Dokumen - Pub Operative Techniques in Foregut Surgery 1nbsped

Editor
Daniel Albo MD, PhD

Dan L. Duncan Professor and Vice Chairman
Director, GI Oncology
Michael E. DeBakey Department of Surgery
Houston, Texas
Editor-in-Chief
Michael W. Mulholland MD, PhD
Professor of Surgery and Chair
Department of Surgery
University of Michigan Medical School
Ann Arbor, Michigan
P.v
Contributing Authors
Matthew Albert, MD
Florida Hospital
Orlando, Florida
Daniel Albo, MD, PhD

Dan L. Duncan Professor and Vice Chairman
Director, GI Oncology
Houston, Texas
Melissa M. Alvarez-Downing, MD
Resident
Department of Colorectal Surgery
Digestive Disease Institute
Cleveland Clinic Florida
Weston, Florida
Daniel A. Anaya, MD
Associate Professor
Chief
Section of General Surgery and Surgical Oncology
Operative Care Line
Michael E. DeBakey VA Medical Center
Division of Surgical Oncology
Baylor College of Medicine
Houston, Texas
Avo Artinyan, MD, MS

Assistant Professor of Surgery
American Cancer Society Cancer Liaison Physician
Houston, Texas
Erik Askenasy, MD
Houston, Texas
Valerie Bauer, MD, FACS, FASCRS

Attending Physician
Bay Area Colorectal Surgical Associates
Texas City, Texas
Assistant Clinical Professor of Surgery
Houston, Texas
David Berger, MD, MHCM

Professor of Surgery
Vice Chair of Surgery
Vice President
Chief Medical Officer
Houston, Texas
Jaime L. Bohl, MD, FACS

Assistant Professor
Department of General Surgery
Wake Forest School of Medicine
Winston-Salem, North Carolina
Reshma Brahmbhatt, MD
Resident
Division of General Surgery
Houston, Texas
Susan M. Cera, MD, FACS, FASCRS
Clinical Professor
Chief of Staff
Physicians Regional Healthcare System
Physicians Regional Medical Group
Naples, Florida
Clinical Professor
Digestive Disease Institute
Cleveland Clinic Florida
Weston, Florida
George J. Chang, MD, MS

Associate Professor of Surgery
Chief Colon and Rectal Surgery
Department of Surgical Oncology
The University of Texas MD Anderson Cancer Center
Houston, Texas
Robert R. Cima, MD, MA

Consultant
Division of Colon and Rectal Surgery
Mayo Clinic
Mayo Medical School
Rochester, Minnesota
Bidhan Das, MD
Clinical Associate Professor
Colon and Rectal Surgery
University of Texas Health Science Center at Houston
Staff Surgeon
Colon and Rectal Clinic of Houston
Staff Colon and Rectal Surgeon
Houston Methodist Center for Restorative Pelvic Medicine
Memorial Hermann Hospital System
CHI St. Luke's Health-Baylor St. Luke's Medical Center
Houston, Texas
Roosevelt Fajardo, MD, MBA, FACS

Fundacion Santa Fe de Bogota
Director
Center for Innovation in Health and Education, Fundacion Santa Fe
Assistant Professor
Los Andes University School of Medicine
Bogotá, Colombia
Barry Feig, MD
Professor
Houston, Texas
Daniel L. Feingold, MD
Associate Professor
New York-Presbyterian Hospital
Columbia University Medical Center
New York, New York
Wayne A.I. Frederick, MD

Interim President
Provost and Chief Academic Officer
Howard University Hospital
Washington, DC
P.vi
Kelly A. Garrett, MD, FACS, FASCRS
Weill Cornell Medical College
New York, New York
Eric M. Haas, MD, FACS, FASCRS

President
Colorectal Surgical Associates, Ltd, LLP
Program Director
Minimally Invasive Colon and Rectal Surgery Fellowship
Clinical Associate Professor
Houston, Texas
Karin M. Hardiman, MD, PhD

Division of Colorectal Surgery
University of Michigan Health System
Ann Arbor, Michigan
Andrew G. Hill, MD, EdD, FRACS, FACS

Colorectal Surgeon
Middlemore Hospital
Professor of Surgery and Head
South Auckland Clinical School
Faculty of Medical and Health Sciences
University of Auckland
Auckland, New Zealand
Joshua S. Hill, MD, MS

Surgical Oncologist
Levine Cancer Institute
Charlotte, North Carolina
Mehraneh D. Jafari, MD
School of Medicine
University of California, Irvine
Orange, California
Douglas W. Jones, MD
Resident
New York, New York
Lillian S. Kao, MD, MS

Professor
Vice Chair for Quality
University of Texas Health Science Center at Houston Houston, Texas
Hasan T. Kirat, MD
Cleveland Clinic Foundation
Cleveland, Ohio
Cherry E. Koh, MD, MBBS (Hons), MS, FRACS

Royal Prince Alfred Hospital
Clinical Research Fellow
Surgical Outcomes Research Centre
University of Sydney
Sydney, New South Wales, Australia
Sang W. Lee, MD
New York, New York
Steven A. Lee-Kong, MD
Assistant Professor
Columbia University Medical Center
New York, New York
Joël Leroy, MD, Hon FRCS

IRCAD/EITS
Department of General, Digestive and Endocrine Surgery
University Hospital of Strasbourg
Strasbourg, France
Edward A. Levine, MD
Section of Surgical Oncology
Mike K. Liang, MD
Houston, Texas
Kathleen R. Liscum, MD
Chief
Section of General Surgery
Ben Taub General Hospital
Houston, Texas
Luis Jorge Lombana, MD

Colon and Rectal Surgeon
Hospital Universitario San Ignacio
Pontificia Universidad Javeriana
Bogotá, Colombia
Jacques Marescaux, MD, FACS, Hon FRCS, Hon FJSES

