Exposure for Reoperative Laparoscopic Fundoplication

For reoperative surgery, we use the same five-trocar technique that was used for the primary operation. Before one can elevate the left lobe of the liver adequately, adhesions between the fun-doplication and the liver must be taken down. It is occasionally necessary to replace the liver retractor several times during the process of this dissection. Adhesiolysis is best performed with electrosurgical scissors, or ultrasonic shears (harmonic scalpel; Ethicon Inc., Cincinnati, OH). The goal of dissection is to identify the diaphragmatic hiatus in its entirety. Similar to a first-time fundoplication, safe dissection is dissection that stays away from the esophagus and stays on the diaphragmatic hiatus. It is usually easiest to approach the diaphragmatic hiatus from the left side of the patient as adhesions between the liver, stomach, and right crus often make the initial approach on the right side more problematic. If the short gastric vessels have been previously mobilized, it is relatively easy to follow the stomach to the left crus of the diaphragm and then follow the left crus down to its base. The right diaphragm is best approached by identifying the caudate lobe of the liver and the gastrohepatic omentum and then proceeding superiorly and to the left until the right crus is identified. If the hepatic branch of the vagus has not been divided during the first operation, it is usually necessary to do so at the second operation to facilitate exposure of the diaphragm. Similarly, if the short gastric vessels were not divided during the first operation, this too needs to be performed during the second procedure. A 360° dissection of the hiatus will allow a Penrose drain to be placed around the esophagus. If the stomach is truly herniated through the hiatus, a longer length of Penrose is passed with which to encircle the her-niated stomach. The drain is held in place with endosurgical clips or with an Endoloop. Inferior traction is then placed on the drain to allow the surgeon to reduce the herniated fundoplication back into the abdomen, or to further dissect out the mediastinal esophagus. A herniated stomach may be easily reduced or may require meticulous dissection to free it from the diaphragm and mediastinal structures. Significant mediastinal adhesions are more common when the fundoplication herniates early postoperatively, and may present a formidable technical challenge. It is occasionally necessary to open the diaphragm by dividing the crural arch anteriorly or laterally to gain more working room during this mobilization. It is not unusual for a pneumothorax to develop during such mobilization but generally this is well tolerated. The anesthesiologist may notice some mild desaturation, but usually notices nothing at all. If we detect a pneumothorax, we usually decrease our intraabdominal pressure to approximately 10 mm Hg, and place a red rubber catheter with several additional side holes cut across the diaphragm and into the chest cavity (usually the left chest).

Once the fundoplication has been reduced from the chest, the next step is to completely take down the previous fundoplication. This is performed with sharp dissection by identifying the sutures on the anterior portion of the fundoplication and dividing them sharply. The

MANAGING FAILED ANTI-REFLUX THERAPY

fundus of the stomach is then peeled to the left and to the right from the midline. The dissection of the left portion of the fundoplication is usually fairly easy, but dissection of the right portion of the fundoplication, off the esophagus, may be more problematic because of extensive adhesions. It is important during the takedown of the fundoplication to identify the anterior and posterior vagus nerves. To prevent injury to these nerves, it is best not to use elec-trosurgery or harmonic scalpel close to the nerves. Generally, the vagal trunks can be found in the fundoplication. When the posterior vagus nerve is left within the fundoplication, it is usually easy to preserve; however, if it was left outside of the fundoplication, it may be sectioned inadvertently. The anterior vagus nerve is closely adherent to the esophagus, often encased in scar, and may be best preserved by staying away from this region. Once the fundo-plication has been entirely taken down, an assessment of intraabdominal length is performed by reapproximating the crura with graspers and letting go of all inferior traction on the gastroesophageal junction. If 2 cm of esophagus remains in the abdomen, without tension, the esophagus is not shortened and a lengthening procedure need not be done. If the gastroe-sophageal junction springs back to within 2 cm of the closed hiatus, an esophageal lengthening procedure is performed. There are several ways to perform a Collis gastroplasty with minimally invasive techniques.12-14 Occasionally, patients appear to have adequate intraabdominal length but will have had a twice-herniated fundoplica-tion without known diaphragmatic stressors. Under these circumstances, we advocate performing an esophageal lengthening procedure regardless of the intraoperative measurements.

I am often asked whether a pyloroplasty is indicated when neither vagal nerve can be identified because of previous operations. We generally do not recommend routine pyloro-plasty because many vagotomized stomachs will empty reasonably normally and pyloroplasty can then be used selectively in those patients who develop postoperative gastric emptying abnormalities. It has been extremely rare that we have found it necessary to return later to perform pyloroplasty.

Occasionally the need for a second or third revision arises. We have reported that the results of redo fundoplications deteriorate with each successive operation.6 Whereas success rates for the first operation range between 90-95%, second operations have been successful between 80-90% of the time, and third operations are successful between 50-66% of the time. Because fourth operations are rarely successful at all, some experts suggest that an esophageal resection be performed after three failed fun-doplications. Despite this policy, we have performed fewer than five esophageal resections over 10 years for repeated fundoplication failure.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

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.

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