laparoscopic surgery of_the_abdomen

1. Laparoscopic Surgery of the Abdomen Bruce V. MacFadyen, Jr., MD, et al., Editors Springer

2. Laparoscopic Surgery of the Abdomen

3. Springer New York Berlin Heidelberg Hong Kong London Milan Paris Tokyo

4. Laparoscopic Surgery of the Abdomen Bruce V. MacFadyen, Jr., MD Professor, Department of Surgery, Chief, General Surgery, Director of Minimally Invasive Surgery, Medical College of Georgia, Augusta, Georgia Maurice E. Arregui, MD Director of Fellowship in Advanced Laparoscopy and Endoscopy and Ultrasound, St. Vincents Hospital and Health Center, Indianapolis, Indiana Steve Eubanks, MD Associate Professor, Department of Surgery, Director of Surgical Endoscopy, Duke University Medical Center, Durham, North Carolina Douglas O. Olsen, MD Attending Surgeon, Centennial Medical Center, Nashville, Tennessee Jeffrey H. Peters, MD Professor, Department of Surgery, Chief, General Surgery, University of Southern California Keck School of Medicine, University of Southern California, Los Angeles, California Nathaniel J. Soper, MD Professor, Department of Surgery, Section of Hepatobiliary, Pancreatic, and Gastrointestinal Surgery, Washington University School of Medicine, St. Louis, Missouri Lee L. Swanstrm, MD Clinical Professor of Surgery, Oregon Health & Sciences University, Director, Department of Minimally Invasive Surgery, Legacy Health System, Portland, Oregon Steven D. Wexner, MD Chairman, Department of Colorectal Surgery, Chief of Staff, Cleveland Clinic Florida, Weston, Florida Editors With 252 Illustrations 1 3

5. Maurice E. Arregui, MD Director of Fellowship in Advanced Laparoscopy and Endoscopy and Ultrasound St. Vincents Hospital and Health Center Indianapolis, IN 46260, USA Douglas O. Olsen, MD Attending Surgeon Centennial Medical Center Nashville, TN 37203, USA Nathaniel J. Soper, MD Professor Department of Surgery Section of Hepatobiliary, Pancreatic, and Gastrointestinal Surgery Washington University School of Medicine St. Louis, MO 63110, USA Steven D. Wexner, MD Chairman Department of Colorectal Surgery Chief of Staff Cleveland Clinic Florida Weston, FL 33331, USA Library of Congress Cataloging-in-Publication Data Laparoscopic surgery of the abdomen / editor, Bruce V. MacFadyen Jr. . . . [et al.]. p. ; cm. Includes bibliographical references and index. ISBN 0-387-98468-2 (h/c : alk. paper) 1. Digestive organsDiseases. 2. Laparoscopy. 3. Gastrointestinal systemDiseases. I. MacFadyen, Bruce V., 1942 [DNLM: 1. Digestive System Diseasessurgery. 2. Laparoscopymethods. WI 900 L2998 2003] RC816.L37 2003 617.43059dc21 2002029447 ISBN 0-387-98468-2 Printed on acid-free paper. 2004 Springer-Verlag New York, Inc. All rights reserved. This work may not be translated or copied in whole or in part without the written per- mission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identied as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed in the United States of America. 9 8 7 6 5 4 3 2 1 SPIN 10664759 www.springer-ny.com Springer-Verlag New York Berlin Heidelberg A member of BertelsmannSpringer Science+Business Media GmbH Bruce V. MacFadyen, Jr., MD Professor Department of Surgery Chief, General Surgery Director of Minimally Invasive Surgery Medical College of Georgia Augusta, GA 30912, USA Steve Eubanks, MD Associate Professor Department of Surgery Director of Surgical Endoscopy Duke University Medical Center Durham, NC 27710, USA Jeffrey H. Peters, MD Professor, Department of Surgery Chief, General Surgery University of Southern California Keck School of Medicine University of Southern California Los Angeles, CA 90033, USA Lee L. Swanstrm, MD Clinical Professor of Surgery, Oregon Health & Sciences University Director, Department of Minimally Invasive Surgery Legacy Health System Portland, OR 97227, USA

6. Preface The use of laparoscopy to remove the gallbladder and appendix in the 1980s opened the door for the expanded application of this minimally invasive technique to be applied to abdominal operations that most surgeons have performed as an open procedure. Several textbooks have recorded the rapid development of these techniques in the 1990s. However, longer term data and experience has led to the development of new techniques, modications of previous procedures, and changes in patient care. These changes resulted in the writing of this book, which addresses new patient management, as well as developments in abdominal and pelvic operations for the general surgeon. Positive and negative aspects of patient management, technique, and results are described. Because the eld of laparoscopy continues to develop and expand, modication of this data will certainly be necessary. But, this book is the most up-to-date and comprehensive review in laparoscopic surgery of the abdomen now available. Each section of the book is edited by an expert in the eld who, along with the individual chapter authors, brings a wealth of experience to the book. All of the section editors and chapter authors are very busy clinical surgeons and integrate very well the theoretical and practical aspects of patient management, not only in the ofce but also in the operating room and in postoperative care. I want to particularly thank the section editors for their hard work and diligence in developing the large number and inclusiveness of each chapter. Without their help, this book would not have been possible. This book is the state of the art in laparoscopic abdominal surgery, and I hope it will stimulate surgeons to push the envelope and advance the frontiers of this rapidly expanding eld. Bruce V. MacFadyen, Jr., MD v

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8. Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii SECTION I MINIMALLY INVASIVE SURGERY OF THE ESOPHAGUS AND STOMACH Section Editor: Jeffrey H. Peters Part I Esophageal Procedures 1 Endoscopic Mucosal Resection in the Esophagus . . . . . . . . . . . . . . . . . . . 5 Haruhiro Inoue 2 Minimally Invasive Treatment of Zenkers Diverticulum . . . . . . . . . . . . . 12 Luigi Bonavina, Surendra Narne, and Alberto Peracchia 3 Laparoscopic Complete and Partial Fundoplication . . . . . . . . . . . . . . . . . 16 Jeffrey A. Hagen and Jeffrey H. Peters 4 Laparoscopic Esophageal Myotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Marco G. Patti, Urs Diener, and Carlos A. Pellegrini 5 Miscellaneous Esophageal Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Hubert J. Stein and Joerg Theisen Part II Gastric Procedures 6 Endoscopic Gastric Procedures: Endo-organ Surgery . . . . . . . . . . . . . . . . 45 Charles J. Filipi and Peter I. Anderson 7 Laparoscopic Approaches to Ulcer Therapy . . . . . . . . . . . . . . . . . . . . . . . 52 Namir Katkhouda, Luca Giordano, and Sharan Manhas 8 Laparoscopic Gastrojejunostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 David W. McFadden and Shirin Towgh 9 Gastric Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Jo Buyske vii

9. viii Contents SECTION II LAPAROSCOPIC CHOLECYSTECTOMY Section Editor: Douglas O. Olsen 10 Historical Overview and Indications for Cholecystectomy . . . . . . . . . . . . 71 Douglas O. Olsen 11 Surgical Anatomy of the Gallbladder, Liver, and Biliary Tree . . . . . . . . . . 73 Paul E. Wise and Michael D. Holzman 12 Laparoscopic Cholecystectomy: The Technique . . . . . . . . . . . . . . . . . . . . . 87 Douglas O. Olsen and Renee S. Wolfe 13 Laparoscopic Cholangiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Karen Draper-Stepanovich and William O. Richards 14 Laparoscopic Cholecystectomy in Children and Adolescents . . . . . . . . . . 108 George W. Holcomb III 15 Complications of Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . . . 115 Jonathan A. Cohen and Kenneth W. Sharp SECTION III COMMON BILE DUCT Section Editor: Lee L. Swanstrm 16 Historical Overview of Surgical Treatment of Biliary Stone Disease . . . . 139 George Berci 17 Operative Cholangiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 George Berci and Carl Westcott 18 Laparoscopic Ultrasound for Assessment of the Common Bile Duct . . . . 151 Nathaniel J. Soper 19 Endoscopic Management of Common Duct Stones . . . . . . . . . . . . . . . . . . 161 John R. Craig and Aaron S. Fink 20 Transcystic Fluoroscopic-Guided Common Bile Duct Exploration . . . . . . 169 Matthew F. Hansman and L. William Traverso 21 Laparoscopic Trancystic Duct Choledochoscopy . . . . . . . . . . . . . . . . . . . . 176 Kristn H. Haraldsdttir, Sigurdur Blondal, and Margret Oddsdottir 22 Laparoscopic Choledochotomy for Common Bile Duct Stones . . . . . . . . 184 Monty H. Cox and Thadeus L. Trus 23 Laparoscopic Management of Difcult Common Bile Duct Stones . . . . . 191 Daniel M. Herron 24 Intraoperative Antegrade Common Duct Stone Treatments . . . . . . . . . . . 197 Karl A. Zucker 25 Laparoscopic Choledochoenterostomies . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Joseph Mamazza, Eric C. Poulin, Christopher M. Schlachta, Pieter A. Seshadri, and Margherita O. Cadeddu