IRCAD/EITS
Strasbourg, France
John H Marks, MD, FACS, FASCRS

Chief
Director
Minimally Invasive Colorectal Surgery and Rectal Cancer Management Fellowship
Lankenau Medical Center
Professor
Lankenau Institute of Medical Research
Wynnewood, Pennsylvania
Craig A. Messick, MD
Clinical Assistant Professor
Section of Colon and Rectal Surgery
Houston, Texas
Stefanos G. Millas, MD
Assistant Professor
Houston, Texas
Somala Mohammed, MD
Resident Michael E. DeBakey VA Médical Center
Houston, Texas
Arden M. Morris, MD, MPH

Associate Professor of Surgery Chief
Ann Arbor, Michigan
P.vii
Matthew G. Mutch, MD
Section of Colon and Rectal Surgery
Washington University School of Medicine
St. Louis, Missouri
Didier Mutter, MD, PhD, FACS

IRCAD/EITS
Strasbourg, France
Govind Nandakumar, MD
New York, New York
Tolulope Oyetunji, MD
Pediatric Surgery Fellowship
University of Missouri
Columbia, Missouri
Rodrigo Pedraza, MD
Colorectal Surgical Associates, Ltd, LLP
Minimally Invasive Colon and Rectal Surgery Fellowship
The University of Texas Medical School at Houston
Houston, Texas
Alessio Pigazzi, MD, PhD

Chief
School of Medicine
University of California, Irvine
Orange, California
Harsha Polavarapu, MD
Florida Hospital
Orlando, Florida
Reese W. Randle, MD
Scott E. Regenbogen, MD, MPH

Assistant Professor
Ann Arbor, Michigan
Feza H. Remzi, MD
Chairman
Cleveland Clinic Foundation
Cleveland, Ohio
Saul J. Rugeles, MD
Chairman
Titular Professor of Surgery
Gastrointestinal Surgeon
Hospital Universitario San Ignacio
Pontificia Universidad Javeriana
Bogotá, Colombia
Tarik Sammour, BHB, MBChB, PhD

Surgical Registrar
Middlemore Hospital
Auckland, New Zealand
William Sanchez, MD, FACS

Chair
Hospital Militar Central
Universidad Militar Nueva Granada
Bogotá, Colombia
Shiva Seetahal, MD
Minimally Invasive Surgery/Bariatric Surgery Fellowship
Atlanta Medical Center
Atlanta, Georgia
Perry Shen, MD
Margaret V. Shields, BA
Main Line Health
Lankenau Medical Center
Wynnewood, Pennsylvania
Eric J. Silberfein, MD
Assistant Professor
Houston, Texas
Michael J. Solomon, MB ChB, BAO, MSc, FRACS

Senior Colorectal Surgeon
Head and Director
Surgical Outcomes Research Centre
Royal Prince Alfred Hospital
Clinical Professor of Surgery
Discipline of Surgery
University of Sydney
Sydney, New South Wales, Australia
Andrew Stevenson, MBBS, FRACS

Head of Unit and Colorectal Surgeon
Colorectal Unit
Royal Brisbane and Women's Hospital
Senior Lecturer
School of Medicine
Faculty of Health Sciences
University of Queensland
Brisbane, Queensland, Australia
John H. Stewart, IV MD, MBA

James Suliburk, MD
Attending Surgeon
Michael E. DeBakey VA Médical Center
Houston, Texas
David Taylor, MBBS, FRACS

Colorectal Surgeon
Colorectal Unit
Royal Brisbane and Women's Hospital
Senior Lecturer
School of Medicine
Faculty of Health Sciences
University of Queensland
Brisbane, Queensland, Australia
Ryan M. Thomas, MD
Assistant Professor
North Florida/South Georgia Veterans Health System
Assistant Professor
Department of Surgery University of Florida College of Medicine Gainesville, Florida
Kathrin Mayer Troppmann, MD, FACS

Division of Gastrointestinal and Minimally Invasive Surgery
University of California Davis School of Medicine
Sacramento, California
Elsa B. Valsdottir, MD
University Hospital of Iceland
Associate Professor
University of Iceland Medical School
Reykjavik, Iceland
P.viii
Oliver Varban, MD
Minimally Invasive Surgery and Bariatrics
Ann Arbor, Michigan
Theodoros Voloyiannis, MD, FACS, FASCRS

Clinical Assistant Professor in Surgery
Medical Group
Memorial Hermann Hospital
Houston, Texas
Konstantinos I. Votanopoulos, MD, PhD, FACS

Assistant Professor
Comprehensive Cancer Center
Rebecca L. Wiatrek, MD
Assistant Professor
Houston, Texas
Curtis J. Wray, MD
Associate Professor
Houston, Texas
Y. Nancy You, MD, MHSc

