Recorded live laparoscopic Heller procedure for mega-esophagus

This is the case of a 64-year-old man presenting with a complex history of symptoms of reflux and dysphagia for some years, with a combination of dysmotility, reflux and anatomical problems in terms of hiatal hernia. This video shows a laparoscopic Heller myotomy with an associated antireflux procedure.

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Recorded live laparoscopic Heller procedure for mega-esophagus

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

This is the case of a 64-year-old man presenting with a complex history of symptoms of reflux and dysphagia for some years, with a combination of dysmotility, reflux and anatomical problems in terms of hiatal hernia. This video shows a laparoscopic Heller myotomy with an associated antireflux procedure.

Classification

live recorded

Keywords

Laparoscopy, Heller procedure, esophageal myotomy, partial fundoplication, motility disorder

Media type

Surgical video

Duration

24'00''

Publication

2010-07

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Subtitles

E-publication

WeBSurg.com, Jul 2010;10(07).
URL: http://www.websurg.com/doi-vd01en3003.htm

Recorded live laparoscopic Heller procedure for mega-esophagus

1. Introduction 00'19''

This is the case of a 64-year-old man presenting with a complex history of symptoms of reflux and dysphagia for some years. Recently, the dysphagia increased, with a little weight loss. Endoscopy and upper GI series showed an enlargement of the esophagus, along with some images that suggest some dysmotility disorder in the relaxation of the lower esophageal sphincter. This was confirmed by three consecutive manometries, which had to be performed in order to identify the exact problem. In fact, when you look at the manometry, there are several things to be highlighted: first, the impairment of the esophageal motility, with non-propulsive waves along the entire length of the esophagus. When you look at the cardia, there is a reduced range of relaxation of the lower esophageal sphincter, so it is not a very typical aspect of achalasia, in which the relaxation of the LES is usually lost and there is no motility in the esophagus. This is why we do not know at this point if it is achalasia that is starting or if it is a motility disorder with diffused spasm of the esophagus with some consequences on the lower part of the esophagus and the esophageal side of the cardia. Moreover, we will see on the upper GI series that there is a hiatal hernia, so probably there is a combination of dysmotility, reflux and anatomical problems in terms of hiatal hernia. This is the general setting of this patient.

2. Opening of pars flaccida 02'29''

You see that we have opened the pars flaccida of the lesser omentum, just to get access to the segment I of the liver; the right crus, you see the left crus is there, vena cava is there.

3. Phrenoesophageal ligament opening 02'45''

We opened the phrenoesophageal ligament in order to gain access to the lower mediastinum and the lower part of the esophagus. We have already mobilized the esophagus.

4. Esophagus dilatation 02'59''

When you get inside the mediastinum, you can see that there is an obvious enlargement of the esophagus. This confirms the dilatation we have observed on GI series and endoscopy; probably there is some problem with the cardia, as I mentioned. We took down the fat part of the cardia. We were just starting to clear the anterior aspect of the esophagus. The main difference with achalasia, usually when you have a pure achalasia, is that you just work on the anterior aspect of the esophagus, so you do not look at the back of the esophagus.

5. Hiatal hernia reduction 03'49''

In this patient, as there is a hiatal hernia, we have to dissect the posterior attachment of the esophagus. We have cleared this posterior channel and this is to reduce the hiatal hernia within the abdominal cavity. Usually, in 60-80% of achalasia, you do not have a hiatal hernia, this is why you just work on the anterior aspect of the GE junction.

6. Mediastinal esophageal dissection 04'18''

In this patient, we will probably perform a myotomy in order to increase the outflow from the esophagus to the stomach, since we know we have a relaxation problem at this part. As we know that we are increasing the risk of reflux, we will add some anti-reflux mechanism. If I create some anti-reflux mechanism, I will divide the first short gastrics. It is important to work quite extensively in the mediastinum because we want to get some length of the esophagus in order to reduce the hiatal hernia. Here we have the mediastinum, the anterior aspect of the esophagus, the vagus trunk there. This is the pulmonary vein so you see that we are coming quite high in the chest. It is again very important to get the esophagus free below the diaphragm. The orientation of the vagus trunk can be seen here. When doing this mobilization, it is always very important to keep in mind that the anterior vagus trunk is going to the left side of the patient. If you look at the incision of the phrenoesophageal ligament, the esophagus was like that in the chest. The insertion can be seen here. Once we have left the traction on the GE junction, we have at least a little segment of the esophagus that still remains below the diaphragm. Now we are working on the GE junction. The stomach is there, the angle of His is over there. We know that, when performing a myotomy, we have to work not only on the esophageal side of the cardia, but also on the gastric side of the cardia, because the high pressure zone has different components, so it is very important to work in this part as well. We usually say that at least 2cm on the gastric side should be opened. This is the head of the patient. This patient had a previous laparotomy for peritonitis. This is the umbilicus, and, given the short distance between the umbilicus and the xiphoid process, which is over there, we have inserted a 30-degree scope within the umbilicus. Just one hand below the xiphoid process, you have another 5mm port, which I use with my left hand. If we move to the left side of the patient, laterally, there is a 5mm subcostal trocar for retraction. You see that the assistant is holding the GE junction. Between those two, I have an ultrasonic device, which I use with my right hand. So I have a quite special positioning of the ports, which is very comfortable when working within the mediastinum. If I move to the patient’s right, the right hypochondrium can be seen. There is another trocar through which we are introducing a liver retractor. I will keep on working on the GE junction. Then I will start with the myotomy. We know that the length of the esophagus is a very important factor of success at least in anti-reflux repair. We focus very much on that because we consider that all the recurrence or complications such as slippage or intrathoracic migration are probably related in part to the length of the esophagus. When we cannot get the length that we want, we add some lengthening procedures such as the Collis gastroplasty. I’m just dissecting the anterior vagus trunk in order to clear the anterior aspect of the esophagus, because I will start the myotomy right there. I am trying not to grab the nerve, but just the tissue around.

