RU2757527C1 - Surgical treatment method for achalasia of cardiac esophagus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to abdominal surgery. The esophagus is mobilized with separation of middle bundle of the right branch of esophageal hiatus (EH). Mobilize EH left branch back from the esophagus until its complete isolation. The lower third of the esophagus is isolated from posterior mediastinum by separation and blunt separation from mediastinal pleura. The mobilized esophagus is lowered and fixed to the right and left EH branches. Access is carried out in vascular-free zone behind EH to posterior wall of the stomach floor with the intersection of short gastric vessels. Starting from the cardiac part of the stomach at a distance of 1.5-2 cm from the cardioesophageal junction, an anterior esophagocardiomyotomy is performed up the esophagus with a length of 6-9 cm. A fundoplication cuff is formed by stitching the anterior wall of the stomach floor to the left side of the esophagocardiomyotomy incision throughout, followed by fixing the same wall to the right side of the esophagocardiomyotomy incision throughout. Then a posterior partial half-sleeve is formed by holding the stomach posterior wall behind the esophagus and fixing it to the right wall of the lower third of the esophagus of the cardiac stomach with at least two nodular sutures. Perform posterior crurography along the diameter of esophagus.

EFFECT: method reduces risks of intraoperative and postoperative complications, reduces number of disease relapses, allows to straighten pathological bends of esophagus, and also prevents development of the main complication of cardiomyotomy, especially gastroesophageal reflux disease (GERD) and gastroesophageal hernia (GEH).

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Description

The technical field to which the invention relates

The invention relates to the field of abdominal surgery and can be used for the surgical treatment of diseases of the esophagus - primary achalasia of the cardiac esophagus of the I-IV degree, as well as the recurrent form of achalasia of the cardiac esophagus.

State of the art

There is a known method of surgical treatment of achalasia (RF Patent No. 2421155 "Method of surgical treatment of esophageal achalasia"), according to which, under conditions of laparoscopic surgery, a longitudinal incision of the muscular membrane is performed in the lower third of the esophagus and the cardiac part of the stomach along the anterior surface while maintaining the integrity of their mucous membranes, which are closed the bottom of the stomach. After a wide dissection of the muscular membrane from the underlying layers of the esophagus, the left and right edges of the dissected muscular membrane of the esophagus are sutured with the adjacent inner surfaces of the left and right legs of the diaphragm in a state of muscular diastasis in the area of the myotomy defect created with a width of at least half the circumference of the esophagus wall. Then the defect of the muscular membrane is closed with an esophageal-gastric fat lump mobilized from the corner of the Hisa on the vascular pedicle, which is fixed and closed with the bottom of the stomach as follows: the posterior part of the bottom is sutured to the outer surface of the left leg of the esophageal opening of the diaphragm, and the anterior part of the bottom is sutured to the outer surface of the right leg esophageal opening of the diaphragm. In this case, the graft from adipose tissue on the vascular pedicle is placed between the fundus of the stomach and the myotonic incision.

The disadvantages of this method include a significant laboriousness of the technique, unjustified violation of the anatomical and physiological features of the region of the esophageal-gastric junction in the absence of the formation of sufficient artificial antireflux mechanisms, which increases the likelihood of postoperative gastroesophageal reflux. In addition, suturing additional tissues to the area of cardiomyotomy (closure of the defect in the muscular membrane of the esophagus with a fat lump) may increase the risk of developing cicatricial changes in this area, which may lead to the risk of recurrence of the disease.