Assistant Professor
Houston, Texas
2015
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Library of Congress Cataloging-in-Publication Data
Operative techniques in foregut surgery/editor, Mary Hawn ; editor-in-chief, Michael W. Mulholland.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4511-9017-5 (hardback: alk. paper)
I. Hawn, Mary T., editor. II. Mulholland, Michael W., editor. III. Operative techniques in surgery. Contained in
(work):
[DNLM: 1. Digestive System Surgical Procedures. 2. Gastrointestinal Diseases—surgery. 3. Upper
Gastrointestinal Tract—surgery. WI 900]
RD32
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Dedication
To my husband, Eben Rosenthal, who inspires me and has not wavered in his support of my career.
Mary T. Hawn
Series Preface
Operative therapy is complex, technically demanding, and rapidly evolving. Although there are a number of
standard textbooks that cover aspects of general, thoracic, vascular, or transplant surgery, Operative
Techniques in Surgery is unique in offering a comprehensive treatment of contemporary procedures. Open
operations, laparoscopic procedures, and newly described robotic approaches are all included. Where
alternative or complementary approaches exist, all are provided. The scope and ambition of the project is one of
a kind.
The series is organized anatomically in sections covering thoracic surgery, upper gastrointestinal surgery,
hepatopancreatico-biliary surgery, and colorectal surgery. Breast surgery, endocrine surgery, and topics related
to surgical oncology are included in a separate volume. Modern approaches to vascular surgery and
transplantation surgery are also covered in separate volumes.
The series editors are renowned surgeons with expertise in their respective fields. Each is a leader in the
discipline of surgery, each recognized for superb surgical judgment and outstanding operative skill. Breast
surgery, endocrine procedures, and surgical oncology topics were edited by Dr. Michael Sabel of the University
of Michigan. Thoracic and upper gastrointestinal surgery topics were edited by Dr. Mary Hawn of the University
of Alabama at Birmingham, with Dr. Steven Hughes of the University of Florida directing the volume on hepato-
pancreatico-biliary surgery. Dr. Daniel Albo of Baylor College of Medicine directed the volume dedicated to
colorectal surgery. Dr. Ronald Dalman of Stanford University edited topics related to vascular surgery, including
both open and endovascular approaches. The discipline of transplantation surgery is represented by Dr. Michael
Englesbe of the University of Michigan. In turn, the editors have recruited contributors that are world-renowned;
the resulting volumes have a distinctly international flavor.
Surgery is a visual discipline. Operative Techniques in Surgery is lavishly illustrated with a compelling
combination of line art and intraoperative photography. The illustrated material was all executed by a single
source, Body Scientific International, to provide a uniform style emphasizing clarity and strong, clean lines.
Intraoperative photographs are taken from the perspective of the operating surgeon so that operations might be
visualized as they would be performed. The result is visually striking, often beautiful. The accompanying text is
intentionally spare, with a focus on crucial operative details and important aspects of postoperative management.
The series is designed for surgeons at all levels of practice, from surgical residents to advanced practice fellows
to surgeons of wide experience. The incredible pace at which surgical technique evolves means that the
volumes will offer new insights and novel approaches to all surgeons.
Operative Techniques in Surgery would be possible only at Wolters Kluwer Health, an organization of unique
vision, organization, and talent. Brian Brown, executive editor, Keith Donnellan, acquisitions editor, and Brendan
Huffman, product development editor, deserve special recognition for vision and perseverance.
Michael W. Mulholland, MD, PhD
Preface
As part of the series Operative Techniques in Surgery, this volume focuses on the detailed technical aspects of
esophageal and gastric surgery. This book will serve as a guide to surgeons and trainees with an interest in
foregut surgery. The unique aspects of this book are the provision of multiple approaches to a surgical problem
with step-by-step instructions complemented by detailed illustrations and photos. The contributors to this book
are surgeons well known for their technical expertise, with a specific focus on innovative approaches to the
challenging practice of surgery.
The goal of the textbook is to provide not only the technical steps of an operation but also the tips and pearls
from master surgeons on how they approach the procedure. The book succinctly describes preoperative,
intraoperative, and postoperative clinical decision making as well as potential pitfalls and how to mitigate them.
This book was a major undertaking and could not have been accomplished without the superb work of the
authors and illustrators. I would like to thank Dr. Michael W. Mulholland, Brendan Huffman, and Keith Donnellan
for their mentorship and guidance in bringing the project together. My hope is that this book will inspire surgeons
to perfect their technical skills and bring the best care to their patients.
Mary T. Hawn, MD, MPH
Chapter 1
Paraesophageal Hernia Repair: Laparoscopic Technique
John G. Hunter
Mark J. Eichler
DEFINITION
For millennia, the existence of hiatal hernias was well known. First described by Henry Bowditch in 1853,
and later in 1951 officially by Philip Allison, the paraesophageal hernia (PEH) presents a physiologic link
to reflux esophagitis, ulceration, stricture, and other esophageal pathology.1,2
Of the four types of hiatal hernias known today, 95% of incidence resides with the type I or sliding hiatal
hernia, which typically can be managed medically with gastric acid suppression. The remaining three
types are lumped as “paraesophageal hernias.” These include the true PEH (type II), combined sliding
and paraesophageal (type III), and extragastric (type IV) (FIG 1). With the advent of modern antireflux
surgery, failed fundoplication overlaps with this classification (FIG 2). Furthermore, disruption of the
esophageal hiatus for other disease processes, such as esophagectomy, potentiates the PEH, especially
type IV.
This chapter, in concert with other procedures such as fundoplication and esophageal lengthening (Collis
gastroplasty), will deal with the surgical management of PEH types II to IV, which anatomically may also
encompass redo fundoplication. Principles of repair include definition of anatomy and symptoms, safe
reduction of abdominal organs back to the peritoneal cavity, excision of the hernia sac, closure of crura
(with or without mesh repair), evaluation of intraabdominal esophageal length, and an antireflux
procedure.3,4
PATIENT HISTORY AND PHYSICAL FINDINGS

Necessity for PEH repair lies with the patient symptomatology, medical status, and chance of obstruction or
strangulation. PEHs can encompass symptoms of gastroesophageal reflux disease (GERD), which includes
typical symptoms of heartburn, acid reflux, and dyspepsia. In contrast, atypical GERD symptoms manifest as
laryngeal and pulmonary complaints of noncardiac chest pain, dyspnea, poor dentition, sinusitis, asthma,
chronic cough, pneumonia, and halitosis. PEH-specific complications include gastric volvulus, incarceration,
gastric outlet obstruction, and higher mortality when performed emergently. Early studies on mortality in the
1960s demonstrated mortality rates over 50% for PEHs with associated gastric volvulus, although more recent
analysis suggests that number to be overestimated and is actually more likely to be under 20% for such
patients in duress from PEH.5,6 For all PEH patients, overall mortality is under 1% and can safely be
performed with a laparoscopic approach even in the face of obstruction, gangrene, and so forth.7
Indications for PEH repair therefore should be tailored to patients who are symptomatic and medically likely to
survive an operation. Ultimately, most patients who have a PEH will become symptomatic.3,5,6
IMAGING AND OTHER DIAGNOSTIC STUDIES