10. SECTION IV LAPAROSCOPIC ADRENALECTOMY AND SPLENECTOMY Section Editor: Nathaniel J. Soper 26 Laparoscopic Adrenalectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 L. Michael Brunt 27 Laparoscopic Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Eric D. Whitman and L. Michael Brunt SECTION V LAPAROSCOPIC HERNIA REPAIR Section Editor: Maurice E. Arregui Part I Laparoscopic Inguinal Hernia Repair 28 History of the Preperitoneal Approach for Inguinal Hernia: Rationale and Various Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Lloyd M. Nyhus 29 Musculoskeletal and Neurovascular Anatomy of the Inguinal Preperitoneal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Mary E. Schultheis, Robert J. Fitzgibbons, and Thomas H. Quinn 30 Laparoscopic Hernia Repair: Indications and Contraindications . . . . . . . 273 David L. Crawford and Edward H. Phillips 31 Laparoscopic Intraperitoneal Onlay Mesh Hernia Repair . . . . . . . . . . . . 282 Morris E. Franklin, Jr. and Jose Antonio Diaz-Elizondo 32 Laparoscopic Groin Hernia Repair: Transabdominal Preperitoneal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 Steven M. Yood and Demetrius Litwin 33 Laparoscopic Totally Extraperitoneal Repair for Inguinal Hernias . . . . . . 295 Jonathan D. Spitz and Maurice E. Arregui 34 Complications and Recurrences of Laparoscopic Hernia Repairs . . . . . . . 303 Edward L. Felix Part II Laparoscopic Repair of Ventral Hernias 35 Laparoscopic Ventral/Incisional Hernioplasty . . . . . . . . . . . . . . . . . . . . . . 315 Frederick K. Toy 36 Laparoscopic Repair of Ventral Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Guy R. Voeller SECTION VI LAPAROSCOPIC PROCEDURES OF THE COLON AND RECTUM Section Editor: Steven D. Wexner 37 Laparoscopic Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Anthony Macaluso, Jr. and Sergio W. Larach Contents ix

11. x Contents 38 Laparoscopic Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352 W. Keat Cheah and Peter M.Y. Goh 39 Laparoscopic Right Hemicolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359 Juliane A. Miranda-Rassi and Jay J. Singh 40 Laparoscopic Transverse Colectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 Laurence R. Sands and Michael D. Hellinger 41 Laparoscopic Left Hemicolectomy and Sigmoidectomy . . . . . . . . . . . . . . 369 Karl A. Zucker 42 Laparoscopic-Assisted Anterior Resection . . . . . . . . . . . . . . . . . . . . . . . . 380 Brian J. Mehigan, John E. Hartley, and J.R.T. Monson 43 Laparoscopic Abdominoperineal Resection . . . . . . . . . . . . . . . . . . . . . . . . 385 Ara Darzi and Jared Torkington 44 Laparoscopic Stoma Creation and Reversal . . . . . . . . . . . . . . . . . . . . . . . 389 Lucia Oliveira 45 Polyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Yoshihisa Saida 46 Colonic Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401 Emina Huang and R. Larry Whelan 47 Laparoscopic Total and Subtotal Colectomy . . . . . . . . . . . . . . . . . . . . . . . 410 Mara R. Salum and Eric G. Weiss 48 Ileocolic Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 Bruce Belin and Steven D. Wexner 49 Restorative Proctocolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420 Jonathan E. Efron and Juan J. Nogueras 50 Surgery for Rectal Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425 Yik-Hong Ho and Francis Seow-Choen 51 Laparoscopic Management of Bowel Obstruction . . . . . . . . . . . . . . . . . . . 429 Alon J. Pikarsky and Petachia Reissman 52 The Role of Transanal Endoscopic Microsurgery and Intraoperative Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 Luca A. Vricella and Bruce A. Orkin 53 Laparoscopic Ultrasound in Minimally Invasive Procedures in the Abdomen and Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446 Anthony J. Senagore and Peter W. Marcello 54 Avoiding Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 Marc E. Sher and T. Cristina Sardinha 55 Cost Consideratons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456 Johann Pfeifer and Selman Urans

12. 56 Avoidance and Treatment of Urological Complications . . . . . . . . . . . . . . 461 Roland N. Chen 57 Avoidance and Treatment of Vascular Complications . . . . . . . . . . . . . . . . 464 Mark K. Grove and Mark E. Sesto SECTION VII DIAGNOSTIC LAPAROSCOPY AND ACUTE ABDOMEN Section Editor: Steve Eubanks 58 Principles of Diagnostic Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471 Ross L. McMahon 59 Bedside Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481 Leena Khaitan 60 Diagnostic Laparoscopy for Pelvic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 Linda Fetko 61 Diagnostic Laparoscopy for Suspected Appendicitis . . . . . . . . . . . . . . . . . 497 Aurora D. Pryor 62 Diagnostic Laparoscopy for Intestinal Disorders . . . . . . . . . . . . . . . . . . . . 507 James J. Gangemi and Edward G. Chekan 63 Diagnostic Laparoscopy for Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . 513 Rebekah R. White and Douglas S. Tyler Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523 Contents xi

14. Contributors Peter I. Anderson, MD Department of Emergency Medicine,Wilford Hall Medical Center,LacklandAir Force Base, TX 78236, USA. Maurice E. Arregui, MD St. Vincents Hospital and Health Center, Indianapolis, IN 46260, USA. Bruce Belin, MD St. Joseph Ofce Park, Lexington, KY 40504, USA. George Berci, MD Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. Sigurdur Blondal, MD Department of Surgery, Landspitali-University Hospital, IS-101 Reykjavik, Iceland. Luigi Bonavina, MD Division of General Surgery, University of Milan, Istituto Policlinico San Donato, Milan, Italy. L. Michael Brunt, MD Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA. Jo Buyske, MD Department of Surgery, Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA 19104, USA. Margherita O. Cadeddu, MD Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, L8L 5G4, Canada. W. Keat Cheah, MBBS Department of Surgery, The National University Hospital, Singapore 119074. Edward G. Chekan, MD University of Virginia, Sewickley Valley Hospital, Sewickley, PA 15143. USA. Roland N. Chen, MD Carson City, NV 89703, USA. xiii

15. xiv Contributors Jonathan A. Cohen, MD Nashville Surgical Associates, St. Thomas Medical Center, Nashville, TN 37205, USA. Monty H. Cox, MD Department of General Surgery, Medical University of South Carolina, Charleston, SC 29425, USA. John R. Craig, MD Department of Surgery, Deaconess Hospital, Billings MT, 59107, USA David L. Crawford, MD Department of Surgery, University of Illinois at Chicago, College of Medicine at Peoria, Peoria, IL 61603, USA. Ara Darzi, MD Department of Surgical Oncology and Technology, Imperial College School of Medi- cine, St. Marys Hospital, Pattington, London W2 1NY, UK. Jose Antonio Diaz-Elizondo, MD Department of General Surgery, Instituto Tecnolgico y de Estudios Superiores de Monterrey, Department Hospital San JosTec de Monterrey, Monterrey, Mxico, C.P. 64718. Urs Diener, MD Department of Gastrointestinal Surgery, University of California, San Francisco, San Francisco, CA 94143, USA. Karen Draper-Stepanovich, MD Department of Surgery, Lexington Clinical, Vanderbilt University Medical Center, Lexington, KY 40504, USA. Jonathan E. Efron, MD Department of Colorectal Surgery, Cleveland Clinic Florida, Naples, FL 34119, USA. Steve Eubanks, MD Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA. Edward L. Felix, MD Department of Surgery, University of California, San Francisco, Fresno, CA 93710, USA. Linda Fetko, MD Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27704, USA. Charles J. Filipi, MD Department of Surgery, Creighton University School of Medicine, Omaha, NE 68131, USA. Aaron S. Fink, MD Department of Surgery, Emory University School of Medicine, Atlanta Veterans Administration Medical Center, Decatur, GA 30033, USA. Robert J. Fitzgibbons, MD Department of Surgery, Division of General Surgery, Creighton University School of Medicine,Omaha,NE 68131,USA.

16. Morris E. Franklin, Jr., MD Department of Surgery, University of Texas at San Antonio, San Antonio, TX 78222, USA. James J. Gangemi, MD Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA. Luca Giordano, MD Department of Minimally Invasive Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. Peter M.Y. Goh, MD Universitt zu Kln, II Lehrstuhl fr Chirurgie, Klinikum ChirurgieKln-Merheim, Germany. Mark K. Grove, MD Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA. Jeffrey A. Hagen, MD Department of Surgery, Division of Thoracic and Foregut Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA 90033-4612, USA. Matthew F. Hansman, MD Department of General Surgery, Virginia Mason Medical Center, Seattle, WA 98101, USA. Kristn H. Haraldsdttir, MD Department of Surgery, Lunds University Hospital, Lund, Sweden. John E. Hartley, MD Department of Surgery, University of Hull,Academic Surgical Unit, Castle Hill Hospi- tal,Cottingham,EastYorkshire,HU16 5JQ,UK. Michael D. Hellinger, MD Sylvester Comprehensive Cancer Center, Division of Colorectal Surgery, University of Miami, Miami, FL 33136, USA. Daniel M. Herron, MD Department of Surgery, Division of Laparoscopic Surgery, Mount Sinai School of Med- icine, New York, NY 10029, USA. Yik-Hong Ho, MBBS Department of Surgery, James Cook University / The Townsville Hospital, Mater Mis- ericordiae,Wesley Park Haven and Cairns Base Hospitals, Queensland 4810,Australia. George W. Holcomb III, MD Department of Surgery, Childrens Mercy Hospital, Kansas City, MO 64108, USA. Michael D. Holzman, MD, MPH Department of Surgery, Vanderbilt University School of Medicine, St. Thomas Hospi- tal, Nashville, TN 37232, USA. Emina Huang, MD Department of Surgery, Columbia Presbyterian Hospital, New York, NY 10032, USA. Contributors xv

17. xvi Contributors Haruhiro Inoue, MD First Department of Surgery, Tokyo Medical and Dental University, Tokyo, Japan. Namir Katkhouda, MD Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA. Leena Khaitan, MD Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA. Sergio W. Larach, MD Department of Surgery, University of Florida College of Medicine, Orlando, FL 32806, USA. Demetrius Litwin, MD Department of Surgery, University of Massachusetts School of Medicine, Worcester, MA 01655, USA. Anthony Macaluso, Jr., MD Texas Colon and Rectal Surgeons, Medical City Hospital, Dallas, TX 75230, USA. Bruce V. MacFadyen, Jr., MD Department of Surgery, Medical College of Georgia, Augusta, GA 30912, USA. Joseph Mamazza, MD Department of Surgery, University of Toronto, St. Michaels Hospital,Toronto, Ontario M5B 1W8, Canada. Sharan Manhas, MD Department of Surgery, University of Southern California Keck School of Medicine, LosAngeles,CA 90033,USA. Peter W. Marcello, MD Department of Surgery,Tufts University School of Medicine, Lahey Clinic, Burlington, MA 01805-0001,USA. David W. McFadden, MD Department of Surgery,West Virginia University, Morgantown,WV 26506-9238, USA. Ross L. McMahon, MD Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA. Brian J. Mehigan, MB Department of Academic Surgery, Trinity College, Dublin 24, Ireland. Juliane A. Miranda-Rassi, MD Department of Gastroenterology, Division of Endoscopy, School of Medicine Universidade Federal de Gois.; Department of Anorectal Physiology, CDI, Goinia, Goinia GO, 74140-020, Brazil. J.R.T. Monson, MD Department of Surgery, University of Hull, Academic Surgical Unit, Castle Hill Hos- pital, Cottingham, East Yorkshire, HU16 5JQ, UK.