A known method of laparoscopic treatment of cardia achalasia (RF Patent No. 2627151 "Method of surgical treatment of cardia achalasia"), including access, revision of the abdominal cavity, mobilization of the lesser curvature, cardia and the fundus of the stomach with the intersection of short vessels, left gastroepiploic arteries and veins, mobilization legs of the diaphragm, as well as the diaphragmatic and lower thoracic parts of the esophagus with its lowering into the abdominal cavity, esophagocardiomyotomy along the midline of the posterior wall of the esophagus with the transition to the posterior wall of the fundus of the stomach, the formation of a fundoplication cuff and its fixation to the diaphragm by suturing the posterior wall of the stomach to the right and left stomach walls esophagus and the corresponding edges of the esophageal opening of the diaphragm. A feature of this method is that after the esophagocardiomyotomy, the posterior wall of the fundus of the stomach is stitched 2-3 cm below the myotomic incision, the same thread is stitched to the posterior wall of the esophagus 3-5 mm above the myotomic incision, the stitched areas are brought together, tying an interrupted suture, thus forming a fundoplication cuff, which is fixed with two interrupted sutures to the right and left lateral walls of the esophagus and the same sutures to the right and left semicircles of the esophageal opening of the diaphragm, the edges of the cuff are sutured together with an interrupted suture above the level of the esophageal-gastric junction, anterior to it without fixation to the wall of the esophagus.

The disadvantages of this method are:

- significant difficulty in performing cardiomyotomy due to the choice of the site for its implementation (esophagocardiotomy incision runs along the posterior wall of the esophagus and stomach), which also negatively affects the visualization of the main anatomical structures of this area and, as a consequence, reduces the safety of the intervention;

- the lack of fixation of the suture to the wall of the esophagus during the formation of the fundoplication cuff, which can lead to dissociation of the peristaltic contractions of the esophagus and stomach;

- preservation of significant mobility of the esophagus, which can adversely affect tissue healing after surgery.

Closest to the claimed one is a method for the treatment of esophageal achalasia by the method of classical laparoscopic cardiomyotomy according to Geller with Dor fundoplication (Pechlivanides G, Chrysos E, Athanasakis E, Tsiaoussis J, Vassilakis JS, Xynos E. Laparoscopic Heller cardiomyotomy factors and Dor predicting outcome Arch Surg 2001; 136: 1240-1243). In this method, after access and revision of the abdominal cavity, the esophagus is mobilized and brought down, the vagus nerve is isolated and preserved, myotomy is carried out from the esophageal-gastric junction, and it is continued 5-6 cm proximally along the length of the esophagus. When carrying out myotomy, the oblique muscle fibers of the esophagus are dissected to the submucosa. The operation is completed by the formation of a Douro fundoplication cuff: the anterior wall of the fundic stomach is placed in front of the abdominal esophagus, then the anterior wall is fixed to the right muscle wall of the esophagatomical incision.

The disadvantages of the known classical method include the risk of recurrence of the disease, as well as the high probability of developing gastroesophageal reflux. The absence of fixation of the esophagus to the legs of the POD, as well as the absence of posterior cruraraphy, can lead to the restoration of the pathological curvature of the esophagus and the resumption of clinical symptoms of achalasia of the cardia. With this variant of cuff formation, the antireflux mechanism may be insufficient, which can lead to reflux.

The technical problem to be solved by the invention is the development of a low-traumatic and effective method of surgical treatment of primary and recurrent achalasia of the cardiac esophagus, which minimizes the likelihood of intraoperative and postoperative complications, reduces the number of relapses of the disease, as well as prevents gastroesophageal reflux and the development of esophageal hernia. diaphragm holes.

Disclosure of invention

The technical result, which the claimed invention is aimed at, is to reduce the risks of developing intraoperative and postoperative complications, and to reduce the number of relapses of the disease. The use of the proposed method allows you to correct pathological bends of the esophagus by straightening it, and also prevents the development of the main complication of plastic surgery of the cardioesophageal junction, namely gastroesophageal reflux disease (GERD) and hiatal hernia (hiatal hernia).