Preoperative diagnostic studies help dictate the range of elective, urgent, and emergent nature of a
symptomatic patient with a PEH. In those patients who are in extremis, the minimum workup needed for urgent
or emergent PEH repair is radiographic evidence of incarceration, perforation, obstruction, or failed antireflux
surgery. However, the majority of patients present in an elective manner, and we therefore advocate for a
complete workup to assist preoperative planning of the symptomatic patient with PEH by the addition of
manometry, pH testing, and endoscopy to rule out pseudoobstruction or esophageal motility disorders.
Chest x-ray: At presentation, whether to an emergency department or a primary care physician's office, the
chest x-ray gives quick and cost-effective information to the severity of the PEH. Mediastinal gas bubble can
be seen on plain film radiography as well as the presence of pneumoperitoneum or pneumomediastinum.
Esophagram: The supine and upright plain film esophagram demonstrates static anatomy and can often locate
the gastroesophageal junction (GEJ) in relation to the diaphragm as well as deduce the presence of reflux on
delayed films. Mucosal abnormalities can be seen with this modality as well (FIG 3A,B).
Computed tomography (CT): Indications for obtaining CT scans include the emergent presentation,
inconclusive but worrisome findings on two-dimensional radiography, and PEH type IV (FIG 4). CT aids the
preoperative planning by alerting the surgeon to the extent of skin preparation and positioning for operative
repair but is not necessary.
Upper endoscopy: All preoperative patients should undergo upper endoscopy if possible. By visualization of
the esophageal and gastric lumen, neoplasm, Barrett's esophagus, and esophagitis can be biopsied, and, in
case esophagectomy is warranted, provide histologic diagnosis. Furthermore, anatomic landmarks can be
seen such as the distance between the hiatus and the GEJ as well as the size of the hiatal hernia.
Manometry: Several studies of benign esophageal disorders confirm the use of preoperative manometry.3,8
Distal esophageal pressures greater than 30 mmHg indicate favorable outcome of response to fundoplication,
which, according to some surgeons, is a threshold for performing a complete versus partial wrap for the
antireflux component of the PEH repair. Manometry also rules out primary esophageal dysmotility including
achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter (LES),
and ineffective esophageal motility. We do not advocate performing a complete fundoplication for patients with
esophageal dysmotility or low distal esophageal pressures.
pH study: Although the previous modalities of the PEH workup provide a robust description of the PEH patient,
pH studies provide data for the decision in failed antireflux
P.2
surgery to dissect and redo a previous fundoplication. In the setting of a negative pH study (by way of
DeMeester score <15),9 a “herniated” fundoplication may indeed be intact, thus saving the risk of tedious and
unnecessary redo fundoplication as a component of the PEH repair.
FIG 1 • The four types of hiatal hernia: type I (sliding): GEJ translates linearly along esophageal axis cephalad
into the mediastinum; type II (paraesophageal): GEJ resides intraabdominally with (usually) the gastric fundus or
body translating cephalad past the GEJ; type III (combined): GEJ and gastric segments both translate above
diaphragm; type IV (extragastric): small bowel, colon, spleen, and even pancreas may translate into the
mediastinum and chest.
SURGICAL MANAGEMENT
Preoperative Planning
All studies, including esophagram, esophagogastroduodenoscopy (EGD), manometry, and pH testing should
be readily available and reviewed prior to and at the time of surgery. The esophagram should be displayed on
a spare or dedicated monitor in the operating theater and EGD images be loaded as well for intraoperative
reference.
Attention to fine detail of the manometric report may avoid an unnecessary and detrimental 360-degree
fundoplication, as a complete wrap may worsen symptoms in the light of the following findings8:
Severe esophageal dysmotility

Very low residual postrelaxation LES pressures less than 30 mmHg during wet swallow
P.3
FIG 2 • Anatomy of fundoplication failure, including A) wrap dehiscence B) recurrent or persistent hiatal hernia
with wrap slippage C) misplaced or slipped wrap, and D) herniation of entire wrap above the diaphragm.
Positioning
An operating table capable of steep reverse Trendelenburg position is required. Arms are tucked at the
patient's sides but can be out 90 degrees and secured. Footboards on a split-leg table are mandatory, and a
preprocedural reverse Trendelenburg test is used for safety confirmation of positioning (FIG 5A).
Assume extensive mediastinal dissection will be warranted, and therefore, pleural compromise is a frequent
occurrence. The sterile skin preparation must be wide enough on either flank in case tube thoracostomies are
necessary from resultant pneumothorax. However, a red rubber catheter between 10 and 14 Fr may be placed
in a witnessed pleural defect intraabdominally, spanning the diaphragm to the hemithorax in question. This
reduces the resultant pneumothorax and peak ventilatory pressures with the aid of lowering insufflation
pressures as well as anesthesia-assisted ventilatory Valsalva.
After Veress needle insufflation in either the supraumbilical or the left upper quadrant, trocar placement
ensues. Five trocars are used for the laparoscopic PEH repair (FIG 5B). After the liver retractor and ports are
placed, the patient is positioned into steep reverse Trendelenburg and the dissection begins.
Instrumentation
As aforementioned, there can be up to a 20% enterotomy rate during PEH repair, especially during redo
operations. Therefore, extraordinary care is tantamount to establishing safe dissection planes, especially near
the esophagus. Ultrasonic shears are the mainstay of dissection (Harmonic Ace curved shears, Ethicon,
Somerville, NJ), whereas when operating extremely close to organs, we advocate switching to laparoscopic
scissors as well as blunt dissection to avoid thermal injury.
FIG 3 • A,B. Esophagram. A. Radiography demonstrating a large PEH with herniation of nearly the entire gastric
lumen into the posterior mediastinum with mesoaxial volvulus. B. Slipped Nissen fundoplication with an intact
wrap proximal to the diaphragm.
FIG 4 • CT of massive PEH type IV in which the entire transverse colon has herniated into the left hemithorax.
P.4
FIG 5 • Patient positioning (A) and trocar placement (B). After pneumoperitoneum is established, lines are drawn
at the inferior edge of the costal margin diagonally up to an imaginary point above the xiphoid as a zero point for
trocar placement. Five trocars are used for the laparoscopic PEH repair. (1) An 11-mm supraumbilical camera
port, offset just to the left of the midline and 15 cm inferiorly. (2) A 12-mm left upper quadrant port, measured 12
cm along the parallel line to the left costal margin, for the surgeon's right hand. This port is placed 1 to 2 cm
inferiorly to the 12-cm mark. (3) A 5-mm right upper quadrant trocar, measured 7 to 10 cm from the supraxiphoid
point and 1 to 2 cm inferiorly, for the surgeon's left hand. This can be placed to the right of the falciform and then
through the falciform. (4) An assistant's 5-mm left flank trocar is placed about a palm's width inferiorly and
laterally from the 12-mm trocar. (5) Finally, a 5-mm port is placed and removed in the subxiphoid region for the
Nathanson liver retractor. Similarly, a port can be placed at the right flank, symmetrically opposite from the
assistant's port for a linear liver retractor, as supplies may vary per operating theater.
TECHNIQUES
REDUCTION OF THE HERNIA
To whatever extent possible, reduce the contents of the mediastinum previously back into the abdominal
cavity by use of both the primary surgeon's hands as well as the assistant's with atraumatic graspers
(FIG 6). Note that there may be various layers to the hiatal hernia sac (FIG 7).
FIG 6 • Reduction of major viscera with blunt retraction back into the abdomen. The dotted lines indicate
the plane of dissection about the hernia sac.
P.5
FIG 7 • Layers of the PEH sac. Note the interface between the visceral peritoneum and endothoracic fascia
(sometimes fused to parietal pleura) should be the plane to establish during dissection.
INITIAL HIATAL DISSECTION