18. Surendra Narne, MD Division of ENT Endoscopic Surgery, Azienda Ospedaliera, Padova, 35100 Padova, Italy. Juan J. Nogueras, MD Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA. Lloyd M. Nyhus, MD Department of Surgery,The Living Institute for Surgical Studies, College of Medicine, University of Illinois, Chicago, IL 60612-7322, USA. Margret Oddsdottir, MD Department of Surgery, Landspitali-University Hospital, IS-101 Reykjavik, Iceland. Lucia Oliveira, MD Department of Anorectal Physiology, Policlnica Geral do Rio de Janeiro, Titular Member Brazilian Society of Coloproctology, Titular Member Brazilian College of Surgeons, Lagoa, Rio de Janeiro, 22470-200, Brazil. Douglas O. Olsen, MD Centennial Medical Center, Nashville, TN 37203, USA. Bruce A. Orkin, MD Department of Surgery, George Washington University Medical Center, Washington, DC 20037,USA. Marco G. Patti, MD Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, USA. Carlos A. Pellegrini, MD Department of Surgery, University of Washington School of Medicine, Seattle, WA 98195, USA. Alberto Peracchia, MD Department of Surgical Sciences, University of Milano, 20122 Milano, Italy. Jeffrey H. Peters, MD Department of Surgery, University of Southern California Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA. Johann Pfeifer, MD Department of Surgery, Karl-Franzens University School of Medicine, A-8010 Graz, Austria. Edward H. Phillips, MD Department of Surgery, Center for Minimally Invasive Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. Alon J. Pikarsky, MD Department of General Surgery, Hadassah Medical Center, Hadassah University Hos- pital, Jerusalem 91120, Israel. Eric C. Poulin, MD Department of Surgery, University of Toronto, St. Michaels Hospital,Toronto, Ontario M5B 1W8, Canada. Contributors xvii

19. xviii Contributors Aurora D. Pryor, MD Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA. Thomas H. Quinn, PhD Department of Biomedical Sciences, Creighton University School of Medicine, Omaha, NE 68178-0405, USA. Petachia Reissman, MD Department of Surgery, Shaare-Zedek University Medical Center, Jerusalem 91031, Israel. William O. Richards, MD Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN 37232, USA. Yoshihisa Saida, MD The Third Department of Surgery, School of Medicine, Toho University, Tokyo 153-8515, Japan. Mara R. Salum, MD Anorectal Physiology Lab, Hospital Srio-Libans; Universidade Federal de So Paulo, Escola Paulista de Medicina; Hospital Srio-Libans, So Paulo 01433-010, Brazil. Laurence R. Sands, MD Department of Surgery, University of Miami School of Medicine, Miami, FL 33136, USA. T. Cristina Sardinha, MD Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, NY 11042, USA. Christopher M. Schlachta, MD Department of Surgery, University of Toronto, St. Michaels Hospital,Toronto, Ontario M5B 1W8, Canada. Mary E. Schultheis, MD Department of Surgery, St. Agnes Hospital, Baltimore, MD 21229, USA. Anthony J. Senagore, MD, MS Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA. Francis Seow-Choen, MBBS Department of Colorectal Surgery, Singapore General Hospital, Nanyang Technolog- ical University, 169608, Singapore. Pieter A. Seshadri, MD Department of Surgery, University of Saskatchewan, Saskatoon, SK S7N 4R5, Canada. Mark E. Sesto, MD Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA.

20. Kenneth W. Sharp, MD Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN 37232, USA. Marc E. Sher, MD Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, NY 11042, USA. Jay J. Singh, MD Piedmont Colorectal Associates, Atlanta, GA 30309, USA. Nathaniel J. Soper, MD Department of Surgery, Section of Hepatobiliary, Pancreatic, and Gastrointestinal Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA. Jonathan D. Spitz, MD Department of Surgery, DuPage Medical Group, Glen Ellyn, IL 60137, USA. Hubert J. Stein, MD, PhD Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universitt Mnchen, D-81677 Munich, Germany. Lee L. Swanstrm, MD Department of Surgery, Oregon Health & Sciences University, Department of Mini- mally Invasive Surgery, Legacy Health System, Portland, OR 97227, USA. Joerg Theisen, MD Department of Surgery, Klinikum rechts der Isar, Munich, Germany. Jared Torkington, MB, MS Department of Colorectal Surgery, Cardiff and Vale NHS Trust, Cardiff, UK. Shirin Towgh, MD Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA. Frederick K. Toy, MD Northeastern Surgical Consultants, P.C., Honesdale, PA 18431, USA. L. William Traverso, MD Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA 98101, USA. Thadeus L. Trus, MD Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA. Douglas S. Tyler, MD Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA. Selman Urans, MD Department of General Surgery, Karl-Franzens University School of Medicine,A-8010 Graz, Austria. Contributors xix

21. xx Contributors Guy R. Voeller, MD Department of Surgery, University of Tennessee, Memphis, TN 38120, USA. Luca A. Vricella, MD Department of Surgery, George Washington University Medical Center, Washington, DC 20037, USA. Eric G. Weiss, MD Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA. Carl Westcott, MD Department of General Surgery,Wake Forest University School of Medicine,Winston- Salem, NC 27157, USA. Steven D. Wexner, MD Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA. R. Larry Whelan, MD Division of Surgical Specialties, Columbia Presbyterian Hospital, New York, NY 10032, USA. Rebekah R. White, MD Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA. Eric D. Whitman, MD Suburban Surgical Associates, St. Louis, MO 63131, USA. Paul E. Wise, MD Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA. Renee S. Wolfe, MD Department of Surgery, St. Elizabeth Medical Center, Boston, MA 02135, USA. Steven M. Yood, MD, MPH Department of Surgery, Yale University School of Medicine, New Haven, CT 06511, USA. Karl A. Zucker, MD (deceased) Formerly University of Arizona School of Medicine, Phoenix, AZ 85004, USA.

22. Section I Minimally Invasive Surgery of the Esophagus and Stomach Jeffrey H. Peters, MD Section Editor

24. Part I Esophageal Procedures

26. stage lesion is extremely difcult because these charac- teristics are not visible. Actually, in IIb-type lesions, no changes can be seen even with meticulous observation using videoendoscopy. Fortunately, the iodine dye stain- ing method is a very useful diagnostic technique for the esophagus. Normal esophageal epithelium, which con- tains glycogen-rich granules, stains dark brown when sprayed with 2% potassium iodide solution. In contrast, a cancerous lesion, which has lost glycogen granules in the epithelial cell layer, is clearly distinguished as an unstained area with a clear margin to the iodine-stained normal mucosa. This test is highly specic and sensitive for squamous cell carcinoma.2 Endoscopic pinch biopsy is essential for histological conrmation of the disease. Indications for Mucosal Resection The inltration depth should be no more than m1 or m2, and supercial spread should be less than half the circumference of the lesion. According to data from the Japanese national survey for histological evaluation of surgically resected esophageal cancer specimens,3 only 4% of mucosal cancer cases that were limited to the mucosal layer had lymph node involvement. In contrast, 35% of cases of submucosally invading cancer had lymph node metastasis. Mucosal cancer without lymph node involvement is considered to be an appropriate candidate for mucosal resection intending to achieve permanent cure of the disease. Among mucosal cancers, we have seen two lymph node-positive cases; these were massively in- vaded mucosal lesions in which the cancer contacted the muscularis mucosae over a wide area and supercial spread of the lesion was more than half its circumference. We restrict the indication to lesions no deeper than m2 that have spread less than half their circumference. Even submucosal cancer, if it is lifted by submucosal saline injection, can be technically resected by this procedure. Submucosal cancer is then a candidate for 1 Endoscopic Mucosal Resection in the Esophagus Haruhiro Inoue Backgound and Historical Development Endoscopic mucosal resection (EMR) is at present the only endoscopic treatment that provides a complete specimen for histopathological analysis. In general, a patient with mucosal cancer with no risk of lymph node metastasis is the best candidate for this procedure. The author developed the EMRC procedure (EMR using a transparent plastic cap) in 1992. Utilizing this technique, any part of the esophageal mucosa from the pharynx to the gastroesophageal junction, excluding the postlaryngeal mucosa, can be easily accessed and safely resected. This chapter describes the indications and technical details of the procedure, our clinical results, and the prevention of complications. In clinical practice, most esophageal cancers are dete- cted in an advanced stage with complaints of tumor- related symptoms such as chronic pain, gastrointestinal obstruction, and bleeding. The prognosis for advanced esophageal cancer is still poor, even when major surgery with wide-area lymph node dissection is carried out in combination with multidisciplinary treatments. To improve the prognosis for esophageal cancer, we must be able to detect the cancer as an early-stage, mucosal lesion before lymph node metastasis.1 Preoperature Investigations Detection of Early-Stage Esophageal Cancer (Squamous Cell Carcinoma) When observed by endoscopy, normal esophageal mucosa usually appears as a smooth, at, and whitish lustrous surface. Early-stage esophageal cancer is char- acterized by changes of color and lusterless and rough surfaces with marginal stepup or stepdown in mucosal architecture. However, detection of a minute or early- 5