The technical result is achieved through the implementation of the method of laparoscopic treatment of achalasia of the cardiac esophagus of the I-IV degree, including the installation of trocars, the imposition of carboxyperitoneum, the introduction of the hepatic retractor, opening the lesser omentum above the hepatic branch of the vagus nerve, visualization of the right pedicle of the diaphragm alimentary opening (POD), mobilization of the esophagus with the isolation of the middle bundle of the right leg of the POD, release and visualization of the left leg of the POD, mobilization of the left leg of the POD from the back of the esophagus, until it is completely isolated, mobilization of the abdominal esophagus, isolation of the lower third of the esophagus from the posterior mediastinum by separation and blunt separation from the mediastinal pleura, bringing down the mobilized esophagus and its fixation to the right and left legs of the POD, access in the avascular area behind the POD to the posterior wall of the fundus of the stomach with the intersection of short gastric vessels, mobilization and release of the anterior and posterior branches of the vagus nerve, performed at a distance of 1.5 -2 cm from the cardioesophageal junction of the anterior esophagocardiomyotomy 6-9 cm long, the formation of a fundoplication cuff by suturing the anterior wall of the fundus of the stomach to the left side of the esophagocardiomyotomy incision along the entire length, followed by fixation of the same wall to the right side of the esophagocardiomyotomy incision along the entire length of the esophagocardiomyotomy, formation half-cuffs by holding the posterior wall in the region of the fundus of the stomach behind the esophagus and fixing it to the right wall of the lower third of the esophagus of the cardiac region of the stomach with at least two interrupted sutures, performing posterior cruraraphy along the diameter of the esophagus with a Z-shaped suture.

Anterior esophagocardiomyotomy provides a minimally invasive etiological approach to the surgical correction of idiopathic esophageal spasm. Making an incision along the anterior wall of the esophagus with a length of 6-9 cm allows to achieve a stable remission of cardiospasm, thereby significantly reducing the risk of recurrence. Wide mobilization of the lower third of the esophagus, stretching and fixation of the esophagus to the right and left pedicles of the alimentary opening of the diaphragm straightens the esophagus and prevents it from returning to a pathological position in case of grade III and IV achalasia. The formation of a fundoplication cuff, in which the cardiac part of the stomach is fixed by the anterior wall to both edges of the esophagotomic incision, with the formation of an additional partial fundoplication cuff by the posterior wall of the fundus of the stomach and the performance of posterior cruraphy, allow creating a powerful combined antireflux mechanism that prevents the development of the main complication of classical cardiomyotomy, namely reflux diseases (GERD) and hiatal hernia (HH).

Brief Description of Drawings

The invention is illustrated by illustrations, where Fig. 1 shows the location of the esophagocardiomyotomy section, Fig. 2 is a diagram of the performed anterior esophagocardiofundomyotomy, FIG. 3-4 - the stage of suturing the anterior wall of the cardiac part of the stomach to the left side of the esophagocardiomyotomy section, in Fig. 5 - the stage of fixing the anterior wall of the cardiac part of the stomach to the right part of the esophagocardiomyotomy section, Fig. 6 - the formed anterior fundoplication cuff, in Fig. 7 - the stage of fixing the posterior wall of the fundus of the stomach to the lateral part of the esophagus, FIG. 8 - formed posterior partial cuff.

Implementation of the invention

The proposed method is carried out as follows.

A nasoesophageal probe is installed to clean the esophagus, followed by its removal before surgery. The patient is given general anesthesia, a new thin nasoesogastric tube is inserted, and the stomach is decompression.

Then, under aseptic conditions, through the upper paraumbilical incision-puncture up to 12 mm, an entrance into the abdominal cavity is made with trocar No. 1, 10 mm in diameter, carboxyperitoneum of 13 mm is applied. rt. Art. with the introduction of a laparoscopic video camera. Examination of the abdominal organs (liver, small and large intestine, spleen, pelvic organs) is performed. Under visual control, additional trocars (10 mm in diameter in the epigastrium, 5 mm in the right hypochondrium, 13 mm in the left hypochondrium, if necessary, 5 mm in the left mesogastrium) are introduced into the abdominal cavity. Next, a hepatic retractor is installed through the epigastric trocar, traction of the left lobe of the liver upwards is performed.