It is usually safe, once countertraction is well established and reduction of the entire PEH is attained, to
initiate dissection on the right crus directly to the right of the esophagus, providing a starting point for
anterior and posterior dissection. Anterior dissection occurs in a 180-degree fashion anteriorly and then
to the left of the hiatus, just in a plane immediately deep to the peritoneum/hernia sac; any deeper and
thermal injury or perforation might happen to the esophagus. If the hernia cannot be completely reduced
intraabdominally, then we advocate an approach from the left crus, anteriorly 180 degrees to the right
crus (FIG 8A,B),
P.6
reasoning that the position of the unreduced PEH and true dissection plane on the left can be more
readily ascertained. The resultant anterior dissection can be seen in FIG 9.
Posterior dissection ensues from the original starting point to the right of the esophagus to free the right
crus posteriorly and deep, then as much as possible, to the left of the GEJ.
FIG 8 • A,B. Dissection from left to right, anteriorly, starting on the left crus. Ultrasonic dissection takes
place directly on the edge of the diaphragm at all times. Countertraction must be kept to prevent retraction
of the hernia sac into the mediastinum.
FIG 9 • Resultant anterior 180-degree dissection.
SHORT GASTRIC VESSEL LIGATION

Before complete 360-degree dissection can take place, the short gastric vessels must be completely
dissected, even if a previous procedure supposedly took place, as some surgeons selectively or
incompletely perform short gastric takedown (FIG 10A-C). This should be performed on the slow setting
of the ultrasonic shears, as premature ligation might allow incompletely ligated vessels to retract into the
gastrosplenic ligament uncontrollably. Although endoscopic surgical clips may help, it is more efficacious
to regrasp the bleeding ligament and vessels for ultrasonic ligation. Occasionally, depending on the
surgeon's skill, an open procedure is necessitated.
FIG 10 • A-C. Short gastric vessel ligation. A,B. Initial dissection begins at a level parallel to the distal
splenic tip. C. Completion of the short gastric ligation. Note the exposure of the posterior stomach to
complete this step.
POSTERIOR GASTRIC ATTACHMENTS

To complete the circular dissection, the surgeon's left hand and assistant splay the stomach to the
anteromedial direction and omentum to the left. This reveals attachments posteriorly from the splenic
vessels to the left gastroepiploic vessels. These can be taken also with ultrasonic dissection. After
reduction of the posterior sac (FIG 11), this completes the 360-degree mobilization (FIG 12). A Penrose
drain can encircle the GEJ for atraumatic retraction.
FIG 11 • Reduction of the posterior sac.
P.7
FIG 12 • Completion of 360-degree dissection.
HERNIA SAC EXCISION

If properly performed, the hernia sac can be removed en bloc by evidence of the mediastinal component
of the hernia sac being contiguous with that of the anterior esophagus and fat pad (FIG 13A,B), which
may also need excision in order to properly perform the antireflux portion of the operation.
If the hernia sac is large and will obstruct mediastinal dissection, excision of the sac is warranted. Start
on the left crus with traction on the hernia sac and use combinations of blunt dissection when near the
esophageal body and ultrasonic dissection to remove the hernia sac when at a safer distance.
Manipulation of tissues too far away from the esophagus may compromise the pleural cavity and
manipulation too close to the esophagus may incur thermal injury, often unrecognized at time of
operation. FIG 14 demonstrates a close, but safe, distance of dissection to the esophagus.
FIG 13 • A,B. Excision of the hernia sac off the anterior esophagus. The sac is placed under countertraction
and bivalved just to the left of the vagus nerve.
FIG 14 • A,B. Demonstration of proper range of proximity to the esophagus during ultrasonic dissection. A.
View from left, near esophagus. B. View from right, approaching endothoracic fascia and pleura.
FUNDOPLICATION TAKEDOWN
If there exists a previous fundoplication and preoperative testing demonstrates incompetence of the
antireflux procedure, the wrap is mandated to be taken down and redone.
Extreme care should be implemented as this is the step that carries the most risk of enterotomy either at
the stomach or at the esophagus. Once completely dissected, inspection and reinspection of the taken
down wrap should take place. Often, the gastric lumen may resemble the shiny planes between the
fundus and esophageal body.
P.8
MEDIASTINAL DISSECTION
Adequate mediastinal dissection for esophageal length is encountered when the endothoracic
fascia/pleura is placed laterally, and the mediastinal esophagus is visualized in a 360-degree fashion up
to the level of the carina or right atrium (FIG 15).
FIG 15 • Adequate mediastinal dissection as evidenced by 360-degree encirclement of the esophagus up to

the level of the carina superiorly, endothoracic fascia/pleura bilaterally, and aorta posteriorly.
ASSESSMENT OF INTRAABDOMINAL ESOPHAGEAL LENGTH