27. 6 H. Inoue mucosal resection if the patient has refused surgery or is a poor surgical risk. Treatment of Barretts Esophagus EMR appears promising in the treatment of Barretts mucosa. So far, few studies that discuss it directly have appeared in the literature. The rst application of EMR for adenocarcinoma on short-segment Barretts esophagus was reported in 1990 by the author.4 Histopatholog- ical analysis of the endoscopically resected specimen showed that esophageal glands in the submucosa were totally resected. Therefore, this procedure is theoretically appropriate for eradication of Barretts esophagus. In our experience of EMR for squamous cell carcinoma, however, totally circumferential mucosal resection often causes severe stenosis. Therefore, the division of the EMR session into a few sessions seems to be preferable. In the future, the author considers that major part resection of Barretts mucosa by EMR will be preferred to obtain a histological specimen to analyze for cancer dif- ferentiation, inltration depth, and vessel involvement. For residual parts, repeated EMR or other ablative therapy should be applied to completely eradicate Barretts mucosa. Endoscopic Mucosal Resection for Early-Stage Cancer in the Esophagus Various local treatments such as laser ablation, argon plasma coagulator, and irradiation have been applied to treat mucosal cancer, but EMR is the only procedure that provides a complete resected specimen for histopathological analysis. We originally developed the EMRC procedure as a technique of mucosal resection. We believe it to be the simplest and safest technique to perform mucosectomy in any part of the gastrointestinal tract. Principles The gastrointestinal (GI) tract consists of two layers: the mucosal layer and the muscle layer. Embryologically, the mucosa is derived from the endodermal cell layer and the muscle layer from the middle germ layer of vivipar- ity. The mucosal and the muscle layers are attached each other by loose connective tissue in the submucosa and can be separated by external force. For this reason, we can safely resect just mucosa from inside the cavity, leaving the muscle layer intact. However, the gastrointestinal wall is less than 4mm thick, so that special care to avoid perforation is extremely important during the procedure. Injection of saline solution into the submucosal layer is a simple and effective technique to avoid muscle involvement. Lifting of the mucosa is always exhibited during submucosal saline injection in any part of the GI tract, without excep- tion. After injection of a sufcient volume of saline, the mucosa, including the target lesion, can be safely captured in the cap, strangulated by a snare wire, and resected by electrocauterization. History In 1955, in the era of the rigid scope, Rosenberg5 reported the importance of submucosal saline injection during polypectomy of rectal and sigmoidal polyps. Mucosal resection for supercial cancer using the berscope was rst performed for early gastric cancer around 1983 in Japan. The original strip-off biopsy technique advo- cated by Tada et al.6 was injection and snaring (Table 1.1). Submucosal saline injection was used to create a bleb; then, this bleb was cut by snare strangulation. This procedure had already been reported by Dehle et al. in 19737 as a technique for sessile colonic polyp resection. Another EMR technique recommended by Takekoshi et al.8 was grasping and snaring (see Table 1.1), that is, retracting the mucosa by a grasper and then strangulat- ing it by snare wire. Martin et al. in 19769 had also reported this technique. Now, these two procedures are combined and integrated as strip biopsy, that is, submucosal saline injection to create a bleb, mucosal retraction by grasper, and capture of the mucosal lesion by a snare loop. Hirao et al.10 reported an injection, precutting, and snaring technique, which means that after submucosal injection the target mucosa was cut by an electrocautery needle knife and the isolated mucosa was then captured by snare wire (see Table 1.1). Table 1.1. Classication of endoscopic mucosal resection (EMR) techniques. Without-suction techniques 1. Strip-off biopsy (injection and snaring)6,7 2. Lift and cut biopsy double-snare polypectomy (grasping and snaring)8,9 3. ERHSE (injection, precutting, and snaring)10 4. EMRT (grasping and snaring using overtube)4a With-suction techniques 1. EEMR tube method (injection and snaring using overtube)13a 2. np-EEM (injection and snaring using overtube)14a 3. EMRC (injection and snaring using cap)1518 4. EMRL (EVL and snaring)20,21 5. Simple-suction technique (snaring using stiff snare)22a ERHSE, endoscopic resection with hypertonic saline-epinephrine solution; EMRT, EMR using a transparent overtube; EEMR, endoscopic esophageal mucosal resection; np-EEM, endoscopic esophageal mucosectomy under negative-pressure control; EMRC, endoscopic mucosal resection using a transparent plastic cap; EMRL, endoscopic mucosal resection using a ligating device. a These techniques are only available for the esophagus.

28. Momma et al. and Makuuchi et al. reported the rst application of EMR in the esophagus utilizing the strip- biopsy technique in 1989 (injection, lift, and snaring).11,12 At the same time, the author reported the EMRT procedure, which uses a lift and cut method utilizing a specially designed EMRT tube4 (Table 1.1). In the same paper,4 the rst application of EMR for adenocarcinoma on a short segment of Barretts esophagus was reported. Makuuchi developed the endoscopic esophageal mucosal resection (EEMR) tube method13 (Table 1.1). By this method, a larger specimen can be obtained than by other techniques. A modied Makuuchi tube is utilized in Kawanos technique.14 This modied tube has a lateral window for mucosal trapping. We rened our EMRT pro- cedure4 to an EMR cap (EMRC) procedure1518 (see Table 1.1). EMRC made the surgical technique simpler and easier and made it possible to apply the procedure to any part of the GI tract from pharynx to anus, pre- cluding the postlaryngeal mucosa and the small intestine. The principle of the EMRC procedure is based upon the endoscopic variceal ligating (EVL) technique developed by Stiegmann.19 EMR utilizing a variceal ligating device (EMRL) is a technically simple and safe procedure (see Table 1.1). Masuda et al. in Japan, Chaves et al.,20 and Freischer et al.21 reported experience utilizing the EVL device. This method is basically similar to the EMRC procedure but divides it into two steps. This method is appropriate to resect a relatively small lesion, less than 10mm, because the size of the specimen is limited by the small capacity of the ligation cap. Soehendra et al. introduced the extremely simple suction technique of mucosectomy.22 In their method, no accessory device is necessary to perform the procedure except a specially designed snare, which is made of monolament stainless steel wire with a diameter of 0.4mm. A large-channel endoscope (Olympus GIF-1T) is utilized in combination with the special snare because that endoscope provides adequate suction alongside an inserted snare. The size of the resected specimen seems to be smaller than that with other techniques, but the simplicity of this procedure is potentially interesting. EMRC Surgical Technique In preparation for the EMRC procedure, a cap made from transparent plastic is attached to the tip of the forward-view endoscope and is xed tightly with adhe- sive tape. A cap is commercially available from Olympus as the Distal attachment and is approved by the FDA in the United States. For the initial session of EMR in the esophagus and stomach, an oblique-cut large-capacity cap with rim (MAJ297; Olympus, Tokyo, Japan) is xed on the tip of the standard-size endoscope (Q240, Q140; Olympus) to obtain a larger sample. For trimming a residual lesion, a straight-cut medium-size cap with rim (MH595; Olympus) is appropriate. Supercial extension of mucosal cancer is often difcult to recognize accurately in routine endoscopic observation but is clearly delineated by chromoendoscopy. For squamous cell carcinoma of the esophagus, iodine (2% iodine potassium solution) is the most promising dye, showing the lesion clearly as an unstained area. Spraying indigocarmine solution emphasizes surface relief in the stomach. The tip of the snare wire carefully marks the mucosal surface that surrounds the margin of the lesion. Markings are positioned 2mm from the actual lesion margin. Visual enhancement during chromoendoscopy disappears within a couple of minutes, and therefore the markings by electrocoagulation become essential, especially to the at lesion. Epinephrine saline solution diluted 500,000 times (0.1% epinephrine solution 0.2ml plus normal saline 100ml) is injected into the submucosa with an injection needle (23 gauge, 4mm tip length). Controlling the position of a needle tip in the submucosal layer is not technically difcult. The most important key to avoiding transmural penetration of the needle is to puncture the mucosa at a sharp angle. The total volume of injected saline depends on the size of the lesion, but it is necessary to inject enough saline to lift up the whole lesion. Usually more than 20ml is injected. In principle, normal mucosa distal to the lesion is punctured rst (Fig. 1.1). When saline is accurately injected into the submucosal layer in any part of the gastrointestinal tract, lifting of the mucosa or bulging of the mucosal surface is always observed. The injected area is also recognizable as a whitish swelling. With the injection of a sufcient volume of submucosal saline, any type of EMR procedure can be performed quite safely. 1. Endoscopic Mucosal Resection in the Esophagus 7 Figure 1.1. Submucosal saline injection. Puncture the distal part of the lesion rst. Puncturing the mucosa at a sharp angle avoids transmural penetration.