Using an ultrasound dissector or with the help of intelligent bipolar coagulation, the lesser omentum (hepato-gastric ligament) is opened above the hepatic branch of the vagus nerve, the right leg of the alimentary opening of the diaphragm (POD) is visualized, the esophagus is mobilized with the release of the middle bundle of the right leg of the POD, visualizing and releasing the left leg UNDER. Mobilization is continued along the left leg behind the esophagus, until it is completely isolated.

To mobilize the abdominal part of the esophagus, the ligaments surrounding the esophagus are transected (including the Laimer-Bertelli membrane), as well as artificial expansion of the POD. By both blunt and acute methods, the lower segment of the esophagus is isolated from the posterior mediastinum, separated from the mediastinal pleura, and brought down into the abdominal cavity. The anterior (left) vagus nerve is isolated atraumatically, displaced to the right of the esophagus. The mobilized esophagus is lowered into the abdominal cavity and fixed with two interrupted sutures to the right and left legs of the POD so that most of the esophagocardiomyotomy incision is in the abdominal cavity.

After that, in the avascular area behind the esophagus, access is made to the posterior wall of the fundus of the stomach, the phrenic-fundus ligament is partially crossed. The fundus of the stomach is freed by crossing 2 short gastric arteries. Mobilization and release of the anterior and posterior branches of the vagus nerve are carried out without damaging it.

Next, the zone of spasm is determined. Starting from the cardiac part of the stomach, at a distance of 1.5-2 cm from the cardioesophageal junction, an anterior esophagocardiomyotomy is performed up the esophagus with a length of 6-9 cm (Figs. 1 and 2).

Then separate interrupted sutures along the contour of the myotomy cut produce the formation of the anterior fundoplication cuff by the anterior wall of the cardiac part of the stomach, first to the left (Figs. 3 and 4), and then to the right of the esophagocardiomyotomy incision throughout (Figs. 5 and 6). Then, the posterior partial cuff is formed by drawing the posterior wall in the area of the stomach fundus behind the esophagus (Fig. 7) and fixing it to the right wall of the lower third of the esophagus of the cardiac part of the stomach with at least two interrupted sutures (the posterior wall of the fundus of the stomach is passed under the esophagus from the side of the lesser curvature stomach and fixed to the lateral part of the esophagus, thus wrapping the esophagus with the posterior wall of the fundus of the stomach). As a result, the posterior wall of the stomach is sutured with at least two interrupted sutures to the wall of the lower third of the esophagus (Fig. 8). Posterior cruraphy is performed with one or two Z-shaped sutures along the caliber of the esophagus.

The final stage of the operation is the installation of a drainage (5 mm) into the left subphrenic space through an access in the left hypochondrium. Control hemostasis, desuflation, and then remove the trocars.

In accordance with the claimed method, 62 operations were carried out, during which the following were performed:

1) preservation of the hepatic branch and the left (anterior) trunk of the vagus nerve;

2) mobilization of the fundus of the stomach through the avascular area of the omental bursa;

3) wide mobilization of the esophagus to the lower third and fixing it to the legs of the POD;

4) anterior esophagocardiomyotomy 6-9 cm long;

5) the anterior fundoplication cuff was formed, which was placed on the esophagocardiomyotomy incision, and the posterior partial cuff was formed;

6) back cruraphy.

At the same time, none of the operated patients had a relapse of the disease and did not develop gastroesophageal reflux.

Examples of implementation of the invention

Example 1. Patient A. 25 years old. Was admitted to the hospital with a diagnosis of achalasia of the cardiac part of the II degree. The diagnosis was confirmed by fluoroscopy and esophagogastroscopy.

