Fig. 5.1
High-resolution manometry of a typical patient with GERD showing normal esophageal motility and decreased lower esophageal sphincter pressure
Preferably, a team of gastroenterologists with a special interest in GERD should evaluate the outcomes of these studies.
In our clinical experience, a group of patients thought to have a clear diagnosis of GERD was confirmed to have achalasia on manometry, with high-resolution manometry (HRM) showing typical pictures of failed swallows, low peristaltic pressures, or no peristalsis (Fig. 5.2).
Fig. 5.2
High-resolution manometry of typical patient with Classic Achalasia showing poor to no peristalsis, the common cavity affects and high resting lower esophageal sphincter pressure without relaxation
One particular patient had been treated for GERD for many years, had done reasonably well on PPI’s, and had a very large paraesophageal hiatus hernia with 70 % of her stomach in the chest. She had regurgitation as a predominant symptom along with heartburn. A diagnostic EGD procedure indicated esophagitis. However, review of the HRM was indicative of a combination of type II and III achalasia. Based on the manometry results, this patient was treated for achalasia with a Heller myotomy and Dor fundoplication.
If patients have significant esophageal dysmotility on HRM and symptoms of dysphagia without anatomic obstruction, in our practice we selectively use this information to perform a partial 270° fundoplication (Toupet procedure) (Fig. 5.3). A loose wrap may function just as well for these patients since a partial wrap has been shown to be as durable as a loose full wrap in several studies [7–9].
Fig. 5.3
High-resolution manometry of patient with GERD showing poor esophageal motility with hiatus hernia and low lower esophageal sphincter pressure
Operative Procedure
There is an obvious difference in the operative time required for patients undergoing robotic-assisted procedures vs. laparoscopic procedures for management of gastroesophageal reflux with robotic surgery requiring a longer time for completion in comparison to the same procedures performed laparoscopically. In addition, the room time (defined as “time in to time out”) is significantly longer with the robotic procedure. In our experience, there exists a learning curve for surgeons, and the room time as well as operative time decreases as the operative team gains experience. The pre-operative time, i.e. time from a patient entering the room to incision time, makes up most of the extra time for the robotic procedure. The operating table needs to be turned away from the anesthesiologist and the logistics of tube and monitoring placement is time consuming. It is best to have an anesthesia team during the initial period of implementation of these procedures, as the set up for esophageal surgery is different from robotic pelvic operations. The docking time from first incision to the surgeon beginning on the console decreases with experience. In our experience, following the first 10–15 cases the docking time stabilizes in the range of 10–15 min.
For experienced laparoscopic surgeons who perform anti-reflux operations frequently the adjustment to using robotic technology is not challenging. Surgeons should be well versed in laparoscopic fundoplication procedures before performing robotic assisted fundoplications. A robotic general surgeon experienced with anti-reflux operations should proctor the first robotic case. Each robotic program must determine the credentialing criteria for privileging surgeons for these procedures. If possible, the first several cases should be performed with an experienced laparoscopic surgeon as an assistant. After the surgeon and operating room team have gained experience, the procedure can be performed assisted by surgical technologists, residents, or physician assistants. As mentioned previously, operative time decreases with experience. The learning curve for using the robotic technology is in the first 10–15 cases for experienced laparoscopic surgeons.
The operation begins with the laparoscopic placement of the ports. The configuration of the port placement is different from the laparoscopic procedure. Placement of the camera port is critical. The typical position of 12 cm caudad and 2 cm to the patient’s left of the xiiphoid for women or small men and 15 cm caudad and 2 cm to the left for large women or men does not always function efficiently. The body habitus is important and with experience the distance from the xiphoid to the camera port becomes shorter. This distance is especially important for patients with large hiatus hernias because of the mediastinal dissection needed to reduce the contents of the hernia sac. The position of the robotic arms is determined by the position of the camera port. This distance is constant, again demonstrating the importance of the first trocar placement for the camera. The 8 mm trocars for the arms of the robot are placed 4 cm cephalad to the 12 mm camera port and 8 cm to either side of the camera port.
