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Laparoscopic modified Hill esophagogastropexy: « Snow » technique
Authors
Abstract
The description of the laparoscopic modified Hill esophagogastropexy: ''Snow'' technique covers all aspects of the surgical procedure used for the management of gastroesophageal reflux.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, mobilization of esophagus, suturing of crura, esophagogastropexy.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, mobilization of esophagus, suturing of crura, esophagogastropexy.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-02
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WeBSurg.com, Feb 2001;1(02).
URL: http://www.websurg.com/doi-ot02en004.htm
URL: http://www.websurg.com/doi-ot02en004.htm
Laparoscopic modified Hill esophagogastropexy: « Snow » technique
1. Introduction
The Hill gastropexy (Hill, Ann Surg, 1967) aims at restoring normal physiological antireflux mechanisms without adverse effects and with a low recurrence rate.Our open surgery technique has been standardized since 1987 and has been performed laparoscopically since 1991 for type I and type II hiatal hernias.
2. Anatomy
• Anti-reflux zone
1. Lesser omentum2. Left lobe of the liver
3. Esophageal hiatus
4. Diaphragm
5. Pleura
6. Spleen
The normal ''anti-reflux zone'' anatomy (ARZ) is composed of a 2 to 5 cm segment of esophagus fixed below the hiatus to the diaphragm, crura and stomach by ligamentous attachments. Maintenance of normal relationships between these structures is essential to the integrity and function of anti-reflux mechanisms.
• Crura/ stomach attachments
1. Triangular ligament2. Phrenoesophageal ligament
3. Gastrophrenic ligament
4. Gastrosplenic ligament
5. Short gastric vessels
6. Left kidney
7. Toldt’s fascia
8. Crura of the diaphragm
• Mechanisms
• Principles
1. Anterior vagus nerve2. Lesser omentum (cut off)
3. Crura
4. Aorta
5. Esophagogastric angle
6. Cardia of the stomach
Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:
- the esophagogastric valve (EGV),
- the lower esophageal 'sphincter effect' (LESE).
• Esophagogastric valve
Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:- the esophagogastric valve (EGV),
- the lower esophageal 'sphincter effect' (LESE).
• LES effect
Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:- the esophagogastric valve (EGV),
- the lower esophageal 'sphincter effect' (LESE).
• Crura
1. Right crus2. Left crus
3. Crural decussation
4. Crural tendon
5. Median arcuate ligament
6. Aorta
3. Classification
• Hiatal hernias
1. Thoracic esophagus2. Thoracic cavity
3. Right crus
4. Left crus
5. Abdominal esophagus
6. Fundus of the stomach
Hiatal hernias cause most gastroesophageal reflux diseases (GERD).
• Type I hiatal hernias
• Classification
Type I, or sliding hiatal hernias, have an intact attenuated phrenoesophageal ligament.They can be subclassified according to 3 anatomically distinct stages of evolution.
• Stage 1
Sliding hiatal hernias occur when the abdominal esophagus migrates through the hiatus while the gastroesophageal junction (GEJ) and stomach remain below.As the abdominal esophagus migrates, the EGV disappears due to the widening of the esophagogastric angle, and the LESE diminishes due to the loss of anatomical relationships and extrinsic pressures.
This may not be appreciated on endoscopy or barium study.
This would explain the reports of GERD without a hiatal hernia.
• Stage 2
Stage 2 sliding hiatal hernias occur when the gastroesophageal junction and stomach migrate above the diaphragm. The EGV can reform above the diaphragm, preventing reflux.
This may explain reports of sliding hiatal hernias without GERD.
• Stage 3
Stage 3 sliding hiatal hernias have a shortened esophagus with fixation of the gastroesophageal junction above the diaphragm due to scarring.True stage 3 hiatal hernias are rare.
• Type II hiatal hernias
Type II, or paraesophageal hiatal hernias, occur through a defect in the phrenoesophageal ligament.The gastroesophageal junction nonetheless remains in the abdominal cavity.
4. Indications
Indications for this procedure are as follows:- type I and II hernias;
- intolerance or noncompliance to continuous medical treatment (required for treatment of GERD);
- complications of GERD (hemorrhage, ulcer).
5. Operating room set-up
• Patient
- general anesthesia;- supine position;
- legs adducted (placed together);
- reverse Trendelenburg (not mandatory);
- dual lumen gastric tube;
- urinary catheter (not mandatory).
• Team
1. The surgeon stands on the patient's left.2. The assistant stands on the patient's right.
3. The scrub nurse stands on the surgeon's left.
• Equipment
The first monitor is used by the surgeon.The second monitor is used by the assistant.
The laparoscopic and video units are on the patient's right.