The patient was examined and prepared for surgery. Before the operation, the nasoesophageal zone was installed, the esophagus was cleaned, followed by the removal of the probe. The operation was performed - laparoscopic esophagocardiomyotomy in Geller's modification with anterior fundoplication in Dora's modification and posterior partial fundoplication with posterior cruroraphy. Moreover, after the installation of 4 laparoscopic ports and the imposition of carboxyperitoneum up to 12 mm Hg. Art. a review of the abdominal organs was performed. Then, through the epigastric trocar, a hepatic retractor was installed, traction of the left lobe of the liver was made upward. A nasogastric tube was installed, and the stomach was decompression. Using an ultrasonic dissector, the lesser omentum was opened above the hepatic branch of the vagus nerve, the right pedicle of the alimentary opening of the diaphragm (PF) was visualized, the esophagus was mobilized with the isolation of the middle bundle of the right leg PF. Next, the left leg was visualized and released. Mobilization was continued along the left leg from the back of the esophagus until its complete discharge. The ligaments surrounding the esophagus were transected and mobilized, then the legs of the POD were artificially expanded. Then, the lower segment of the esophagus was isolated from the posterior mediastinum by blunt and sharp methods, separated from the mediastinal pleura and brought down into the abdominal cavity. The anterior (left) vagus nerve was atraumatically displaced to the right of the esophagus. After that, in the avascular area behind the POD, access was made to the posterior wall of the fundus of the stomach, the phrenic-fundus ligament was partially transected. The fundus of the stomach was freed with the intersection of 2 short gastric arteries. The esophagus was lowered into the abdominal cavity and fixed with two interrupted sutures to the right and left legs of the POD so that most of the esophagocardiomyotomy incision was in the abdominal cavity. Next, an anterior esophagocardiomyotomy was performed, starting from the cardiac part of the stomach at a distance of 2 cm from the cardioesophageal junction, and further up the esophagus with a length of 6 cm. then to the right of the esophagocardiomyotomy incision throughout. Then the posterior wall of the fundus of the stomach was carried out under the esophagus from the side of the lesser curvature, subsequently, the posterior partial hemibuff was formed by fixing the posterior wall of the fundus of the stomach to the lateral part of the esophagus. Thus, the posterior wall of the stomach was sutured with two interrupted sutures to the wall of the esophagus. Posterior cruraphy was performed with one Z-shaped suture along the caliber of the esophagus. At the final stage of the operation, a drainage (5 mm) was installed into the left subphrenic space through an access in the left hypochondrium. Control of hemostasis, desuflation and then removal of trocars were performed. The postoperative period was uneventful, complex postoperative drug therapy, control of analyzes and activation of the patient were carried out. The next day after the operation, fluoroscopy with a water-soluble contrast agent was performed - there are no streaks, the contrast freely passes into the stomach. Food on this day was carried out through a tube. On the second day after the operation, the patient was removed the nasogastric tube, the patient began to self-feed. On the 7th day in a satisfactory condition, the patient was discharged for outpatient treatment. Control fluoroscopic examination carried out 3 months later showed the absence of contrast agent retention in the esophagus. There are no data on dysphagia and heartburn.

Example 2. Patient B. 47 years old. Was admitted to the hospital with a diagnosis of achalasia of the cardiac part of the IV degree. The diagnosis was confirmed by fluoroscopy and esophagogastroscopy. Previously, the patient in another clinic was offered extirpation of the esophagus, the patient refused.

