RU2371140C1 - Laparoscopic oesophagofundoplication technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, namely surgery, can be used in laparoscopic treatment of gastroesophageal reflux disease. Video laparoscopic aided diaphragm-oesophageal ligament is dissected. Right and left cruses of diaphragm are separated. It is followed with transhiatal dissection of oesophagus to be gripped with a handle. Retrooesophageal window is formed. Posterior gastric fundus is delivered through said opening. The delivered posterior gastric fundus is closed with anterior gastric fundus from the opposite side with fixing the formed fundoplication cuff at the level of abdominal oesophagus. A thick probe is preliminary inserted into lumen of oesophagus. Cruses of diaphragm are sutured with nonabsorbable suture material under oesophagus. Suturing is performed so that closed oesophageal hiatus opening in upper half is formed to provide free longitudinal relocation of oesophagus. In lower half hiatus opening shall be slit-like with its length exceeding width of the prospected fundoplication cuff. Then posterior gastric fundus with its free end is sutured to the left crus of diaphragm. Anterior gastric fundus is similarly fixed to the right crus of diaphragm. Thus the fundoplication cuff is formed without suturing gastric fundi ensuring free expansion of oesophagus within disjoin cuff while bolus passing and following origin return of tight closing of oesophagus walls.

EFFECT: method allows preventing postoperative dysphagia, providing antireflux mechanism of the cuff ensured by expansion of oesophagus inside of the cuff while bolus passing and soft closing thereafter, eliminating oesophagus compression with the cuff, preventing opening of cuff joints due to elimination of uncontrolled tension, allows preventing migration of oesophagus with the cuff owing to reliable and flexible fixation of the cuff, reducing injuries of tissues ensured by lower number of stitches as a result of fusion of fundoplication and hiatoplasty procedures, improving reliability of hiatoplasty owing to application of proper elastron.

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Description

The invention relates to medicine and can be used in surgery for laparoscopic treatment of gastroesophageal reflux disease.

A known method of laparoscopic performance of posterior partial fundoplication according to Toupet, used with antireflux for gastroesophageal reflux disease [Soper J.N., Swanstrom L.L., Eubanks W.S. Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia, Lppincott Willians & Wilkins, 2005, Second Edition, P. 650]. This method consists in the fact that under conditions of laparoscopy, after isolating the legs of the diaphragm and eliminating, if there is a hernia of the esophageal opening of the diaphragm, the abdominal part of the esophagus partially (partially) is enveloped by the bottom of the stomach behind the esophagus.

The disadvantage of this known partial method of fundoplication is its significantly lower antireflux result compared to the method of total fundoplication [Karim S.S., Clifton J., Storseth C. Comparison of total versus partial laparoscopic fundoplication in the management of gastroesophageal reflux disease // Am. J. Surg. - 1997. - Vol.l73, No. 5, - P.375-378]. All this leads to relapses of gastroesophageal-reflux disease and, accordingly, the need to perform repeated antireflux surgery or subsequently use expensive and side-effects drugs, including from the group of proton pump inhibitors [Lundell L. et al. Continued (5-year) followup of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coil SurgFebruary 2001; 192: 172-81].

A known method of total fundoplication according to Nissen, selected as a prototype [Dallemagme B., Weerts J.M., Jehaes C. Laparoscopic Nissen fundoplication: preliminary report // Surg. Laparosc. Endosc. - 1991 .-- Vol. 1. No. 1. - R. 138-143].

This method is as follows. Under video-laparoscopic observation, the esophagus-diaphragmatic ligament is dissected, the right, left legs of the diaphragm are isolated, transhiatal dissection of the esophagus is carried out with its holding and, after the formation of a retroesophageal window of sufficient width, a posterior flap from the bottom of the stomach is drawn through this opening and is brought closer to it from the opposite side the same front flap with fixation of the formed circular fundoplication cuff at the level of the abdominal esophagus, into the lumen of which is previously thick lead probe. In a modification of Nissen's Rosseti operation, the fundoplication cuff is made entirely from the anterior wall of the stomach [ME Rosseti ME, Liebermann-Heffert D, Braun RB. The "Rossetti" modification of the Nissen fundoplication: technique and results. Dis Esoph 1996; 9: 251-257].