The left crus is now pulled from left to right, and without any bougie or orogastric tube in place, the
intraabdominal esophageal length can be assessed in a relaxed position. If the length is shorter than 2.5
to 3 cm, perform a Collis gastroplasty (see Chapter 2).
CRURAL CLOSURE
Over a 42-Fr bougie, the hiatus is sutured with the appropriate number of coated, braided nonabsorbable
suture (0 Ti-Cron, Covidien, Mansfield, MA). Spacing of sutures is approximately 1 cm apart from each
other and is placed 1 cm back from the crural edges (FIG 16A,B).
Pledgets are used on the sutures with the exception of the last sutures needed to avoid pledget ingrowth
into the esophagus.
The quantity of sutures usually numbers two to four, until there is a gap left between the esophagus and
crura to easily interpose laparoscopic graspers between the closure.
If the esophageal hiatus is gigantic, then anterior, in addition to posterior, crural closure can be safely
performed to prevent severe angulation of the esophagus at the newly reconstructed hiatus.
FIG 16 • A,B. Crural closure with 0 Ti-Cron pledgeted sutures with 1-cm spacing, both from each suture
and from the left and right crural edges. Depending on proximity to the esophagus, the last suture may be
unpledgeted to avoid erosion.
P.9
MESH PLACEMENT
If mesh is to be used, two main strategies exist, and both may be affixed by Ti-Cron suture (see “Pearls
and Pitfalls”):
Keyhole (three-sided) mesh can be sutured or glued to the diaphragm (FIG 17A).
Rectangular mesh is secured along the diaphragm posteriorly (FIG 17B).
FIG 17 • A. Keyhole placement of mesh. B. Rectangular placement of mesh.
ANTIREFLUX PROCEDURE
The principles of fundoplication apply here, whether a complete (Nissen) (FIG 18A,B) or partial (Toupet)
wrap is indicated. This completes the goal of reconstructing the angle of His and valvular mechanism of
the LES. Refer to the corresponding chapters accordingly.
FIG 18 • A,B. Nissen fundoplication.
P.10
LEAK TEST
Two leak tests can be performed.
Methylene blue: With dilute methylene blue dripped liberally into a nasogastric tube with the tip above
the GEJ, intracorporeal placement of two radiopaque white sponges can detect subtle leaks. Inspect
the removed sponges against a white background and back-table light. Any positive test is mandated
to be investigated thoroughly with the tear or enterotomy repaired.
Bubble leak test (alternative to methylene blue): With the placement of an endoscope and
Trendelenburg positioning, irrigate sterile saline intracorporeally and distend the stomach and lower
esophagus with insufflation. Any bubbles emanating mandates investigation.
UPPER ENDOSCOPY
The last portion of the procedure entails direct visualization with an upper endoscope to see the position
of the Z line, GEJ, and integrity of the wrap. With retroflexion, the endoscope should move back and forth
freely without buckling of the mucosa of the newly reconstructed LES.
PEARLS AND PITFALLS
Enterotomy ▪ It is well established that the PEH repair carries up to a 20% risk of enterotomy
along the esophagus or stomach, especially in redo operations. If an enterotomy is
noticed, for example, during dissection of a slipped Nissen fundoplication, a linear
staple firing is warranted across the enterotomy.
Deep hernia ▪ There is a fine line between removing the hernia sac and perforating or causing
sac dissection thermal injury to the esophagus and/or vagal nerves. With proper superficial
dissection at the outset of hiatal dissection allows the surgeon to stay above the
esophagus and allows the hernia sac to be excised en bloc.
Pneumothorax ▪ Prepare into the field the bilateral lower chest cavities that would access each
hemithorax in case a percutaneous tube thoracostomy is needed. Our first
recommendation, however, if peak ventilatory pressures are high from a
pneumothorax, is to decompress the affected side with the placement of a red rubber
catheter through a working 12-mm port and lay it from the hemithorax in question with
the opposite end intraabdominally. The lower chest wall should be prepped into the
field in case chest tube placement is needed. However, when a pneumothorax is
identified, a 14 French red rubber catheter can be placed through the hole with the tip
in the chest and the butt in the abdomen. At the completion of the procedure the butt
is pulled out a trocar site and is placed in a tub of water (water seal) while the
anesthesiologist reinflates the lung with positive pressure ventilations. When the
bubbling stops the tube is pulled out the trocar site. A chest x ray in the recovery
room confirms re-expansion of the lung.
Inadequate ▪ If redo fundoplication is being performed, it is imperative to obtain preoperative

antireflux manometry to test the integrity of a “slipped” Nissen versus a simple herniation. If
procedure manometry indicates reflux above the wrap, the previous fundoplication should be
completely dissected and redone.
Short gastric ▪ Do not assume during a redo operation that the previous surgeon has performed
vessel ligation adequate short gastric dissection. This tethers the fundoplication, therefore placing
improper physiologic vectors on the wrap. Dissect completely the short gastric
vessels to avoid tethering.
Intraabdominal ▪ Inadequate mediastinal dissection results in incomplete abdominal length of the

