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Laparoscopic reoperation for severe dysphagia after two previous open fundoplications

Authors

Abstract

This live demonstration emphasizes the problems encountered during re-operation for gastroesophageal reflux disease (GERD). The wrap is dissected off the gastroesophageal junction (GEJ) with great difficulty and on-table gastroscopy is performed.

Keywords

GE junction, GERD, gastroesophageal junction, wrap, gastroscopy, GEJ

Media type

Duration

19'14''

Publication

2007-03

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E-publication

WeBSurg.com, Mar 2007;7(03).
URL: http://www.websurg.com/doi-vd01en1780.htm

Laparoscopic reoperation for severe dysphagia after two previous open fundoplications

1. Trocar placement 00'33''

We got inside the abdomen without too much struggle, now we have some adhesions here in the left hypochondrium. I am just managing now some space for my port placement. When we look at the X-rays, the main option would be an esophagectomy. It’s a pseudo achalasia, an achalasia created by the fundoplication. I am a little bit lower than the xiphoid process there, so I will try to go a little bit lower. This is the stomach. Now we have 4 trocars, I don’t use the liver retractor by now but my assistant on my right side has another hand so he will help me with traction and counter-traction. The aim is to try and find the fundoplication and be as minimal as possible, just take down the fundoplication and do nothing else.

2. Hiatal adhesiolysis 01'35''

Of course, there is no question of redoing an anti-reflux repair in this patient. The liver is probably fixed to the abdominal wall so I don’t need a liver retractor. There are some stitches there. You wouldn’t add a myotomy after the take down? No, if I can take the fundoplication down, it will be OK, and then afterwards if we want, we can run with some dilation, if needed, but I won’t do a myotomy. I am moving from one side to the other to find the best option. Even cutting a little bit on the liver is not a problem, the only thing is that it bleeds but it’s not usually very dangerous. So I prefer to work very close to the liver. Some people recommend going directly to the diaphragm, the problem is that here my goal is not to look for the esophagus, my aim is to go on the fundoplication because I know where the problem is. So working into the diaphragm won’t help me I think. I am very cautious. I think it is the diaphragm, so I think that the fundoplication should be somewhere here. You see clips again, so probably some clips on the curvature of the stomach. We exert traction on what I believe to be the valve. I have to be careful here because I think that this could be the crus there and there the mediastinum.

3. Left crus dissection 04'30''

So I don’t want to go into the mediastinum because you don’t know the exact limits of the esophagus so I try to avoid this area. The dilated esophagus is just right up. I’m just looking for landmarks; a gastroscopy with light wouldn’t help search in these situations? Sure I agree. It’s an infrared probe with cameras that detect what you introduce into the esophagus. This problem is interesting because of the history of this patient but also because the laparoscope is wonderful to get access to the area. In open surgery, this type of redo can be difficult because we don’t have the view that we can get through the scope; this is the esophagus I think. You see the upper clips are probably the ones we see on the diaphragm. That looks like the left crus. That esophagus is a very narrow spot and it dilates, I won’t go inside. You’ve seen the tube passing down the esophagus and the obstacle is probably somewhere here, there was a blockage here.

4. Old fundoplication taken down 06'19''

This is stomach so we have to find the edge of the fundoplication. This is the left crus. The esophagus is lying just down there. What tube did they pass down, normally it is a nasogastric tube. It was a tube of the gastric banding, a calibration tube, it’s very soft, it is 30 to 40cm and is atraumatic. I don’t like the bougie in these conditions because you perforate. It is quite well fixed, clips again, I think this is probably the plane. Even to do a small perforation into the stomach it’s not very important in the general context of this patient of course, we can suture that. I prefer to work on the gastric size rather than the esophageal size because an injury to the esophagus is much more dangerous than one to the stomach, which can be repaired very easily by a single suture. Where do you want to stop the inferior limit of the dissection, is it necessary to open completely the valve? What I want to do is to continue a little bit, then I will check again with the tube and see if the tube passes easily or not. In terms of redo surgeries, is it more difficult than usual or less difficult? About the same, it was quite simple in terms of access, taking down the adhesions from the previous surgery takes time, usually afterwards the problems become a little bit more complicated. I think that the problem is here. It looks very distorted and unnatural. I think you are below the esophagus, maybe the wrap has slipped onto the stomach. In a few seconds, we’ll test with the tube and I am sure that we will have the problem here. The problem is here so if we can find a plane we will be OK. The goal is that at the end of the operation, the tube should pass down with no problem. What is the diameter of the tube? Around 36. This tube has a balloon to calibrate. This is the cause of the problem here. See this little cord here, maybe it’s related to the small perforation during the dilation, I don’t know. It looks like a fibrotic area. We are going ahead; looks like the stomach. See the dilation of the esophagus there. There should be some planes here but they are very difficult to find. Is it necessary to open here in the mediastinum? I think that I have to find my way here, if I do, it’s done. I should find my place in this area. It’s really on the cardia. Maybe if you start by taking the right side of the wrap? I don’t have that many planes. Finding sutures is perhaps a good way to find your way around. This is the cardia there. It looks like the valve is very long. I think that we are coming to the end of the fundoplication, we will then test with the tube again. We are progressively coming to the end, very long valve. I have got the feeling that the stomach is completely wrapped around. The stomach is way too long, so what about stomach motility? I would be very pleased if this woman can swallow normally after the operation. Talking about vagus trunk and such things is impossible in this context so if the only problem that we have is gastric emptying, we will be very pleased. This is the access of the esophagus, we see the bougie that is inside, this is probably the cardia, the left part of the valve that we have already detached here. At the beginning, it was like this. The right part of the valve and I am trying to free the cardia as much as possible. I don’t know if this is a band, it looks like it’s coming from the right part of the fundoplication, so I think that we will divide it. It’s triangulating the cardia, the cardia is here. Then we will check the passage of the bougie afterwards and we should be OK. These adhesions here are probably the last part of the operation.

5. Gastroscopy 17'25''

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