29. 8 H. Inoue A specially designed small-diameter snare SD-7P (1.8 mm outer diameter; Olympus) is essential to the prelooping process. The snare wire is xed along the rim of the EMRC cap. To start the prelooping process, moderate suction is applied to the normal mucosa to seal the outlet of the cap (Fig. 1.2A), and then the snare wire that passes through the instrumental channel of the endoscope is opened (Fig. 1.2B). The opened snare wire is xed along the rim of the cap, and the outer sheath of the snare extends up to the rim of the cap (Fig. 1.2B). This step completes the prelooping process of the snare wire. When the endoscope approaches, the target mucosa, including the lesion, is fully sucked inside the cap (Fig. 1.3) and is strangulated by simple closing of the prelooped snare wire. At this moment, the strangulated mucosa looks like a snared polypoid lesion. The pseudopolyp of the strangulated mucosa is cut by blend current electrocautery. The resected specimen can be easily taken out by keeping it inside the cap without using any grasping forceps. The smooth surface of the muscle layer is observed at the bottom of the articial ulcer. In this case, a large vessel was observed at the center of the articial ulcer; a hemostatic clip was applied to it to prevent bleeding.23 Bleeding is usually nonexistent or minor and stops spontaneously with compression of the lateral wall of the transparent cap. To conrm complete resection of the lesion, iodine dye spraying is useful. If additional resection is necessary to completely remove residual lesion, all procedures, including saline injection, should be repeated step by step. Injected saline usually inltrates and disappears from the injection site within around 5min, ending its role as a cushion between the mucosa and the muscle layer. Repeated saline injection, therefore, becomes necessary to reduce the risk of muscle involvement during the procedure. Our only experience of perforation of the esophagus hap- Seal outlet of EMRC cap Normal mucosa A. B. Open snare wire to rim Figure 1.2. The endoscopic mucosal resection cap (EMRC) prelooping process. A. Suction the normal mucosa and seal the outlet of the EMRC cap. B. Open the snare wire; it then goes along the rim of the cap. The prelooping condition is created. The outer sheath of the snare wire is pushed up to the distal end of the cap, and the snare wire is xed along the rim of the EMRC cap. A. B. Prelooped snare wire Figure 1.3. The EMRC procedure. A. After creating the prelooping condition, target mucosa is drawn inside the cap. B. The strangulated mucosa.

30. pened during the second strangulation,with no additional saline injection. Histopathological Assessment The resected specimen should be stretched and xed on a rubber plate using ne needles and then bathed in 10% formalin solution. The xated specimen is divided into 2-mm columns. Histopathological analysis of semiserial sections makes it possible to reconstruct the supercial extension of the cancer. Postoperative Care Three days after EMR, the articial ulcer is covered by a white coating. Twelve days after EMR, the articial ulcer is almost recovered with thin but normal squamous epithelium. Almost all patients complain of mild post- sternal pain and mild throat pain, which will disappear within a couple of days using medication. Just after EMR, a mucosal protective agent (for example, Marlox) is prescribed four times a day. Anti- biotics are also administered intravenously for the rst 2 days, followed by 7 days of oral antibiotics. In our experience, one patient who received near-total circumferential resection in the esophagus, with only 2 days of antibiotics followed by no medication, suffered a severe stricture. That stricture was considered to have been caused by chronic, persistent inammation. A few hours after treatment, the patient can start to drink cold water. On the following day, the patient receives a soft meal. On the second day after treatment, the patient receives a normal diet. In almost all cases of mucosal resection, quality of life can be maintained,24 so we believe that early detection of cancerous lesions and treatment by endoscopic mucosal resection is an ideal means of cancer treatment. Results In our institute, more than 180 cases of early-stage esophageal cancer underwent mucosal resection, mainly by two techniques.25 Of these cases, 72% were absolute indications for mucosal resection according to our criteria. The other cases were only relatively indicated because of poor risk for surgery or refusal of surgery. In absolutely indicated cases, no local or no distant metastasis occurred during the follow-up period. The 5-year survival rate was 95%, including other causes of death. All patients who died during the 5-year follow-up period suffered from other fatal diseases such as myocardial infarction, liver cirrhosis, and stroke. As a major complication in the esophagus, one patient in our early series suffered perforation during the second cauterization. That patient recovered by conser- vative treatments such as intravenous hyperalimentation and antibiotic administration, resulting in no concomitant problems. Eight years later, she is healthy with no surgery-related complaints. Another patient who received near-total circumferential mucosal resection developed persistent stenosis that could not be controlled by repeated forceful balloon dilatation. He was nally treated by surgical esophagectomy. Five years after esophagectomy, he is in good health. In this case, antibiotics were administered for only 2 days, which may have allowed chronic inammation to develop, resulting in stenosis. Complications Mechanism of Perforation When the EMR procedure is performed without saline injection, the muscle layer beneath the surface mucosa is also drawn inside the cap, together with the covering mucosa, which risks muscle involvement at the moment of closure of the snare loop. A small-volume saline injection is not sufcient to avoid muscle involvement because this creates only a small bleb (Fig. 1.4A). Full suction for a small bleb causes muscle entrapment in the cap, resulting in muscle strangulation with the mucosa (Fig. 1.4B,C). An extra-large-volume saline injection creates a large bleb (Fig. 1.4D). This large cushion mechanically pre- vents muscle involvement during snare strangulation (Fig. 1.4D,E). In the other words, snaring of the mucosa should never be done at the base of the lifted mucosa (Fig. 1.4B) but rather should always be done at the middle part of the lifted mucosa (Fig. 1.4E,F). To prevent perforation, a large-volume saline injection is important. In the esophagus, about 20ml saline causes more than half-circumferential mucosal dissection, keeping the mucosal surface about 1cm apart from the muscle layer. When saline is accurately injected into the submucosa in any part of the gastrointestinal tract, lifting or bulging of mucosa can be always observed. The with suction techniques listed in Table 1.1 have a potentially greater risk of muscle involvement than the without suction techniques, and therefore injecting a larger volume of saline into the submucosa is highly recommended. The author usually injects at least 10ml for each snaring. Large-volume saline injection is in itself a safe procedure. In our experience of removal of a creep- ing tumor in the rectum, a total of about 100ml saline was injected, and the whole lesion was safely removed with inducing a half-circumferential ulceration. In this case, posttherapeutic treatment was uneventful, and therefore 1. Endoscopic Mucosal Resection in the Esophagus 9

31. 10 H. Inoue large-volume saline injection is considered a safe procedure in itself. Control of Bleeding from the Ulcer Bed Low-concentration epinephrine saline solution (epinephrine saline solution diluted 500,000 fold) is denitely effective to control bleeding during EMR. In the esophagus, submucosal injection of this solution results in almost complete hemostasis, but in the stomach bleeding from an articial ulcer sometimes cannot be controlled by the solution.At present,the hemostatic clip is the most reliable therapeutic modality to control spurting bleeding from the ulcer bed.23 Consequently, bleeding from the ulcer bed can be relatively easily controlled. Conclusion Mucosal cancer in the esophagus generally has no risk of lymphnodemetastasis.ItiscuredbyEMR,whichprovides a resected specimen for histopathological analysis. References 1. Lambert R. Endoscopic detection and treatment of early esophageal cancer: a critical analysis. Endoscopy 1995;27: 1218. 2. Endo M,Takeshita K,Yoshida M. How can we diagnose the early stage of esophageal cancer? Endoscopic diagnosis. Endoscopy 1986;18:1118. 3. Endo M, Kawano T. Analysis of 1125 cases of early esophageal carcinoma in Japan. Dis Esoph 1991;4:7176. 4. Inoue H, Endo M. Endoscopic esophageal mucosal resection using a transparent tube. Surg Endosc 1990;4:198 201. 5. Rosenberg N. Submucosal saline wheal as safety factor in fulguration of rectal and sigmoidal polypi. Arch Surg 1955; 70:120122. 6. Tada M, Murakamai A, Karita M, et al. Endoscopic resection of early gastric cancer. Endoscopy 1993;25:445450. 7. Dehle P, Largiader F, Jenny S, et al. A method for endoscopic electroresection of sessile colonic polyps. Endoscopy 1973;5:3840. 8. Takekoshi T, Baba Y, Ota H, et al. Endoscopic resection of early gastric carcinomas: results of a retrospective analysis of 308 cases. Endoscopy 1994;26:352358. A. D. B. E. C. F. Insufficient Sufficient Figure 1.4. Submucosal saline injection. A. Small-volume injection of saline creates a small bleb. B. During suction of the target mucosa, the muscle layer is also sucked into the cap. C. Muscle layer entrapment at closure of the snare wire. D. Large-volume saline injection creates a large bleb. E. Even during full suction, only the top of the bleb is captured inside the cap. F. The mucosa is strangulated at the middle part of the bleb. This step makes the procedure safe.