esophageal esophagus. Complete and high 360-degree mediastinal dissection allows the true
length determination if an esophageal lengthening procedure (Collis) is required when
performing the antireflux portion of the operation.
Mesh use and ▪ Several studies have investigated the controversy to use or not to use mesh, but no
material standardization in practice exists due to the many types of mesh material available,
shapes into which it is fashioned, and length of study investigated.10,11,12 and 13 The
efficacy of mesh to reinforce the closed crura tapers over time, although the degree
of this degeneration is a moving target in the literature. The material choice is widely
subject to debate with longer term studies showing no effect on recurrence with small
intestine submucosa (Surgisis, Cook Medical, Bloomington, IN), while shorter term
studies with human acellular dermal matrix (AlloDerm, LifeCell Corporation,
Bridgewater, NJ). Studies ongoing currently involve bioabsorbable woven suture
(BIO-A, W. L. Gore & Associates, Inc, Flagstaff, AZ) and porcine acellular dermal
matrix (AlloDerm, LifeCell Corporation, Bridgewater, NJ). We currently espouse the
use of a rectangular, lightweight, polypropylene, synthetic mesh with four fixation
points along the crura (Parietex, Covidien, Inc, Mansfield, MA).
Mesh erosion ▪ To avoid mesh erosion, do not place a circular piece of mesh around the closed
crura. Keyhole or U-shaped mesh is acceptable with the open end facing anteriorly.
Also, a rectangular mesh can be used instead of the U shape with placement from left
to right along the closed crura. Care with suture fixation to not place the mesh in
contact with the esophagus can alleviate mesh ingrowth and perforation of that
organ.
P.11
POSTOPERATIVE CARE
There are two main strata of postoperative care given to patients who undergo PEH repair: with significant
adhesiolysis and without significant adhesiolysis.
Without significant adhesiolysis: For those undergoing their first repair, the dissection can be as simple as an
“easy” type I or sliding hiatal hernia. Therefore, if adhesiolysis is simple and straightforward, we elect to give
the patients sips of clear liquids immediately postoperatively and advance to full liquids by postoperative day
(POD) 1, with discharge for 4 weeks on a proton pump inhibitor. We do not advocate for same day discharge.
Home medications should be in liquid or crushable form, and patients are prescribed antinausea, analgesia,
and bowel regimen medications. Diet consists of full liquids for 2 weeks then soft mechanical for another 2
weeks.
With significant adhesiolysis: Redo antireflux disease and technically challenging PEH repairs are usually the
mainstay of such operations. The risk of perforation, missed or noticed at the time of surgery, is increased,
and therefore, these patients follow a different postoperative pathway. They are kept nihil per os (NPO)
overnight and studied with a formal esophagram in fluoroscopy, regardless of the ultimate outcome of our
intraoperative leak test. If the radiologic exam is negative on the morning of POD 1, the patient's diet is
advanced per earlier mentioned protocol with discharge anticipated for POD 2 and the earlier mentioned
medication routine. Although it is acceptable to discharge a healthy, good candidate on POD 1, the majority of
our patients leave on POD 2 and so forth, depending on medical comorbidities.
OUTCOMES
Results depend on the nature of the disease process for which an operation is indicated and the number
of components of the operation used.
PEH repair: Mori et al.6 refer to eight studies that had a mean or median follow-up of 6 to 40 months with
a range of 2% to 43% recurrence. Andujar et al.14 describe laparoscopic PEH repairs being associated
with a low incidence of recurrence and reoperation in a series of 166 patients. Improvement was seen in
heartburn, regurgitation, dysphagia, and chest pain with an overall 6% reoperation rate for symptomatic
PEH (1.2%), reflux (2.4%), and dysphagia (2.4%). With the exception of fundoplication wrap failure in
which all required reoperation, one-third of recurrences required surgery, whereas one-tenth of sliding
hiatal hernias required surgery; so overall, the reoperation rate is quite low.
Redo antireflux procedures: In a series of 124 patients, four major failure mechanisms were noticed by
Ohnmacht et al.15: recurrent hiatal hernia (65%), disrupted fundoplication (32%), perigastric
fundoplication (14.5%), and tight fundoplication and hiatal closure (10%).
Use of mesh: A sentinel series by Oelschlager et al. of patients undergoing crural repair with small
intestine submucosa (Surgisis, Cook Medical, Bloomington, IN) mesh initially showed promising data for
decreased PEH recurrence rate at 6 months (9% Surgisis, 24% primary repair),10 but the same group
demonstrated that long-term follow-up at a median of 58 months showed no statistical difference (54%
Surgisis, 59% primary repair).11 Notwithstanding shape and material (bioprosthetic vs. synthetic) of mesh
used, these studies may be updated in years to come with the use of bioabsorbable mesh, acellular
dermal matrix, and various types of synthetic mesh. Ringley et al.12 reported the use of acellular dermal
matrix (AlloDerm, LifeCell Corporation, Bridgewater, NJ) with an initial 6-month follow-up without
recurrence versus primary closure involving 9% recurrence. We do not advocate, therefore, prohibiting
the use of mesh in PEH repair at this time.
Choice of antireflux operation: A prospective, randomized trial by Koch et al.16 of 50 patients in each arm
of Nissen versus Toupet fundoplication demonstrated that Nissen procedures favored improvement in
hoarseness and showed significant improvement in outcomes manometrically and via multichannel
impedance imaging, whereas the Toupet fundoplication was favored by lower dysphagia, inability to
belch, and bowel symptoms. Nonetheless, both procedures improved gastrointestinal quality of life
indices, GERD symptoms, reconstructed LES pressures, cough and asthma symptoms.
COMPLICATIONS
PEH recurrence
Mesh erosion
Dysphagia
Esophageal stricture
Gas bloat syndrome
Recurrent GERD
Slipped antireflux procedure
REFERENCES
1. Allison PR. Reflux esophagitis, sliding hiatal hernia, and the anatomy of repair. Surg Gynecol Obstet.
1951;92(4):419-431.
2. Stylopoulos N, Rattner D. The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann Surg.
2005;241(1):185-193.
3. Ahad S, Oelschlager BK. Laparoscopic repair of paraesophageal hernias. In: Soper NJ, Swanstrom LL,
Eubanks WS, et al, eds. Mastery of Endoscopic and Laparoscopic Surgery. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2009:122-129.
4. Nissen R. A simple operation for control of reflux esophagitis [in German]. Schweiz Med Wochenschr.
1956;86(suppl 20): 590-592.
5. Minjarez RC, Jobe BA. Surgical therapy for gastroesophageal reflux disease. GI Motility Online. 2006.
doi:10.1038/gimo56.
6. Mori T, Nagao G, Sugiyama M. Paraesophageal hernia repair. Ann Thorac Cardiovasc Surg.
2012;18(4):297-305.
7. Nguyen NT, Christie C, Masoomi H, et al. Utilization and outcomes of laparoscopic versus open
paraesophageal hernia repair. Am Surg. 2011;77(10):1353-1357.
8. Zaninotto G, Costantini M, Rizzetto C, et al. Four hundred laparoscopic myotomies for esophageal
achalasia: a single centre experience. Ann Surg. 2008;248(6):986-993.
9. DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease.
Evaluation of primary repair in 100 consecutive patients. Ann Surg. 1986;204(1):9-20.
10. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after
laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized
trial. J Am Coll Surg. 2011;213(4):461-468.
P.12
11. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic
paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006;244(4):481-490.
12. Ringley CD, Bochkarev V, Ahmed SI, et al. Laparoscopic hiatal hernia repair with human acellular dermal
matrix patch: our initial experience. Am J Surg. 2006;192(6):767-772.
13. Soricelli E, Basso N, Genco A, et al. Long-term results of hiatal hernia mesh repair and antireflux
laparoscopic surgery. Surg Endosc. 2009;23(11):2499-2504. doi:10.1007/s00464-009-0425-3.
14. Andujar JJ, Papasavas PK, Birdas T, et al. Laparoscopic repair of large paraesophageal hernia is
associated with a low incidence of recurrence and reoperation. Surg Endosc. 2004;18(3):444-447.
15. Ohnmacht GA, Deschamps C, Cassivi SD, et al. Failed antireflux surgery: results after reoperation. Ann
Thorac Surg. 2006;81(6): 2050-2053; discussion 2053-2054.
16. Koch OO, Kaindlstorfer A, Antoniou SA, et al. Laparoscopic Nissen versus Toupet fundoplication:
objective and subjective results of a prospective randomized trial. Surg Endosc. 2012;26(2):413-422.
Chapter 2
Collis Gastroplasty
John G. Hunter
Mark J. Eichler
DEFINITION
Encountering a foreshortened esophagus during surgery at the hiatus, a lengthening procedure is
necessary for adequate distal abdominal esophageal length for an antireflux pro cedure. First described
in Thorax by John Leigh Collis in 1957 for patients with a short esophagus and hiatal her nia, with or
without reflux, a gastroplasty is performed via a thoracotomy on the left aspect of the herniated proximal
stomach.1 This technique has subsequently evolved through thoracoscopic and laparoscopic means for
hiatal hernia re pairs as well as reflux disease in order to lengthen the ab dominal portion of the
esophagus for an adequate axial distance around which to perform gastric fundoplication. The Collis
gastroplasty commonly involves a laparoscopic stapling technique about the gastroesophageal junction
(GEJ) by removing a wedge of stomach at the angle of His, thereby lengthening the effective distal
esophageal dimen sion intraabdominally, about which a fundoplication can be wrapped.2