The patient was examined and prepared for surgery. Before the operation, the nasoesophageal zone was installed, the esophagus was cleaned, followed by the removal of the probe. The operation was performed - laparoscopic esophagocardiomyotomy in Geller's modification with anterior fundoplication in Dora's modification and posterior partial fundoplication with posterior cruroraphy. Moreover, after the installation of 5 laparoscopic ports and the imposition of carboxyperitoneum up to 12 mm Hg. Art. a review of the abdominal organs was performed. Then a hepatic retractor was installed through the epigastric trocar, and the left lobe of the liver was tractioned upward. A nasogastric tube was installed, and the stomach was decompression. Using an ultrasonic dissector, the lesser omentum was opened above the hepatic branch of the vagus nerve, the right pedicle of the alimentary opening of the diaphragm (PF) was visualized, the esophagus was mobilized with the isolation of the middle bundle of the right leg PF. Next, the left leg was visualized and released. Mobilization was continued along the left leg behind the esophagus, until its complete release. The ligaments surrounding the esophagus were transected and mobilized, then the legs of the POD were artificially expanded. Then, the lower segment of the esophagus was isolated from the posterior mediastinum by blunt and sharp methods, separated from the mediastinal pleura and brought down into the abdominal cavity. The anterior (left) vagus nerve was atraumatically displaced to the right of the esophagus. After that, in the avascular area behind the POD, access was made to the posterior wall of the fundus of the stomach, the phrenic-fundic ligament was partially intersected. The fundus of the stomach was freed with the intersection of 2 short gastric arteries. The esophagus was lowered into the abdominal cavity and fixed with two interrupted sutures to the right and left legs of the POD so that most of the esophagocardiomyotomy incision was in the abdominal cavity. Next, an anterior esophagocardiomyotomy was performed, starting from the cardiac part of the stomach at a distance of 1.5 cm from the cardioesophageal junction, and further up the esophagus with a length of 7 cm.A wound of the esophageal mucosa was performed, which was sutured intraoperatively with an interrupted suture. Then the anterior fundoplication cuff was formed by the anterior wall of the cardiac part of the stomach with separate interrupted sutures along the myotomy incision contour, first to the left and then to the right of the esophagocardiomyotomy incision throughout. Then the posterior wall of the fundus of the stomach was carried out under the esophagus from the side of the lesser curvature, after which the posterior partial half-cuff was formed by fixing the posterior wall of the fundus of the stomach to the lateral part of the esophagus. Thus, the posterior wall of the stomach was sutured with two interrupted sutures to the wall of the esophagus. Posterior cruraphy was performed with two Z-shaped sutures along the caliber of the esophagus. At the final stage of the operation, a drainage (5 mm) was installed into the left subphrenic space through an access in the left hypochondrium. Control of hemostasis, desuflation and then removal of trocars was performed. The postoperative period was uneventful, complex postoperative drug therapy, control of analyzes and activation of the patient were carried out. Three days after the operation, fluoroscopy with a water-soluble contrast agent was performed - there are no streaks, the contrast freely passes into the stomach. Food was administered through a tube the next day after surgery. On the 5th day after the operation, the patient underwent repeated fluoroscopy, and then the nasogastric tube was removed, the patient began to self-feed. In a satisfactory condition on the 9th day, the patient was discharged for outpatient treatment. Control fluoroscopic examination carried out 3 months later showed the absence of contrast agent retention in the esophagus. There are no data on dysphagia and heartburn.

Example 3. Patient S. 41 years old. Was admitted to the clinic with a diagnosis of recurrence of achalasia of the cardiac part. History - Geller esophagocardiomyotomy with Douro fundoplication. The diagnosis was confirmed by fluoroscopy and esophagogastroscopy. Previously, the patient in another clinic was offered extirpation of the esophagus, the patient refused.