32. 9. Martin TR, Onstad GR, Silvis SE, et al. Life and cut biopsy technique for submucosal samplings. Gastrointest Endosc 1976;23:2930. 10. Hirao M, Masuda K, Asanuma T, et al. Endoscopic resection of early gastric cancer and other tumors with local injection of hypertonic saline-epinephrine. Gastrointest Endosc 1988;34:264269. 11. Monma K, Sakaki N,Yoshida M. Endoscopic mucosectomy for precise evaluation and treatment of esophageal intra- epithelial cancer (in Japanese). Endosc Dig 1990;2:501 506. 12. Makuuchi H, Machimura T, Sugihara T, et al. Endoscopic diagnosis and treatment of mucosal cancer of the esophagus (in Japanese). Endosc Dig 1990;2:447452. 13. Makuuchi H. Endoscopic mucosal resection for early esophageal cancer. Dig Endosc 1996;8:175179. 14. Kawano T, Miyake S, Yasuno M, et al. A new technique for endoscopic esophageal mucosectomy using a transparent overtube with intraluminal negative pressure (np-EEM). Dig Endosc 1991;3:159167. 15. Inoue H, Takeshita K, Hori H, et al. Endoscopic mucosal resection with a cap-tted panendoscope for esophagus, stomach, and colon mucosal lesions. Gastrointest Endosc 1993:5862. 16. Inoue H, Noguchi O, Saito N, et al. Endoscopic mucosectomy for early cancer using a pre-looped plastic cap. Gastrointest Endosc 1994;40:263264. 17. Tada M, Inoue H, Endo M. Colonic mucosal resection using a transparent cap-tted endoscope. Gastrointest Endosc 1996;44:6365. 18. Izumi Y, Teramoto K, Ohshima M, et al. Endoscopic resection of duodenal ampulla with a transparent plastic cap. Surgery (St. Louis) 1998;123:109110. 19. Stiegmann GV. Endoscopic ligation: now and the future. Gastrointest Endosc 1993;39:203205. 20. Chaves DM, Sakai P, Mester M, et al. A new endoscopic technique for the resection of at polypoid lesions. Gas- trointest Endosc 1994;40:224226. 21. Freischer DE, Dawsey S, Tio TL, et al. Tissue band ligation followed by snare resection (band and snare): a new technique for tissue acquisition in the esophagus. Gastrointest Endosc 1996;44:6872. 22. Soehendra N, Binmoeller KF, Bohnacker S, et al. Endo- scopic snare mucosectomy in the esophagus without any additional equipment: a simple technique for resection of at early cancer. Endoscopy 1997;29:380383. 23. Hachisu T, Yamada H, Satoh S, Kouzu T. Endoscopic clip- ping with a new rotatable clip device and a long clip. Dig Endosc 1996;8:172173. 24. Takeshita K, Tani M, Inoue H, et al. Endoscopic treatment of early oesophageal or gastric cancer. Gut 1997;40:123127. 25. Inoue H. Endoscopic mucosal resection for esophageal and gastric mucosal cancers. Can J Gastroenterol 1998;12:355 359. 1. Endoscopic Mucosal Resection in the Esophagus 11

33. Background and Historical Development of Endoscopic Treatment Toward the end of the nineteenth century, Zenker and von Ziemssen formulated the hypothesis that a pharyngoesophageal diverticulum is caused by increased hypopharyngeal pressure producing herniation through an area of structural weakness, that is, the junction of the inferior pharyngeal constrictor and the cricopharyngeus muscle, also known as Killians triangle. It is currently believed that inadequate opening of the upper esophageal sphincter, resulting from brosis of the cricopharyngeal muscle, considerably increases hypopharyngeal intrabolus pressure.1,2 For this reason, when surgical resection or suspension of the diverticulum is performed without a concomitant myotomy, the procedure may fail to relieve dysphagia and to prevent complications or recurrence of the pouch.3,4 Unlike the traditional surgical approach, which varies depending on the preference of the individual surgeon, the endoscopic approach is by principle centered on the upper esophageal sphincter. First proposed early in the twentieth century by Mosher, it consists of division of the septum interposed between the pouch and the cervical esophagus, thus allowing the creation of a common cavity with simultaneous section of the upper esophageal sphincter. This procedure has been performed in some institutions using electrocoagulation or laser; although the results appear satisfactory, complications such as bleeding, perforation, and the need for repeated treatment have been reported. Moreover, postoperative pain is quite common, especially after electrocoagulation.5,6 During the last decade, interest in the transoral treatment of Zenkers diverticulum has been renewed by the introduction of endostaplers.79 In fact, it has been shown that division of the septum can be safely and effectively performed through an endosurgical approach under general anesthesia. Indications for Endoscopic Therapy Treatment of Zenkers diverticulum is indicated to relieve symptoms such as dysphagia and pharyngo-oral regurgitation and to prevent the life-threatening complication of aspiration pneumonia. The tendency of the pouch to progressively enlarge and the possible, although rare, development of a squamous cell carcinoma represent additional arguments in favor of early treatment. Myotomy is regarded today as an essential component of the operation. It has been shown that myotomy and virtual elimination of the pouch may be achieved via an endosurgical approach. The principle of this video- assisted operation is to establish a common cavity between the hypopharyngeal pouch and the adjacent esophageal lumen by means of a linear endostapler. Division of the common wall by stapling is a one-stage operation, requires a few minutes, and appears simpler and safer than using electrocoagulation or laser. Compared to the conventional surgical operation, the advantages of endostapling include absence of skin inci- sion, shorter operative time, minimal or no postoperative pain, quicker resumption of oral feeding, and shorter hospital stay. An additional advantage of this approach is expected in patients who present with recurrent diverticulum after conventional operation or in those who have undergone surgery in the left side of the neck. In such circumstances,the conventional operation may pose a major technical challenge to the surgeon and may be associated with a high risk of leakage or recurrent nerve palsy. Diverticula smaller than 2cm represent a formal con- traindication to the endosurgical approach because the common wall is too short to accommodate one cartridge of staples and to allow complete division of the sphincter. The result would be an incomplete myotomy, causing persistent dysphagia. Although the postoperative outcome of these patients, who often are elderly and compromised, suggests greater comfort and a quicker recovery compared to the con- 2 Minimally Invasive Treatment of Zenkers Diverticulum Luigi Bonavina, Surendra Narne, and Alberto Peracchia 12

34. ventional operation, it should be taken into account that the endosurgical approach requires general anesthesia. Therefore,in patients with excessive operative risk,a conventional operation carried out under simple local anesthesia still remains the procedure of choice. Preoperative Assessment and Preparation A barium swallow study and upper gastrointestinal endoscopy are routinely performed before operation. The diverticulum is carefully entered with the endoscope, and the mucosa is examined to rule out carcinoma. The length of the diverticulum is measured from the upper esophageal sphincter to the bottom of the pouch. The remaining esophagus is examined for the presence of hiatal hernia or esophagitis. A thin guidewire inserted at the end of the endoscopic examination may assist in positioning the manometric catheter within the esophageal lumen if a motility study is planned. The patients are kept on a liquid diet the day before the operation. Intravenous antibiotics and intensive respiratory physiotherapy are recommended for a few days before surgery in patients admitted on an emergency basis for aspiration pneumonia. In some circumstances, especially in elderly individuals, preoperative nutritional support may be necessary. Short-term antibiotic prophy- laxis is given before induction of anesthesia. Surgical Technique The operation is performed under general anesthesia with nasotracheal intubation. The patient is placed supine on the operating table, with a small pillow below the upper back and the head hyperextended. The surgeon is sitting behind the patients head. A modied Weerda endoscope (Karl Storz,Tuttlingen, Germany) is introduced into the hypopharynx under direct vision and gently pushed behind the endotracheal tube. The two self-retracting valves, which can be approx- imated and angulated to t the patients hypopharyngeal anatomy, are then allowed to enter the diverticulum and the esophageal lumen, respectively (Fig. 2.1). After visualization of the septum interposed between the diverticulum and the esophagus, the diverticuloscope is xed and held in place by means of a chest support (Fig. 2.2). A 5-mm wide-angle 0 telescope is inserted through the diverticuloscope and connected to a cold-light source and to a video camera to obtain a magnied vision of the operative eld on a television screen. The depth of the diverticulum can be checked using a graduated rod. This maneuver also allows the surgeon to straighten the pouch and to elongate the common wall (Fig. 2.3). The diverticulum esophagostomy is performed using a disposable linear endostapler (EndoGIA 30, Tyco, or ETS 35, Ethicon Endo-surgery) with a shorter anvil, thus allowing tissue stapling and sectioning down to the bottom of the septum. The anvil is placed in the lumen of the diverticulum and the cartridge of staples into the lumen of the cervical esophagus (Fig. 2.4). The instrument jaws are placed across the septum along the midline before ring. With a single application of the endostapler, the posterior esophageal wall is sutured to the wall of the diverticulum, and the tissue is transected between three rows of staples on each side. Multiple stapler applications may be necessary according to the size of the diverticu- 2. Minimally Invasive Treatment of Zenkers Diverticulum 13 Figure 2.1. Weerda diverticuloscope. Figure 2.2. Position of the diverticuloscope. The lower valve is inserted into the Zenker diverticulum and the upper valve into the esophageal lumen.

35. 14 L. Bonavina et al. Postoperative Care A nasogastric tube is generally not required. A gastro- graphin swallow study is performed on the rst postoperative day. The patient is then allowed to drink and eat and is discharged from the hospital. A soft diet is recom- Diverticulum Sphincter Upper blade Scope Septum Lower blade Diverticulum Figure 2.3. Visualization of the septum. The telescope is inserted through the instrument. Ethicon 35mm cartridge A Endo-GIAB Figure 2.4. Endoscopic linear staplers. A. The Ethicon device has a shorter staple head and a 35- mm cartridge; this does not require any mechanical modication, making the instrument more suitable for the operation. B. The endo-GIA instrument required sawing off the anvil to avoid a residual spur. The shorter anvil allows tissue stapling and sectioning down to the bottom of the diverticulum. lum. Using the tip of the anvil, the bottom of the diverticulum can be pushed gently downward to lengthen the common wall and to minimize the size of the residual spur. Electrocoagulating endosurgical scissors may be used to complete the section at the distal end of the staple line (Fig. 2.5). After removal of the stapler, the two wound edges retract laterally because of the division of the cricopharyngeal muscle (Fig. 2.6). Finally, the suture line is checked for hemostasis, and the hypopharynx is irrigated with saline solution. Figure 2.5. Suture section of the septum interposed between esophagus and diverticulum. Figure 2.6. Frontal view of the stapled and divided septum. A common cavity has been created.