6. Trocar placement
• Anatomical landmarks
1. Xiphoid 2. Costal margin
3. Midline
The procedure is performed with 5 trocars (three 10 mm trocars, two 5 mm trocars).
An important principle is to place ports so as to prevent the instruments from interfering with each other.
• Trocars
Port A is 10mm in size, accommodates the laparoscope and is positioned on the midline above the umbilicus.Port B is 5mm in size, accommodates the grasping forceps and is positioned in the right upper quadrant.
Port C is 10mm in size, accommodates the liver retractor and is positioned in the right subcostal area.
Port D is 10mm in size, accommodates the atraumatic grasper and is positioned in the left subcostal area.
Port E is 5mm in size, accommodates the dissecting and suturing devices and is positioned in the left upper quadrant.
7. Instrumentation
• Instruments
A: 30° or 45° laparoscopeB: Grasping forceps
C: Liver retractor
D: Atraumatic grasper
E: Hook dissector and scissors for diathermy, suction-irrigation device, needle holder
• Optical device
A: 30° or 45° laparoscope• Operating devices
B: Grasping forcepsE: Hook dissector and scissors for diathermy, suction-irrigation device, needle holder
• Retracting devices
C: Reusable liver retractor, disposable liver retractor D: Atraumatic grasper
8. Major principles
The laparoscopic Hill gastropexy aims at restoring both normal anatomy and physiological antireflux mechanisms. It involves:- freeing of the abdominal esophagus;
- retroesophageal cruroplasty;
- posterior gastropexy down to the origin of the crura;
- recreation of the angle of His with a gastropexy sutured to the diaphragm.
9. Exposure
• Reverse Trendelenburg
The reverse Trendelenburg position causes the spontaneous lowering of the abdominal organs, giving a greater exposure of the operative field. However, it is not mandatory.• Gastric clearance
A dual lumen gastric tube is placed to decompress the stomach.It is removed at the beginning of the reapproximation of the crural defect.
• Reducing the hernia
The liver and falciform ligament are retracted.The hernia is reduced with graspers via the operating trocars.
10. Mobilization/esophagus
• Principles
The following structures are respectively dissected:1. Inferior part of the lesser omentum
2. Phrenoesophageal ligament
3. Phrenogastric ligament
• Peritoneal layer opening
1. Caudate lobe of the liver2. Right crus
3. Esophagus and anterior vagus nerve
4. Left crus
5. Aorta
The gastrohepatic ligament is divided. The dissection is continued across the attenuated phrenoesophageal ligament near its origin in the diaphragm, and then posteriorly over the left crus, exposing the esophagus, the right and left crura, and the esophagocrural grooves.
• Crura/ preaortic region dissection
1. Crural decussation2. Right crus
3. Left crus
4. Arcuate ligament
5. Celiac trunk
The right crus is bluntly dissected on its left aspect, beginning slightly beyond the crural muscle decussation and continuing until the origin of the celiac trunk is visualized. The arcuate ligament is visualized during this operative step.
11. Suturing/crura
• Objective
The aim is to restore an anatomically correct position while preventing stenosis of the hiatus. • Anterior esophageal retraction
The esophagus is retracted anteriorly, exposing both crura and the crural tendon, just proximal to its insertion into the median arcuate ligament.• Repair of crural defect
The crural defect is closed with a 0 polypropylene (PPP) suture in a running fashion starting at the superior edge of the crural decussation. The hiatal opening is assessed as sufficient with a 1 cm open grasper.The suture is tied, approximating the crural muscles without strangulation.
12. Esophagogastropexy
• Principles
By lowering the position of the cardia of the stomach, the normal anatomy of the ARZ is restored, thus enabling the recreation of the angle of His.• Anchoring the cardia
The distal abdominal esophagus is fixed by suturing the posteriomedial wall of the cardia to the body of the crural decussation and tendon with a figure-of-eight 0 PPP suture.• Esophagogastropexy
The EGV is re-established by suturing the fundus of the stomach to the entire length of the abdominal esophagus and to the diaphragm with a running, 2-0 PPP suture. • Final suture strengthening
The final running stitch anchors the fundus to the diaphragm, while reinforcing and protecting the previous stitch (which included the stomach, crura, phrenoesophageal ligament and proximal end of the abdominal esophagus).The phrenoesophageal ligament is then sutured to the proximal abdominal esophagus with several interrupted 4-0 PPP sutures.
The sutures are placed so as not to create tension or injure the vagus nerves.
The entire abdominal esophagus is now secured within the abdominal cavity, restoring both the LESE and the EGV.
13. Postop management
The nasogastric tube is removed a few hours after the end of the procedure.Fluid intake begins on the day of the procedure.
Solid intake begins on the first postoperative day.
The patient usually leaves hospital on the second postoperative day.
14. Reference
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