrent herniation, a
common cause of fundoplication failure. It is also the explanation
for the slipped Nissen fundoplication. In many such instances, the
initial repair is incorrectly constructed around the proximal
tubular- ized stomach rather than the terminal esophagus. Although
no ideal method exists to detect signicant esophageal shortening,
the combination of video roent- genographic contrast studies and
endoscopic ndings (Fig. 3.1) will alert the surgeon to a situation
in which esophageal shortening is likely.26 A large hiatal hernia
on endoscopy or on video esophagram is likely to be associ- ated
with esophageal shortening, as is the presence of an esophageal
stricture. Hernia size is measured endoscopi- cally as the distance
between the diaphragmatic crura (identied by having the patient
sniff), and the gastroe- sophageal junction (identied as the loss
of gastric rugal folds). We consider the possibility of a short
esophagus in patients with strictures or those with large hiatal
hernias (>5cm), particularly when the latter fail to reduce in
the upright position on a video barium esophagram. Because of the
risk of failure due to excessive tension after transabdominal
repair, these patients are best treated by a thoracic approach that
allows a more thorough mobilization of the esophagus. After
complete mobilization, esophageal length can be appraised by
assessing the ability to reduce the gastroesophageal (GE) junction
beneath the diaphragm without excessive tension. When this is not
possible, a Collis gastroplasty coupled with either a partial or
complete fundoplication achieves excellent control of reux in the
majority of these patients.27,28 Evaluation of Esophageal Body
Function Selection of the appropriate antireux operation in an
individual patient requires a careful assessment of esophageal body
function. Otherwise, the resistance to emptying imparted by a
complete fundoplication will result in troublesome dysphagia in
patients with poor peristaltic function. Assessment of esophageal
body function is also important from a prognostic standpoint
because esophageal body function has been shown to correlate with
the likelihood of relief of regurgitation, dysphagia, and
respiratory symptoms following surgery. When peristalsis is absent,
or severely disordered (>50% simultaneous contractions), or the
amplitude of the contractions in one or more of the lower
esophageal segments in below 20mmHg, most surgeons would opt for a
partial fundoplication. Persistent poor esophageal propulsive
function and the continued regurgitation of esophageal contents may
explain the less favorable response after fundoplication of
atypical compared to typical reux symptoms.2931 Figure 3.1.
Radiograph showing esophageal shortening.
40. Indications for Antireux Surgery Historically, antireux
surgery was reserved for patients with severe esophagitis or
stricture or to those refractory to medical therapy, that is, to
patients with relatively severe reux disease, largely because of
the relatively high morbidity and mortality associated with
antireux surgery in the era of open antireux procedures. The
demonstration of decreased morbidity and shorter hospital stays and
periods of disability associated with minimally invasive antireux
surgery, coupled with the demonstration of the success of these
procedures, have shifted the balance such that patients with less
severe disease are now considered surgical candidates. In fact, it
is likely that it is precisely these patients with less severe
disease that are probably the best candidates for a laparoscopic
Nissen (see following). Furthermore, the traditional concept, that
a decient lower esophageal sphincter is the primary cause of GERD
and that a defec- tive sphincter was a requirement before surgery,
is no longer valid in the era of laparoscopic fundoplication.29 It
is now clear that reux frequently occurs during temporary loss of
the gastroesophageal barrier and that patients with normal resting
sphicter parameters can have excellent outcomes following surgery.
The ideal candidate for a laparoscopic antireux procedure is the
patient with typical symptoms of heart- burn or regurgitation (as
opposed to atypical symptoms such as cough, asthma, or hoarseness),
with a pH test- proven abnormal esophageal acid exposure, and who
has responded to, but is dependent on, proton pump inhibitors for
symptom relief. A multivariate analysis of the factors predicting a
successful outcome after laparo- scopic Nissen has identied these
three parameters as the most important preoperative predictors of a
successful outcome.32 As mentioned, the most important aspect of
patient selection is to be as certain as possible that
gastroesophageal reux is the underlying cause of their complaints.
