Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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238 Section III • The Esophagus

STEP 5: PEARLS AND PITFALLS

◆ Without fundoplication, approximately 60% of patients report symptoms of reﬂ ux, most of

which can be managed medically. Most surgeons therefore add an antireﬂ ux procedure to

the myotomy. No technique has proven superior, but most avoid a 360-degree fundoplica-

tion because of its higher rate of dysphagia.

◆ In prospective studies, laparoscopic Heller myotomy has been shown to achieve comparable

outcomes with open surgery, with longer operative time and shorter hospital stay. Long-

term follow-up has demonstrated satisfactory outcomes in 80% to 90% of cases.

◆ Patients with esophageal dilation of up to 6 cm have had patient satisfaction of greater than

90% from laparoscopic Heller myotomy.

◆ Patients with a sigmoid esophagus should be considered for myotomy ﬁ rst, then esophagec-

tomy if symptoms do not resolve. Studies have demonstrated good to excellent patient sat-

isfaction in 54% to 71% of patients at 7 to 11 years follow-up with myotomy of the

sigmoid esophagus.

SELECTED REFERENCES

1. Tsiaoussis J, Athanasakis E, Pechlivanides G, et al: Long-term functional results after laparoscopic surgery

for esophageal achalasia. Am J Surg 2007;193:26-31.

2. Constantini M, Zaninotto G, Guirroli E, et al: The laparoscopic Heller-Dor operation remains an effective

treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 2005;19:345-351.

3. Bonatti H, Hinder RA, Klocker J, et al: Long-term results of laparoscopic Heller myotomy with partial

fundoplication for the treatment of achalasia. Am J Surg 2005;190:874-878.

4. Douard R, Gaudric M, Chaussade S, et al: Functional results after laparoscopic Heller myotomy for

achalasia: A comparative study to open surgery. Surgery 2004;136:16-24.

5. Gaissert HA, Lin N, Wain JC: Transthoracic Heller myotomy for esophageal achalasia: Analysis of long-

term results. Ann Thorac Surg 2006;81:2044-2049.

240

STEP 1: SURGICAL ANATOMY

◆ Allows gastric decompression

◆ Access for enteral feeding (Figure 20-1)

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Anesthesia: general

◆ Position: supine

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Incision and exposure: upper midline

◆ Use scalpel to create stab wound through skin and anterior fascia just lateral to rectus abdo-

minus muscle left of midline (see Figure 20-1).

2. DISSECTION

◆ With retraction and visualization, the surgeon should use forceps through the stab wound

to enter through the peritoneum and into the abdomen.

◆ The surgeon should use the same forceps to grasp a mushroom catheter (12F) and retract

the external end of the catheter through the stab wound (Figure 20-2).

CHAPTER

Stamm Gastrostomy

Dennis C. Gore

CHAPTER 20 • Stamm Gastrostomy 241

Liver

Stomach

Mushroom

catheter

FIGURE 20 –2

Upper midline

incision

Exit site

2 cm or more

below costal

margin

FIGURE 20 –1

242 Section IV • The Abdomen

◆ Place 2-0 silk purse-string suture to the anterior wall of the stomach (Figure 20-3).

◆ Using two Babcock clamps for traction, the surgeon uses the cautery to create gastrotomy

within the purse-string suture (Figure 20-4).

First purse-string suture

FIGURE 20 –3

Babcock clamp

Gastrotomy

FIGURE 20 –4

◆ Two Babcock clamps are used for traction and forceps are used to stent the mushroom

catheter tip, which is placed through gastrotomy (Figure 20-5, A).

◆ The ﬁ rst purse-string suture is secured around the catheter (Figure 20-5, B).

Second purse-string suture

Mushroom catheter

First purse-string suture

FIGURE 20 –5

CHAPTER 20 • Stamm Gastrostomy 243

244 Section IV • The Abdomen

◆ The second purse-string of 2-0 silk sutures is placed around the tube and secured

(Figure 20-6).

◆ 2-0 silk sutures are used to anchor the anterior wall of the stomach to the peritoneum in

simple, interrupted fashion (Figure 20-7).

◆ The mushroom catheter is retracted to approximate the anterior stomach wall with the

peritoneum, then secured, and silk sutures are tied.

Mushroom catheter

Transversalis muscle

Parietal

peritoneum

Stomach

FIGURE 20 –6

Anchor

sutures

FIGURE 20 –7

CHAPTER 20 • Stamm Gastrostomy 245

3. CLOSING

◆ Closure of fascia with suture

◆ Closure of skin

STEP 4: POSTOPERATIVE CARE

◆ Routine

STEP 5: PEARLS AND PITFALLS

◆ Two Babcock clamps grasping the edges of the gastrotomy along with a forceps inserted

into the tip of the mushroom catheter and then held under tension provide an excellent

means of retraction for placing the mushroom catheter within the stomach.

◆ The catheter should remain in place until the gastrostomy tract and the anterior stomach

wall are securely healed to the peritoneal surface, which usually takes 10 days.

◆ First place all the sutures from the stomach to the peritoneum, then retract the catheter to

approximate the anterior surface of the stomach to the peritoneum and secure ligatures.

This sequence allows good visualization and room for placing sutures.

SELECTED REFERENCES

1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations. New York, MacMillan, 1983, p 30.

246

STEP 1: SURGICAL ANATOMY

◆ See Figure 21-1.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indication: access for enteral feeds

◆ Anesthesia: general

◆ Position: supine

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Periumbilical midline laparotomy (Figure 21-1).

2. DISSECTION

◆ After entering the peritoneal cavity, use scalpel to create stab wound through skin and ante-

rior fascia, just lateral to rectus abdominus muscle, usually to the left (see Figure 21-1).

◆ With retraction and visualization, use forceps through stab wound to enter through

peritoneum and into abdomen (Figure 21-2).

◆ Use this same forceps to grasp mushroom catheter (20F) and retract external end of

catheter through stab wound.

CHAPTER

Witzel Jejunostomy

Dennis C. Gore

Omentum

Mushroom

catheter

Periumbilical midline

laparotomy incision

Exit site of

tube through

abdominal wall

(stab wound)

FIGURE 2 1–1

FIGURE 2 1–2

CHAPTER 21 • Witzel Jejunostomy 247

248 Section IV • The Abdomen

◆ Place 3-0 silk suture as purse string into antimesenteric wall of selected jejunum, usually

approximately 30 cm distal to ligament of Treitz yet with sufﬁ cient mobility to reach

peritoneum at the site of the catheter exit (Figure 21-3).

◆ Using two Babcock clamps for traction, use cautery to create enterotomy within purse

string (Figure 21-3).

Enterotomy

within jejunum

Mushroom

catheter

First purse-string

suture

FIGURE 2 1–3