The liver retractor port is placed at a convenient position beneath the right costal margin. We use a standard liver retractor from this position; however, a Nathanson retractor can be used in a sub-xiphoid position. The last port is placed in a convenient left lateral subcostal position. This port is used by the assistant for retraction and passing needles as well as for the stapler for patients who are having a Collis gastroplasty.
Once all the ports and the liver retractor are placed, the robot is brought into the field. The patient is placed into a reverse Trendelenburg position and the camera port and two robotic arms are attached to the appropriate trocars. In our surgical practice, we do not routinely use the third arm of the robot. The operating surgeon then goes to the console and initiates the robotic part of the operation.
Dissection of the hiatus with the robot is similar to a laparoscopic approach. The advantage of robotic technology is that the camera can be positioned and secured in place by the operator. If necessary, the camera can literally be placed through the hiatus to gain better visualization for large paraesophageal hernias. This placement is important for maximum mobilization of the esophagus in the mediastinum, so that an adequate length of esophagus, usually 3 cm below the diaphragm, can be obtained for the wrap (Fig. 5.4).
Fig. 5.4
Dissection of the hiatus in-patient with GERD and moderate hiatus hernia
Once the hiatus is dissected and the esophagus circumferentially mobilized preserving the anterior and posterior vagus nerves, the short gastric arteries are taken down to mobilize the greater curvature of the stomach for a Nissen fundoplication. The number of short gastrics taken depends on the amount of fundus needed for the wrap or if a Collis gastroplasty is indicated. The harmonic scalpel is used for all of the dissection including the mediastinum, mobilization of the esophagus and takedown of short gastric arteries.
The next step is taking the gastroesophageal fat pad and separation of the anterior vagus nerve from the esophagus and GE junction (Fig. 5.5).
Fig. 5.5
Dissection of the Anterior Vagus Nerve showing the development of a sling, which will hold the fundoplication in place
Removing the fat pad clears the distal esophagus and cardia of excess tissue, which might interfere with an exact placement of the wrap, but more importantly with this procedure the GE junction can be better visualized. As the anterior vagus is preserved after it is mobilized from the esophagus with the GEJ fat pad the wrap can be brought underneath the vagus and this sling can serve to hold the wrap in place so that it does not slip (Fig. 5.6). The hiatus is then repaired with primary closure of figure of eight stitches with pledgets for reinforcement, if necessary (Fig. 5.7).
Fig. 5.6
Takedown of the gastroesophageal fat pad to clearly identify the junction of the longitudinal esophageal muscle and the serosa of the stomach
Fig. 5.7
Primary closure of the hiatus with figure of 8 suturing, without use of onlay or pledgets as reinforcement
Bridging grafts, whether biologic or synthetic have a high failure rate and multiple complications associated with their use. Most of the time, a primary closure is possible. We use an onlay graft only if the closure needs reinforcement with GoreTex suture and U clips (Fig. 5.8a, b).
Fig. 5.8
(a and b) Hiatus Hernia repair with primary closure and reinforcement with an onlay Gore-Tex graft
Following repair of the hiatus, the esophagus is examined to determine if a standard Nissen fundoplication can be performed. If the esophagus can be brought down to at least 3 cm below the diaphragmatic hiatus without tension, a 3 stitch Nissen fundoplication over a 50–56 fr. dilator is performed. We often will tack the wrap to the diaphragm at the end of the procedure (Figs. 5.9, 5.10, and 5.11). The robot is then undocked and the liver retractor removed, followed by evacuation of the pneumoperitoneum and incision closure.
Fig. 5.9
Mobilizing the fundus and bringing it around the back of the esophagus under vagus nerve sling and mobilized gastroesophageal fat pad
Fig. 5.10
Preparing the fundoplication for suturing to the esophagus
Fig. 5.11
Completed 360° Nissen fundoplication
Partial Fundoplication (The Toupet Procedure)
The principal indications for our patients undergoing a 270° fundoplication (or the Toupet procedure) were dysphagia or esophageal dysmotility diagnosed on HRM. Partial fundoplication is no different from the full wrap until the actual suturing of the wrap. The reduction and repair of hernia as well as mobilization of the esophagus and greater curvature of the stomach are all similar to the standard Nissen fundoplication. In the Toupet procedure, the fundus is brought around behind the esophagus and sutured with three stitches to the esophagus at 10 o’clock position. Left side of the fundic wrap is sutured to 2 o’clock position on the esophagus. This leaves the anterior esophagus open and approximately 270° of the posterior esophagus wrapped (Figs. 5.12 and 5.13).