36. mended during the rst postoperative month. A barium swallow study is performed after 6 to 12 months. Results Conversion to open surgery was required in 3% of cases in a recent series8 ; the reason was a difcult exposure of the common wall in two cases and a mucosal tear in another. In these individuals, introduction of the endoscope and stapler manipulation were difcult due to limited mouth opening or reduced neck extension. No postoperative morbidity or mortality was recorded. In most patients, two applications of linear endostapler with a modied anvil were used. Before modication of the anvil of the endo-GIA stapler, ve patient complained of persistent postoperative symptoms; three patients underwent repeat endosurgical operation, one underwent laser treatment by means of exible endoscopy, and one even- tually required open surgery. Overall, this procedure has proven safe and effective. Radiologic, manometric, and scintigraphic studies over a follow-up period up to 5 years consistently show decreased outow resistance at the pharyngoesophageal junction. The short hospital stay, lack of morbidity, minimal patient discomfort, and complete symptom relief associated with this operation have prompted us to change the approach to Zenkers diverticulum in our institution during the past decade. References 1. Cook I, Dodds W, Dantas R. Opening mechanisms of the human upper esophageal sphincter. Am J Physiol 1989;257: G748G759. 2. Mason R, Bremner C, DeMeester T, et al. Pharyngeal swal- lowing disorders. Selection for and outcome after myotomy. Ann Surg 1998;228:598608. 3. Bonavina L, Khan N, DeMeester T. Pharyngoesophageal dysfunctions. Arch Surg 1985;120:541549. 4. Shaw D, Jamieson G, Gabb M, Simula M, Dent J. Inuence of surgery on deglutitive upper oesophageal sphincter mechanics in Zenkers diverticulum. Gut 1996;38:806811. 5. Dohlman G, Mattson O. The endoscopic operation for hypopharyngeal diverticula. Arch Otolaryngol 1960;71: 744752. 6. Van Overbeek J, Hoeksema P, Edens E. Microendoscopic surgery of the hypopharyngeal diverticulum using electrocoagulation of carbon dioxide laser. Ann Otol Rhinol Laryngol 1984;93:3436. 7. Collard J, Otte J, Kestens P. Endoscopic stapling technique of esophagodiverticulostomy for Zenkers diverticulum. Ann Thorac Surg 1993;56:573576. 8. Narne S, Bonavina L, Guido E, Peracchia A. Treatment of Zenkers diverticulum by endoscopic stapling. Endosurgery 1993;1:118120. 9. Peracchia A, Bonavina L, Narne S, Segalin A, Antoniazzi L, Marotta G. Minimally invasive surgery for Zenker diverticulum. Analysis of results in 95 consecutive patients. Arch Surg 1998;133:695700. 2. Minimally Invasive Treatment of Zenkers Diverticulum 15

37. Background and Historical Development Gastroesophageal reux disease (GERD) is arguably one of the most common disorders in Western civiliza- tion. For reasons that are not clear, it appears to be increasing in prevalence. Historically, the treatment of GERD has included dietary modication, weight loss, and intermittent antacid therapy. These measures were often ineffective, however, and surgical therapy has been applied to those who failed. In the early days of surgical antireux therapy, these were usually patients with refractory ulcers and severe brotic strictures. With the introduction of specic medical therapy with H2 receptor antagonists and, more recently, proton pump inhibitors, the number of patients with these acid-pepsin-related complications of reux disease has declined. In their place, patients with malignant complications of reux disease have emerged as a larger problem, with the recognition of the relationship between GERD and Barretts esophagus. Because cancer of the esophagus is frequently fatal, and because patients with Barretts esophagus are often relatively asymptomatic, formal investigation of patients with a history of signicant reux symptoms and institution of effective therapy has become important. Historically, two problems have prevented the wide- spread acceptance of antireux surgery. The rst was the observation that a fundoplication was frequently complicated by dysphagia and gas bloat, complications related to an overly competent lower esophageal high-pressure zone. Second was the perioperative morbidity and mortality associated with antireux surgery. Hospital stays were routinely a week or more, with up to 6 or 8 weeks of additional disability from work. The development of more potent acid suppression medications further restricted the application of antireux surgery, to the point where referral to surgery was limited to patients with complicated reux disease who proved refractory to medical therapy.1 Two major developments over the past several decades have dramatically changed both the outcome and acceptance of antireux surgery. The rst was the appreci- ation that a shorter, loose, fundoplication markedly reduced the postoperative sequelae associated with antireux surgery.25 With these modications in technique, most patients are able to belch normally and eat without long-term dysphagia, without sacricing efcacy in controlling reux of gastric contents into the esophagus. The second development that has revolutionized antireux surgery was the introduction of the laparoscopic Nissen fundoplication. Bernard Dallemagne rst recreated the procedure that Nissen had serendipitously discovered in 1936.6,7 Because of the diminished morbidity of these minimally invasive antireux procedures, the threshold for referral to surgery for patients with GERD rapidly decreased. As a result, the laparoscopic Nissen fundoplication has become one of the most commonly performed laparoscopic procedures in everyday surgical practice. The explosion of laparoscopic antireux surgery worldwide has stimulated a new interest in the study of surgical treatment of GERD. Through this experience, much has been learned, but signicant controversies remain. Nonetheless, in the setting of relatively early GERD, laparoscopic antireux procedures have been established as safe, highly effective, and long-lasting alternatives to lifelong medical therapy. Clinical Features GERD is a syndrome that includes a variety of clinical manifestations including symptoms and tissue injury patterns associated with abnormal esophageal exposure to gastric contents. The presenting symptoms can vary widely, but they can conveniently be grouped into three 3 Laparoscopic Complete and Partial Fundoplication Jeffrey A. Hagen and Jeffrey H. Peters 16

38. categories: typical symptoms, atypical symptoms, and complications. The indications for antireux surgery and the results to be expected vary in these three groups, and as such they warrant separate consideration. Heartburn and regurgitation are the most common typical symptoms of GERD. Heartburn is most often described as a substernal burning sensation that may radiate up into the throat. It may occur following meals, or with physical activity such as bending or stooping, and in some patients it occurs predominately at night. It has been estimated that 10% of the population experiences heartburn daily, with up to one-third experiencing heartburn at least once a month.8 Patients with heartburn also frequently complain of regurgitation, which is described as the appearance of acid or bitter uid, without warning, into the back of the throat. Regurgitation is particularly likely to occur after meals and when the patient lies down at night. The patient or their spouse may describe episodes of awakening from sleep coughing or choking. In addition to heartburn and regurgitation, the patient with typical symptoms of GERD may experience dysphagia. It is more common in patients with complicated reux disease and stricture formation, but dysphagia may occur in the absence of segmental narrowing, as a result of either a large hiatal hernia9 or the presence of reux-induced esophageal peristaltic dysfunction. When present, the symptom of dysphagia warrants particular attention to exclude the possibility of cancer. Atypical symptoms of reux disease include chest pain, hoarseness, and pulmonary symptoms such as asthma,chronic cough,and aspiration pneumonia. Rarely, patients may present with protracted hiccups, night sweats, and erosions of their dental enamel. It has been shown, in patients with angina-like chest pain who have a negative cardiac evaluation, that abnormal gastroesophageal reux will occur in up to 50%.10 Thus, GERD is the most common abnormality in these patients. Chronic hoarseness or reux laryngitis is associated with abnormal esophageal acid exposure in as many as 75% of patients studied by prolonged pH monitoring.11 Ambulatory monitoring of pH in the cervical esophagus may be particularly helpful in these patients. Respiratory symptoms occasionally associated with GERD include repeated episodes of aspiration pneumonia, chronic cough, and, more commonly, nonallergic asthma. Recent studies have shown that as many as 20% of patients with chronic cough have abnormal reux,12 with reux being documented in up to 80% of patients with chronic asthma.13 Complications of GERD include the development of esophageal ulcers or strictures, as well as the malignant complications of GERD, including the development of Barretts esophagus and esophageal adenocarcinoma. It has been estimated that approximately 10% of unse- lected patients with reux symptoms have evidence of Barretts esophagus on endoscopy,14 making endoscopic evaluation an important part of the evaluation of any patient presenting with chronic reux symptoms. Preoperative Investigations To document that gastroesophageal reux is responsible for symptoms, and to maximize the chances of success with antireux surgery, patients suspected of having GERD should be carefully investigated before consider- ing antireux surgery. It has been shown that success in antireux surgery is largely determined by two objectives: to achieve the long-term relief of reux symptoms, and to do so without the development of complications or complaints induced by the operation. In practice, achiev- ing these two deceptively simple goals is difcult. Both depend heavily upon establishing that the symptoms for which the operation is being performed are caused by excess esophageal exposure to gastric juice. In addition, it is critical that the appropriate antireux procedure be performed in the proper fashion. Success can be expected in most patients if these two criteria are met. To achieve these goals, the evaluation of patients suspected of having GERD who are being considered for antireux surgery has four important components: 1. Establishing that GERD is the underlying cause of the patients symptoms 2. Estimating the risk of progressive disease 3. Determining the presence or absence of esophageal shortening 4. Evaluating esophageal body function and, occasionally, gastric emptying function Objective Documentation of GERD In the past, patients referred for antireux surgery had more advanced disease, usually associated with severe esophagitis, and often with stricture formation. Estab- lishing reux as the cause was generally not difcult. However, as the threshold for surgical referral has decreased, increasing numbers of patients without endoscopic esophagitis or other objective evidence of the presence of reux are now considered for laparoscopic antireux surgery.15,16 In these patients, formal diagnostic testing is required to document the presence of abnormal esophageal exposure to gastric contents, the hallmark of GERD. The gold standard for diagnosing GERD is the use of ambulatory 24-h pH testing.17 Estimating the Risk of Progressive Disease Identication of patients likely to develop progressive reux disease in spite of medical therapy would allow us 3. Laparoscopic Complete and Partial Fundoplication 17