The disadvantage of this method according to Nissen, selected as a prototype, is the high frequency of postoperative dysphagia, lasting from several weeks to several months, which in some cases requires reoperation [Hunter JG, Swanstrom L., Waring P. Dysphagia after laparoscopic antireflux surgery: The impact of operative tehnique // Ann. of Surg. - 1996. - Vol. 244, No. 1. - P.51-57].

Dysphagia is observed not only due to the insufficient experience of the operating surgeon and the weak propulsive function of the esophagus, but, first of all, due to the fundamental lack of technology for performing total fundoplication Nissen [Utkin V.V., Ambalov G.A., Demchenko Yu.M. Dangers and complications of Nissen fundoplication // Surgery. - 1986. - No. 3. - S.88-91].

In fact, the total fundoplication cuff according to the Nissen method is a rigid compression ring that prevents the esophagus from expanding under the cuff, while dysphagia as a result of compression is not completely excluded by preliminary introduction, for calibration, before suturing the cuff, a thick probe into the lumen of the esophagus.

Another drawback of total Nissen fundoplication is the axial migration of the abdominal esophagus with the fundoplication cuff down to the stomach body with the development of the "telescopic" Nissen syndrome or upward displacement - with the herniation of the fundoplication cuff.

In addition, as a result of the tension of the fundoplication cuff, the sutures of the connected flaps of the fundus of the stomach are stretched, which leads to the eruption of these sutures and the divergence of both flaps with a complete loss of antireflux function [Hunter J.G., Smith C. D., Branum G. D., et al. Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 1999; 230: 595-606].

In our experience, in the case of free application of the Nissen fundoplication cuff, the cardia gapes and the antireflux effect decreases due to the lack of a cuff tension regulator.

The objective of the invention is to develop an elastic antireflux esophagogastric valve with the ability to regulate the degree of tension of the fundoplication cuff due to the elastic muscle component for preventing divergence of cuff sutures or postoperative dysphagia and for reliable fixation of the fundoplication cuff in order to prevent its axial migration with the abdominal esophagus, free expansion of the esophagus inside the opening cuff when passing and bolus and its subsequent tight closure due to the tension created by the controller from the patient's own biological tissue.

The problem is solved in that according to the author’s method, the following actions are performed: the legs of the diaphragm under the esophagus are sutured with non-absorbable suture material so that the sutured esophageal hiatus opening in the upper half is formed with the possibility of the esophagus for free longitudinal movements, and in the lower half in shape it would be slit-like and in length - more than the width of the planned fundoplication cuff, after which the posterior flap from the bottom of the stomach with a free end is sewn to the left leg of the diaphragm, and the single flap is likewise fixed to the right leg and in this way a total fundoplication cuff is formed, but without sewing the flaps together and with the possibility of free expansion of the esophagus inside the opening cuff when passing the food lump and subsequent return to the initial state of tight closure of the esophagus walls. A comparative analysis with the prototype, where the front and back flaps are sewn together with each other in the form of an unregulated compressive or free (“dangling”) ring, shows that a significant distinguishing feature in the form of hemming flaps from the bottom of the stomach held around the esophagus to the muscle formations presented the diaphragm legs located perpendicular to the plane of the conditional ring of the fundoplication cuff provides a fully adjustable antireflux effect with the opening of the compression ring of the cuff of swallowing solid food, as well as a secure fit fundoplikatsionnoy cuff.

All this provides new technical results:

- prevention of postoperative dysphagia and improvement of the antireflux mechanism of the fundoplication cuff due to the free expansion of the esophagus inside the opening ring of the cuff during passage of the food lump and its subsequent dense soft closure due to the created elastic tension regulator from the “springing” longitudinal muscles of the patient's hiatus, i.e. taken from their own biological tissue;

- lack of compression of the esophagus under the fundoplication cuff;

- prevention of divergence of the cuff seams due to the lack of rough unregulated tension of the fundoplication cuff;

- reliable and flexible fixation of the fundoplication cuff to prevent axial migration of the abdominal esophagus with the fundoplication cuff when swallowing or during the occurrence of vomiting;

- reduction of tissue trauma due to a decrease in the number of sutures on the esophagus and stomach as a result of the merger of the fundoplication procedure and hiatoplasty;

- improving the reliability of hiatoplasty using its own plastic material in the form of the bottom of the stomach, covering the hiatus opening.

