Table 5 - Indications for laparoscopic GERD surgery

Medically recalcitrant GERD with or without significant hiatal hernia Absence of inflammatory esophageal shortening Reflux-related esophagitis without significant stricture Most paraesophageal hernias GERD-induced cough or "asthma" recalcitrant to medical therapy

In the last several years, many esophageal surgeons, including the team at Allegheny University Hospitals, Allegheny General, have preferentially utilized laparoscopic approaches to repair lower esophageal sphincter dysfunction resulting in pathologic GERD (Table 5). Familiarity with the technical nuances of endosurgical instrumentation and the general conduct of laparoscopic surgical approaches are vital prerequisites before attempting laparoscopic anti-reflux surgery. The basic concepts of anti-reflux surgery applied to open surgical approaches also hold true when laparoscopic techniques are considered (Table 4). Accordingly, the surgeon should first be experienced with the "open surgical" approaches to fundoplication, as the technical standards of "open surgical" management must be main-tained to avoid suboptimal results.

Five sites of trochar access are routinely employed to conduct these laparoscopic anti-reflux procedures (Figure 4). Unless the patient has had a previous abdominal surgical intervention, a "Veres needle puncture" approach is used to gain access to the abdominal cavity for carbon dioxide insufflation. A supra-umbilical site for this needle entry is chosen. After abdominal insufflation is achieved, an initial trochar access for the laparoscopic camera unit is established. We choose a left paramedian location 3 to 5 centimeters above the umbilicus for this access as this gives the greatest direct visibility of the esoph-ageal hiatal anatomy. After making an appropriately sized skin incision to accommodate an 11 millimeter sealed endosurgical trochar, two towel clips are positioned laterally to provide upward traction upon the abdominal wall during the introduction of the trocar through the rectus sheath and into the abdominal cavity.

When the possibility of intraperitoneal adhesions exists, an open approach to the initial trochar cannulation is performed to visually confirm the freedom of adhesions at the site of the ini- tial trochar access. This same left paramedian site would be used when the "open" cut down method for initial trochar access is used. A careful laparoscopic exploration of the peritoneal cavity follows. Subsequent trochar access is then achieved under direct laparoscopic visibility using the same towel clip counter traction technique previously described.

The second 11 millimeter trochar access achieved is in the right upper quadrant 3 centimeters below the costal margin. It is best to keep this trochar access site in a far lateral position to prevent crowding of subsequent instrumentation. This right upper quadrant site is primarily utilized to introduce an expandable retracting instrument beneath the left lobe of the liver to expose the esophageal hiatus. The hiatal exposure is facilitated by leaving the triangular ligamentous attachments of the liver intact.

A third trochar access site is established in the left upper quadrant for the "right-handed" endoscopic instrument access used to accomplish the hiatal dissection. A fourth trochar access is placed approximately 4 to 5 centimeters below the first left upper quadrant site. This site is primarily used for retraction of the gastric fundus during the hiatal dissection. A final trochar access is achieved in the midline sub-xiphoid position to introduce the "left-handed" endoscopic dissecting instrumentation.

Figure 4 - Four to five individual half-inch incisions are used for laparoscopic anti-reflux surgery.

The basic operative technique for the hiatal dissection is the same as that utilized for "open" anatomic repair of the defective lower esophageal sphincter mechanism. Sharp dissection begins at the right of the gastroesophageal junction. The phreno-esophageal ligament is incised along the entirety of the crural arc allowing for exposure of the gastroesophageal junction. Care is taken to identify and avoid injury to the vagal nerve trunks during this phase of the dissection. The distal esophagus is separated from the posterior retroperitoneal attachments which then establishes a posterior tunnel through which the fundus will be subsequently delivered to create the fundoplication. At this point in the operation, a large intra-esophageal Bougie (54 Fr) is introduced transorally by the anesthesiologist into the stomach. Proper positioning of this Bougie is confirmed under direct laparoscopic vision. Posterior re-approximation of the right and left crural muscular bellies is then accomplished with the Bougie in place. Endoscopic suturing is utilized with coaxially oriented endoscopic needle holders and extracorporeal knot tying techniques.

After repair of the crura, the upper three short gastric vessels connecting the fundus of the stomach to the spleen are ligated and divided so as to allow for posterior mobilization of the fundus without tension. A reticulating forceps is introduced behind the distal esophagus to grasp the fundus and bring it around the back of the esophagus for the subsequent plication. The esophageal Bougie is left in place during the suturing of the fundus about the distal esophagus, creating the wrap/flutter valve mechanism. Pexing sutures are then placed between the upper aspect of the fundic "collar" and each margin of the diaphragmatic crura to prevent slippage of the repair. The procedure is completed after meticulous hemostasis is assured. The skin incisions are closed with subcuticular dissolving sutures and covered with bandaids.

These laparoscopic techniques can also be readily applied in the management of paraesophageal hiatal herniation (Figure 4). This "true" hernia of the esophageal diaphragmatic hiatus is commonly associated with GERD symptoms; however, the most important pathologic feature of this hernia is its propensity to result in gastric incarceration and possible gastric mesenteric strangulation. This latter circumstance is a true surgical emergency that is associated with a high mortality if left unattended. The trochar access utilized to conduct the laparoscopic repair of paraesophageal hernias is similar to that utilized for the more common problem of GERD associated with a defective lower esophageal sphincter and a sliding hiatal hernia (Figure 1). As with other laparoscopic surgical techniques, the surgeon must also be prepared to convert to an open surgical approach when the operative conditions preclude a safe or effective surgical repair of the paraesophageal hernia.

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