39. 18 J.A. Hagen and J.H. Peters to prevent complications of GERD such as strictures or Barretts esophagus by early application of antieux surgery. Although absolute predictors do not as yet exist, a combination of 24-h pH testing, detection of abnormal esophageal exposure to duodenal contents (Bilitec monitoring), and the use of esophageal motility studies have provided us with some useful guidance. Patients with very high degrees of acid exposure, particularly at night, are at particular risk for the development of complicated reux disease.18 Thus, careful review of both the pattern and severity of acid reux is important. Complications of reux disease have also been shown to correlate with the presence of abnormal esophageal exposure to bilirubin.19 As a result, before instituting long-term medical therapy in patients with GERD, consideration should be given to Bilitec monitoring. Finally, complicated reux disease has also been shown to be more common in patients with a defective lower esophageal sphincter (LES),20 and in those with impaired esophageal body function.21 In patients with one or more of these risk factors for complications of reux disease, early surgical therapy should be considered. Detection of Esophageal Shortening In a manner analogous to stricture formation, esophageal shortening can occur as a consequence of scarring and brosis associated with repetitive esophageal injury.22,23 Recognition of anatomic shortening of the esophagus is important because it can compromise the ability to perform an adequate tension-free antireux repair. In our experience,24 and the experience of others,25 un- recognized esophageal shortening is a major cause of recurrent herniation, a common cause of fundoplication failure. It is also the explanation for the slipped Nissen fundoplication. In many such instances, the initial repair is incorrectly constructed around the proximal tubular- ized stomach rather than the terminal esophagus. Although no ideal method exists to detect signicant esophageal shortening, the combination of video roent- genographic contrast studies and endoscopic ndings (Fig. 3.1) will alert the surgeon to a situation in which esophageal shortening is likely.26 A large hiatal hernia on endoscopy or on video esophagram is likely to be associated with esophageal shortening, as is the presence of an esophageal stricture. Hernia size is measured endoscopically as the distance between the diaphragmatic crura (identied by having the patient sniff), and the gastroesophageal junction (identied as the loss of gastric rugal folds). We consider the possibility of a short esophagus in patients with strictures or those with large hiatal hernias (>5cm), particularly when the latter fail to reduce in the upright position on a video barium esophagram. Because of the risk of failure due to excessive tension after transabdominal repair, these patients are best treated by a thoracic approach that allows a more thorough mobilization of the esophagus. After complete mobilization, esophageal length can be appraised by assessing the ability to reduce the gastroesophageal (GE) junction beneath the diaphragm without excessive tension. When this is not possible, a Collis gastroplasty coupled with either a partial or complete fundoplication achieves excellent control of reux in the majority of these patients.27,28 Evaluation of Esophageal Body Function Selection of the appropriate antireux operation in an individual patient requires a careful assessment of esophageal body function. Otherwise, the resistance to emptying imparted by a complete fundoplication will result in troublesome dysphagia in patients with poor peristaltic function. Assessment of esophageal body function is also important from a prognostic standpoint because esophageal body function has been shown to correlate with the likelihood of relief of regurgitation, dysphagia, and respiratory symptoms following surgery. When peristalsis is absent, or severely disordered (>50% simultaneous contractions), or the amplitude of the contractions in one or more of the lower esophageal segments in below 20mmHg, most surgeons would opt for a partial fundoplication. Persistent poor esophageal propulsive function and the continued regurgitation of esophageal contents may explain the less favorable response after fundoplication of atypical compared to typical reux symptoms.2931 Figure 3.1. Radiograph showing esophageal shortening.

40. Indications for Antireux Surgery Historically, antireux surgery was reserved for patients with severe esophagitis or stricture or to those refractory to medical therapy, that is, to patients with relatively severe reux disease, largely because of the relatively high morbidity and mortality associated with antireux surgery in the era of open antireux procedures. The demonstration of decreased morbidity and shorter hospital stays and periods of disability associated with minimally invasive antireux surgery, coupled with the demonstration of the success of these procedures, have shifted the balance such that patients with less severe disease are now considered surgical candidates. In fact, it is likely that it is precisely these patients with less severe disease that are probably the best candidates for a laparoscopic Nissen (see following). Furthermore, the traditional concept, that a decient lower esophageal sphincter is the primary cause of GERD and that a defective sphincter was a requirement before surgery, is no longer valid in the era of laparoscopic fundoplication.29 It is now clear that reux frequently occurs during temporary loss of the gastroesophageal barrier and that patients with normal resting sphicter parameters can have excellent outcomes following surgery. The ideal candidate for a laparoscopic antireux procedure is the patient with typical symptoms of heartburn or regurgitation (as opposed to atypical symptoms such as cough, asthma, or hoarseness), with a pH test- proven abnormal esophageal acid exposure, and who has responded to, but is dependent on, proton pump inhibitors for symptom relief. A multivariate analysis of the factors predicting a successful outcome after laparoscopic Nissen has identied these three parameters as the most important preoperative predictors of a successful outcome.32 As mentioned, the most important aspect of patient selection is to be as certain as possible that gastroesophageal reux is the underlying cause of their complaints. Taken in this context, it immediately becomes evident that each of the predictors of success just outlined helps do just that, to establish that gastroesophageal reux disease is indeed the cause of the patients symptoms. There are several specic situations in which antireux surgery should be considered. The rst is the patient who has demonstrated the need for long-term medical therapy, particularly if escalating doses of proton pump inhibitors are needed to control symptoms; this is particularly true in patients who are less than 50 years of age, for whom the lifetime cost of medical therapy could easily exceed the cost of surgical therapy.33 Patients who are noncompliant with medical therapy, those for whom the medications are a nancial burden, or those who favor a single denitive intervention over long-term drug treatment, should also be offered the option of surgery. Patients who are at high risk of progression to complications of GERD despite medical therapy (see earlier dis- cussion) should also be considered for antireux surgery. Minimally invasive antireux surgery may be the treatment of choice in these patients. Assuming the patient is physiologically t, and that reux has been carefully documented,there are no specic contraindications to laparoscopic antireux surgery. Experience has shown, however, that difculties may be encountered in patients who have a large left lateral segment of the liver, those who are morbidly obese, and those who have undergone prior upper gastrointestinal surgery. Patients with large paraesophageal hernias represent a specic technical challenge. Although the majorityofthesedifcultiescanbeovercomewithincreas- ing experience, an open transabdominal or transthoracic approach may be the wisest choice in such patients. This decision, that is, when to abandon the laparoscopic approach in favor of the traditional open approach, is a difcult one that is currently under investigation. Surgical Techniques Laparoscopic Nissen Fundoplication Port Positioning The technique of laparoscopic Nissen fundoplication has been relatively well standardized. Access is via ve upper abdominal ports (Fig. 3.2). We prefer an open technique 3. Laparoscopic Complete and Partial Fundoplication 19 Figure 3.2. Port location.

41. 20 J.A. Hagen and J.H. Peters type scissors and ne grasping forceps are preferred for dissection. In all except the most obese patients, a very thin portion of the gastrohepatic omentum overlies the caudate lobe of the liver. The right crus is exposed by incising the gastrohepatic omentum above and below the hepatic branch of the anterior vagal nerve, which we routinely spare. A large left hepatic artery arising from the left gastric artery will be present in about 25% of patients. It should be identied and avoided. After incising the gastrohepatic omentum, the lateral surface of the right crus will become evident (Fig. 3.4). The peritoneum overlying the anterior aspect of the right crus is incised with scissors and electrocautery, and the right crus dissected as much as possible from anterior to posterior (Fig. 3.5). By blunt dissection along the medial surface of the right crus, the mediastinum is entered. The for placement of the Hasson trochar used for camera access. Placement of this port through the left rectus abdominus muscle appears to result in more secure closure of the wound and fewer incisional hernias. Two lateral retracting ports are placed in the right and left anterior axillary lines, respectively. The right-sided liver retractor is best placed in the right midabdomen (midclavicular line), at or slightly below the camera port. This placement allows the proper angle toward the left lateral segment of the liver and thus the ability to push the instrument toward the operating table, lifting the liver. A second retraction port is placed at the level of the umbili- cus, in the left anterior axillary line. The surgeons right- handed trocar is placed in the left midclavicular line, 1 to 2in. below the costal margin. The liver is then retracted, and the fth and nal port is placed just to the right of the falciform ligament in the subxyphoid area. The esophageal hiatus is exposed by placement of a fan retractor in the right anterior axillary port.A table retractor can then be used to securely x the liver in place, which minimizes trauma to the liver, and frees the hand of an assistant for other work. Mobilization of the left lateral segment by division of the triangular ligament is not necessary. A Babcock clamp is placed into the left anterior axillary port and the stomach retracted toward the patients left foot. This maneuver exposes the esophageal hiatus. Commonly, a hiatal hernia will need to be reduced (Fig. 3.3). An atraumatic clamp should be used, and care should be taken not to grasp the stomach too vigorously, as gastric perforations can occur. Hiatal Dissection Identication of the right crus is the rst and most important step in safe dissection of the hiatus. Metzenbaum- Figure 3.3. Intraoperative photograph of gastrohepatic ligament with replaced left hepatic artery. A hiatal hernia of moderate size can be seen in the upper right corner. Figure 3.4. A window is created above and below the hepatic branch of the vagus nerve and any associated vascular structures. The right crus becomes evident. Figure 3.5. The peritoneum along the anterior border of the right crus is marked and incised.

42. 3. Laparoscopic Complete and Partial Fundoplication 21 esophagus will then become evident in the lower mediastinum. Lateral retraction of the right crus exposes the tissues behind the esophagus. No attempt is made at this point to dissect behind the gastroesophageal junction. Meticulous hemostasis is critical, as otherwise blood and uid tend to pool in the hiatus, obscuring the view

laparoscopic surgery of_the_abdomen

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