The patient was examined and prepared for surgery. Before the operation, the nasoesophageal zone was installed, the esophagus was cleaned, followed by the removal of the probe. The operation was performed - laparoscopic esophagocardiomyotomy in Geller's modification with anterior fundoplication in Dora's modification and posterior partial fundoplication with posterior cruroraphy. Moreover, after the installation of 5 laparoscopic ports and the imposition of carboxyperitoneum up to 13 mm Hg. Art. a review of the abdominal organs was performed. Then a hepatic retractor was installed through the epigastric trocar, and the left lobe of the liver was tractioned upward. A nasogastric tube was installed, and the stomach was decompression. Using an ultrasonic dissector, adhesiolysis was performed, then the lesser omentum was opened above the hepatic branch of the vagus nerve, the right pedicle of the alimentary opening of the diaphragm (POD) was visualized, the esophagus was mobilized with the isolation of the middle bundle of the right pedicle of the POD. Next, the left leg was visualized and released. Mobilization was continued along the left leg behind the esophagus, until its complete release. The adhesions surrounding the esophagus were transected and mobilized, then the legs of the POD were artificially expanded. Further, the lower segment of the esophagus was isolated from the posterior mediastinum by blunt and sharp methods, which was hardly separated from the mediastinal pleura and brought down into the abdominal cavity. The anterior (left) vagus nerve was atraumatically displaced to the right of the esophagus. After that, in the avascular area behind the POD, access was made to the posterior wall of the fundus of the stomach. The previously applied Door cuff was disassembled. The esophagus was lowered into the abdominal cavity and fixed with two interrupted sutures to the right and left legs of the POD so that most of the esophagocardiomyotomy incision was in the abdominal cavity. Next, anterior esophagocardiomyotomy was performed, starting from the cardiac part of the stomach at a distance of 1.5 cm from the cardioesophageal junction, and further up the esophagus up to 9 cm long. Then the anterior fundoplication cuff was formed by the anterior wall of the cardiac part of the stomach with separate interrupted sutures along the myotomy incision contour, first to the left and then to the right of the esophagocardiomyotomy incision throughout. Then the posterior wall of the fundus of the stomach was carried out under the esophagus from the side of the lesser curvature of the stomach, after which the posterior partial half-cuff was formed by fixing the posterior wall of the fundus of the stomach to the lateral part of the esophagus. Thus, the posterior wall of the stomach was sutured with two interrupted sutures to the wall of the esophagus. Posterior cruraphy was performed with two Z-shaped sutures along the caliber of the esophagus. At the final stage of the operation, a drainage (5 mm) was installed into the left subphrenic space through an access in the left hypochondrium. Control of hemostasis, desuflation and then removal of trocars were performed. The postoperative period was uneventful, complex postoperative drug therapy, control of analyzes and activation of the patient were carried out. Four days after the operation, fluoroscopy with a water-soluble contrast agent was performed - there are no streaks, the contrast freely passes into the stomach. Food was administered through a tube the next day after surgery. On the 7th day after the operation, the patient underwent repeated fluoroscopy, and then the nasogastric tube was removed, the patient began to self-feed. On the 10th day in a satisfactory condition, the patient was discharged for outpatient treatment. Control fluoroscopic examination carried out 3 months later showed the absence of contrast agent retention in the esophagus. There are no data on dysphagia and heartburn.

Thus, the above examples clearly demonstrate the fact that the proposed method of laparoscopic treatment of achalasia of the cardiac esophagus of the I-IV degree really relieves the patient of the symptoms of the disease and prevents possible postoperative complications associated with this surgical intervention. The proposed method significantly increases the efficiency and safety of the Geller method of laparoscopic cardiomyotomy with Doru fundoplication by reducing the risks of intraoperative and postoperative complications.

Claims (1)

The method of laparoscopic treatment of achalasia of the cardiac esophagus of the I-IV degree, including the installation of trocars, the imposition of carboxyperitoneum, then the hepatic retractor is inserted, the lesser omentum is opened above the hepatic branch of the vagus nerve, the right pedicle of the esophageal opening of the diaphragm is visualized, the bundle of the right esophagus is mobilized with the release of the middle legs POD, visualize and release the left leg POD, mobilize the left leg POD from the back of the esophagus until it is completely isolated, mobilize the abdominal esophagus, isolate the lower third of the esophagus from the posterior mediastinum by separation and blunt separation from the mediastinal pleura, lower the mobilized esophagus and fix it to the right and left legs of the POD, access is made in the avascular area behind the POD to the posterior wall of the fundus of the stomach with the intersection of the short gastric vessels, the anterior and posterior branches of the vagus nerve are mobilized and released, then starting from the cardiac part of the stomach at a distance of 1.5-2 cm from the cardioe zophageal junction, perform an anterior esophagocardiomyotomy up the esophagus with a length of 6-9 cm, form a fundoplication cuff by suturing the anterior wall of the gastric fundus to the left side of the esophagocardiomyotomy incision along the entire length, followed by fixing the same wall to the right side of the esophagocardiomyotomy, then forming the posterior part of the esophagocardiomyotomy a partial half-cuff by passing the posterior wall of the fundus of the stomach behind the esophagus and fixing it to the right wall of the lower third of the esophagus of the cardiac part of the stomach with at least two interrupted sutures;

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