Taken in this context, it immediately becomes evident that each of
the predictors of success just outlined helps do just that, to
establish that gastroe- sophageal reux disease is indeed the cause
of the patients symptoms. There are several specic situations in
which antireux surgery should be considered. The rst is the patient
who has demonstrated the need for long-term medical therapy,
particularly if escalating doses of proton pump inhibitors are
needed to control symptoms; this is partic- ularly true in patients
who are less than 50 years of age, for whom the lifetime cost of
medical therapy could easily exceed the cost of surgical therapy.33
Patients who are noncompliant with medical therapy, those for whom
the medications are a nancial burden, or those who favor a single
denitive intervention over long-term drug treatment, should also be
offered the option of surgery. Patients who are at high risk of
progression to complica- tions of GERD despite medical therapy (see
earlier dis- cussion) should also be considered for antireux
surgery. Minimally invasive antireux surgery may be the treat- ment
of choice in these patients. Assuming the patient is
physiologically t, and that reux has been carefully
documented,there are no specic contraindications to laparoscopic
antireux surgery. Experience has shown, however, that difculties
may be encountered in patients who have a large left lateral
segment of the liver, those who are morbidly obese, and those who
have undergone prior upper gastrointestinal surgery. Patients with
large paraesophageal hernias represent a specic technical
challenge. Although the
majorityofthesedifcultiescanbeovercomewithincreas- ing experience,
an open transabdominal or transthoracic approach may be the wisest
choice in such patients. This decision, that is, when to abandon
the laparoscopic approach in favor of the traditional open
approach, is a difcult one that is currently under investigation.
Surgical Techniques Laparoscopic Nissen Fundoplication Port
Positioning The technique of laparoscopic Nissen fundoplication has
been relatively well standardized. Access is via ve upper abdominal
ports (Fig. 3.2). We prefer an open technique 3. Laparoscopic
Complete and Partial Fundoplication 19 Figure 3.2. Port
location.
41. 20 J.A. Hagen and J.H. Peters type scissors and ne grasping
forceps are preferred for dissection. In all except the most obese
patients, a very thin portion of the gastrohepatic omentum overlies
the caudate lobe of the liver. The right crus is exposed by
incising the gastrohepatic omentum above and below the hepatic
branch of the anterior vagal nerve, which we routinely spare. A
large left hepatic artery arising from the left gastric artery will
be present in about 25% of patients. It should be identied and
avoided. After incising the gastrohepatic omentum, the lateral
surface of the right crus will become evident (Fig. 3.4). The
peritoneum overlying the anterior aspect of the right crus is
incised with scissors and electrocautery, and the right crus
dissected as much as possible from anterior to posterior (Fig.
3.5). By blunt dissection along the medial surface of the right
crus, the mediastinum is entered. The for placement of the Hasson
trochar used for camera access. Placement of this port through the
left rectus abdominus muscle appears to result in more secure
closure of the wound and fewer incisional hernias. Two lateral
retracting ports are placed in the right and left anterior axillary
lines, respectively. The right-sided liver retractor is best placed
in the right midabdomen (mid- clavicular line), at or slightly
below the camera port. This placement allows the proper angle
toward the left lateral segment of the liver and thus the ability
to push the instrument toward the operating table, lifting the
liver. A second retraction port is placed at the level of the
umbili- cus, in the left anterior axillary line. The surgeons
right- handed trocar is placed in the left midclavicular line, 1 to
2in. below the costal margin. The liver is then retracted, and the
fth and nal port is placed just to the right of the falciform
ligament in the subxyphoid area. The esophageal hiatus is exposed
by placement of a fan retractor in the right anterior axillary
port.A table retrac- tor can then be used to securely x the liver
in place, which minimizes trauma to the liver, and frees the hand
of an assistant for other work. Mobilization of the left lateral
segment by division of the triangular ligament is not necessary. A
Babcock clamp is placed into the left anterior axillary port and
the stomach retracted toward the patients left foot. This maneuver
exposes the esophageal hiatus. Commonly, a hiatal hernia will need
to be reduced (Fig. 3.3). An atraumatic clamp should be used, and
care should be taken not to grasp the stomach too vigorously, as
gastric perforations can occur. Hiatal Dissection Identication of
the right crus is the rst and most impor- tant step in safe
dissection of the hiatus. Metzenbaum- Figure 3.3. Intraoperative
photograph of gastrohepatic ligament with replaced left hepatic
artery. A hiatal hernia of moderate size can be seen in the upper
right corner. Figure 3.4. A window is created above and below the
hepatic branch of the vagus nerve and any associated vascular
structures. The right crus becomes evident. Figure 3.5. The
peritoneum along the anterior border of the right crus is marked
and incised.
42. 3. Laparoscopic Complete and Partial Fundoplication 21
esophagus will then become evident in the lower medi- astinum.
Lateral retraction of the right crus exposes the tissues behind the
esophagus. No attempt is made at this point to dissect behind the
gastroesophageal junction. Meticulous hemostasis is critical, as
otherwise blood and uid tend to pool in the hiatus, obscuring the
view