Figure 1 schematically shows a diaphragmatic crurography with a decrease in diastasis between the legs to the esophagus from above and to the slit in the lower half of the esophageal hiatus.

Figure 2 schematically shows the hemmed flaps from the bottom of the stomach, held around the esophagus to the muscle masses, represented by the legs of the diaphragm and located perpendicular to the plane of the fundoplication cuff.

Figure 3 schematically shows the stage of free expansion of the esophagus inside the opening cuff when passing the food lump due to the created elastic antireflux muscle valve that regulates the tension of the fundoplication cuff.

The proposed method for performing laparoscopic esophagofundoplication is implemented as follows.

(Not shown in the drawings). After the standard installation of trocars and pneumoperitoneum under video-laparoscopic observation, the following standard actions are sequentially performed: dissect the esophageal-diaphragmatic ligament, isolate the right and left legs of the diaphragm, conduct transchiatal dissection of the esophagus with its holding and form a retroesophageal window of sufficient width. Then, for the stage of chiatoplasty and fundoplication, a thick probe is inserted into the lumen of the esophagus and stomach for calibration.

(According to figure 1). According to the developed method, the rear diaphragmatic crurography is performed with the non-absorbable suture (s) 1 superimposed on the right diaphragmatic leg 2 and the left leg 3 so that in the upper half, above the suture 1, the hiatus opening 4 is narrowed to normal values, with the possibility of free longitudinal movements of the esophagus 5, and in the lower half, below this suture 1, a slit-like diastasis 6 would remain between the legs of the diaphragm for the implementation of esophagofundoplication.

(According to figure 2). After the above steps for the proposed method of laparoscopic esophagofundoplication, the posterior flap 7 from the bottom of the stomach is passed through the retroesophageal window and sewn under the abdominal esophagus 5 to the inner surface of the left leg of the diaphragm 3 with the free end of the flap 7 to the center of the slit-shaped distas 6, and the front flap 8 is fixed in the same way, under the esophagus 5 to the right leg 2 with the formation of a total fundoplication cuff 8 due to sutures 9, 10, but without stitching the flaps together. The cuff 8 is fixed along the upper and lower edges to the center of the anterior wall of the esophagus with two additional sutures 10.

(According to figure 3). During swallowing, the esophagus 5 and its lumen 12 expand freely inside the opening cuff 8 during passage of the food lump and its subsequent closure to the initial state (in FIG. 2) due to the created antireflux muscle valve from the patient’s own biological tissue, consisting of muscle-patchwork a pair that adjusts the tension of the fundoplication cuff 8.

We used this method in 5 patients with gastroesophageal reflux disease. The immediate results of operations for 3 months showed an excellent antireflux effect without cases of postoperative dysphagia and axial migration of the fundoplication cuff.

Claims (1)

A method of performing laparoscopic esophagofundoplication, including dissection under videolaparoscopic observation of the esophageal-diaphragmatic ligament, isolation of the right and left legs of the diaphragm, transhiatal dissection of the esophagus with its holding, formation of a retro-esophageal window, conducting through the posterior posterior part of the fundus of the stomach, on the opposite side with the anterior part of the fundus of the stomach with fixation of the formed fundoplication cuff at level a of thedominal section of the esophagus, into the lumen of which a thick probe is preliminarily inserted, characterized in that the legs of the diaphragm are sewn with non-absorbable suture material under the esophagus so that the sutured esophageal hiatus opening in the upper half is formed with the possibility of the esophagus for free longitudinal movements, and in the lower half it would be slit in shape and longer than the planned fundoplication cuff in length, after which the posterior part of the fundus with a free end is sutured to the left leg the diaphragm, and the anterior part of the fundus of the stomach is similarly fixed to the right leg of the diaphragm, forming a fundoplication cuff without stitching the departments of the fundus of the stomach with each other and with the possibility of free expansion of the esophagus inside the opening cuff when the food lump passes and then returns to the initial state of tight closure of the esophagus walls.

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