7. Myotomy 09'32''

As can be seen, I have mobilized a little bit the anterior vagus trunk. This is the esophageal side of the cardia. This is the gastric side. So we will clear a little bit more. These are the longitudinal fibers that you can see quite well. I will try to stay in the middle of the esophagus. I will do a small incision first in the musculature. Longitudinal and circular muscles can be seen, as well as the mucosa. The cleavage plane will be made using the ultrasonic scissors. The position must be changed to have the passive blade on the mucosa. I have created the plane with the scissors. I put some traction with my left hand. The position of the assistant is slightly changed. The main risk during this procedure is perforation. But, if you perforate, it is not a big issue. You just have to suture using a very small suture. The esophageal musculature is bigger than normally. So I clear a little bit the vagus trunk to gain access to the anterior esophageal wall. The grasper is changed and we go below the vagus trunk and grab the muscular layer. Do you use sometimes intraoperative manometry? Yes, we do, not intraoperative manometry but we have a new tool, a system that can measure the compliance, that can measure the distensibility of the GE junction. With this new concept, we can measure the possibility of distension of the esophagus and the cardia. It is very interesting. I am freeing a little bit the mucosa. We have done the esophageal side. Now we will move below and start the gastric side of the myotomy. I have to go back on the gastric side and this will be quite difficult if I use the scissors, so I will start with the hook. I come this way, as it is a little more difficult to grab the fibers. The orientation of the fibers changes, as can be seen. The longitudinal and the circular ones are beginning to cross; this is what we call the “clasped fibers”. At the gastric side, the cleavage plane does not usually exist any more, so the majority of the small perforations take place in this area. If you have perforation there, usually if you perform an anti-reflux anterior mechanism, you cover the perforation with it, so it does not have big consequences. The view of these cameras is perfect. Fibers by fibers can be seen. This is a great advantage in terms of quality of the operations we are doing today. The 2cm are there. The angle of His is there, and this is it, since, as aforementioned, we are not dealing with a true achalasia. In fact, it is completely clear that, thanks to the changes in cameras and views, current operations have nothing to do with the ones performed years ago: insufflating the balloon, putting light transparency and so on. At this point, one advantage of endoscopy would be to inflate, making sure that you have not done any perforation. But, as during the myotomy, we have had no evident problems, this will not be necessary.

8. Gastric fundus mobilization 15'12''

Now, we will move to the upper gastric fundus, because, as I mentioned, I am used to doing all anti-reflux mechanisms with fundic mobilization. I am back to my ultrasonic system. It is not a full gastric mobilization, it is just the upper part of the gastric fundus. We are not mobilizing from there, but just the upper part. Usually, at the upper part of the gastrosplenic, you find a little fat pad that you find on the upper part of the fundus. This fat pad can be found in all patients and I use it as a landmark. When dealing with a motility disorder, you need to have a very floppy valve and, for that purpose, I feel a fundic mobilization is needed. See these attachments on the spleen. We see very well posteriorly the little artery going directly to the fundus. It is very interesting. Do you think that you have to free it every time? Yes, 80% of the time. As soon as I divide this, everything comes in my hand and I know that I can adapt the floppiness of the anti-reflux mechanism. Here’s the gastrosplenic ligament. See? The fundus comes very easily. The posterior fundic vessel still blocks the fundus, so I will divide it. Everything comes as I continue with the division. May I ask something? Is it the same mobilization that we are doing in the sleeve gastrectomy, right? Yes, that’s right, perfect.

9. Hiatus closure 17'54''

The next step is the hiatal hernia. So we will close the hiatus to recalibrate it. Therefore, I am using non-absorbable material. It is a 2/0 Mersilene suture. Usually I do a figure of 8 stitch, left crus and right crus. What do you propose if the crus is in bad quality? Our first choice is to reinforce with a Teflon pledget. Finally, if nothing really works, we may consider using a mesh, but this is very rare.

10. Valve creation 19'16''

So you see how floppy this can be. This is due to the mobilization of the fundus. And I will fix it. The myotomy edges on the crura; here I fix my valve on the crura. Here, I am trying to get not the nerve, but the muscle. There are different techniques of knot-tying. This shows that the ability to suture is so important in laparoscopic surgery, because as long as you are able to suture and tie knots, you can do whatever you like. This is why Didier Mutter is organizing the lab focusing a lot on suturing, knotting, etc, as we believe this is a crucial parameter for advanced laparoscopic surgery. As can be seen, my port positioning is not perfect because sometimes you have to fight with the camera, but it is perfect for the operator, because my instruments do not have to cross. The patient can drink water tonight and the next morning, he will have a dye test with gastrograffin and if it is good, we will start to feed him. So today it is just a glass of water during the night, just to refresh, and tomorrow we will check with the dye.