Esophageal perforation during open anti-reflux surgery is very uncommon.20 Use of a safe method of esophageal dissection helps ensure this low rate of perforation: encircling of the esophagus is performed with the surgeon's index finger passed smoothly from left to right, the fingertip touching the left crus of the diaphragm, the anterior aspect of the aorta, and the right crus successively, rather than the posterior aspect of the esophageal wall itself. In contrast, because of the loss of tactile perception, intraoperative perforation during laparo-scopic anti-reflux procedures is more common and may involve either the distal esophagus or gastric fundus.24 Excessive cautery, inadvertent puncture, undue traction, and incorrect identification of the anatomic planes are the most common mechanisms involved.25,26 Posterior esophageal perforation attributed to blind dissection of the lower esophagus flush with its outer muscular layer has been reported by several authors.10,24,27 Perforation of the esophagus or stomach represents the third most frequent intraoperative complication of anti-reflux surgery, occurring in 0.78% of cases.16 Similar to other complications, the risk of perforation follows a learning curve. Schauer et al.24 demonstrated that most perforations occur early (first 10 cases) during the course of a surgeon's experience with fundoplication.
An adequate approach to the hiatal area includes starting the dissection just above the hepatic branches of the left vagus nerve within the lesser omentum on the right crus of the diaphragm, which must be clearly identified. Further dissection around the lower esophagus through the mediastinum must be done under careful visual control. The use of a 30° telescope during laparoscopic surgery may be helpful. Conditions predisposing to intraoperative esopha-geal injury include failure to preoperatively diagnose a short esophagus (Figure 6.1), dense adhesions in relation to severe periesophagitis, and previous hiatal surgery.
Another mechanism involved in intraoperative perforation is the passage of a large-diameter bougie across the gastroesophageal junction. To do this safely, any maneuvers by the
anesthetist must be done in perfect coordination with those by the surgeon. This is especially important with the laparoscopic technique because the surgeon is unable to palpate the gas-troesophageal junction as the bougie is being passed. In addition, during laparoscopy no traction can be exerted on the lower esophagus when the distal tip of the bougie is thought to have reached the cardia.
Another process involved in some of the reported perforations is the presence of a bougie in the lower esophagus during esophageal dissection.28 Under these circumstances, the bougie puts the esophageal wall under tension so as to make it more rigid. Most surgeons agree that it is best to insert the calibration bougie just before suturing the fundic wrap after the lower esophagus has been isolated from its crural attachments.29
The worst problem is failure of recognition of the tear at the time of the operation. This
is especially possible for both posterior esophageal and gastric tears. Any doubtful surgical maneuver requires careful checking of the esophagogastric junction. Either methylene blue injected through the channel of the naso-gastric tube lying across the esophagogastric junction or intraoperative upper gastrointestinal endoscopy with transillumination and insufflation are useful adjuncts for detecting even very small transmural tears.30'31
When a perforation is discovered intraopera-tively' primary repair of the tear in two layers with interrupted stitches is simple and rarely results in postoperative complications. Coverage of the suture line with the fundoplication may help to reinforce the repair.
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.