Fig. 5.12
270° fundoplication for patients with esophageal dysmotility or patients who refuse a 360° fundoplication because of unwanted side effects
Fig. 5.13
Toupet, the 270° fundoplication
Dor (Anterior) Fundoplication
We have had minimal experience in using the anterior fundoplication i.e. the Dor fundoplication for patients having GERD as their indication for operation. We have used the anterior fundoplication almost exclusively for patients with achalasia. The Dor fundolplication has been an effective procedure for the reduction of symptomatic GERD following esophageal myotomy. The Dor fundoplication has been suggested as an alternative for a full Nissen fundoplication (Figs. 5.14 and 5.15).
Fig. 5.14
Anterior 180° fundoplication or Dor fundoplication. For this case the anterior fundoplication was performed with a Heller myotomy
Fig. 5.15
Completed 180° anterior fundoplication
Several studies have shown similar results comparing an anterior wrap to a 360° wrap, with fewer side effects for the anterior fundoplication in comparison to the full fundoplication [10].
Collis Gastroplasty
Our surgical practice has used the Collis gastroplasty procedure for the past 3 years almost exclusively for the management of patients with large paraesophageal hiatus hernia or giant sliding hernia with foreshortened esophagus. The esophagus is mobilized as much as possible and the hiatus is closed. The gastroesophageal junction must be at least 3 cm below the diaphragm without tension; otherwise a Collis gastroplasty is performed. This is especially important in patients with a BMI > 35. To perform the Collis, a second surgeon, surgical resident, or physician assistant is required because the procedure requires stapling of the cardia of the stomach. A wedge resection of the cardia using one of the GIA stapling devices is used to lengthen the esophagus (Fig. 5.16a).
Fig. 5.16
Collis Gastroplasty—Photographs and corresponding illustrations of resecting a wedge of the gastric cardia and creating a neo-esophagus to lengthen the esophagus and prevent undue cephalad tension on the fundoplication. (a and b) Illustration of the first cut across the gastric cardia in the beginning of the lengthening of the esophagus
A 46–50 fr. dilator is placed into the esophagus to prevent narrowing of the “neo-esophagus” (Fig. 5.16b).
We have used the Echelon stapler with a green load of both 60 and 45 mm. In our experience, the 45 mm is much easier to manipulate in the upper abdomen. It is used through the assistant’s port in the lateral upper abdomen. The standard 8 mm trocar is changed to a 12 mm trocar to accommodate the stapler. The amount of cardia removed depends on the anatomy. A relatively small wedge of cardia can be removed and accomplish the lengthening procedure.
The first two staple lines are directed at the dilator that is positioned nest to the lesser curvature of the stomach (Fig. 5.17). The third staple line is parallel to the esophagus and held against the dilator (Fig. 5.18a, b). After the wedge resection is performed (Fig. 5.19), the remaining fundus is wrapped around the neo-esophagus (Figs. 5.20 and 5.21). A Nissen fundoplication is then performed which allows a tension free wrap with reduced chance for recurrence due to herniation or a slipped Nissen (Fig. 5.22).
Fig. 5.17
Collis Gastroplasty—Photographs and corresponding illustrations of resecting a wedge of the gastric cardia and creating a neo-esophagus to lengthen the esophagus and prevent undue cephalad tension on the fundoplication. The “second cut” using an Echelon 45 mm green load to create a neo-esophagus. Illustration showing the “second cut” ending at the point where the stapler is at the edge of the dilator to prevent narrowing of the Neo-esophagus
Fig. 5.18
Collis Gastroplasty—Photographs and corresponding illustrations of resecting a wedge of the gastric cardia and creating a neo-esophagus to lengthen the esophagus and prevent undue cephalad tension on the fundoplication. (a and b) The “third cut” using an Echelon 45 mm green load to finish the creation of the neo-esophagus. Accompanying illustration showing the completed segmental resection of a portion of the cardia of the stomach leaving the remaining fundus for the fundoplication
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