Secondary to chronic acid inflammation and subsequent fibrotic remodeling of the distal esophagus,
approximately 10% to 25% of patients with reflux have a shortened esophagus.3,4 The majority of these
patients, however, do not need an esophageal lengthening procedure for a tension-free fundoplication if
adequate mediastinal dis section gains return of abdominal esophageal length.5 Sufficient intraabdominal
length can be evidenced by the GEJ lying intraabdominally with a distance between the diaphragmatic hiatus
and the GEJ of at least 2.5 cm. It is at this threshold of 2.5 cm (approximately the length of a fully opened
atraumatic laparoscopic grasper) after ad equate mediastinal and crural dissection should the deci sion to
perform a Collis gastroplasty take place,3 with an overall incidence of implementation of 3% to 4% of reflux
operations.

The preoperative workup for reflux disease spans endoscopy (esophagogastroduodenoscopy [EGD]),
esophagography (upper gastrointestinal contrast swallow or esophagram), manometry, and pH probe testing.
However, there is no gold-standard radiologic imaging study for preoperative preparation in reflux disease, as
the surgical decision mak ing to perform a Collis gastroplasty is done ultimately intraoperatively. Yet,
esophagography and endoscopy may be the optimal studies to demonstrate a foreshortened esophagus by
the following signs6:
Hiatal hernia of 5 cm or more

Giant type III paraesophageal hernia (FIG 1)
Esophagitis, Barrett's changes, and/or stricture
SURGICAL MANAGEMENT
Because the Collis gastroplasty is an adjunctive procedure during gastric fundoplication, the principles of a
proper antireflux procedure (wrap) or gastropexy apply, including left and right crural exposure, adequate
mediastinal dissection, atraumatic esophageal retraction, and division of the short gastric vessels. Please refer
to Chapters 1 and 5 for further details.
All studies, including esophagram, EGD, manometry, and pH testing should be readily available and reviewed
prior to and at the time of surgery. The esophagram should be displayed on a spare or dedicated monitor in
the operating theater and EGD images be loaded as well for intraoperative reference.
Attention to fine detail of the manometric report may avoid an unnecessary and detrimental 360-degree
fundoplication, as a complete wrap may worsen symptoms in the light of the following findings7:
Severe esophageal dysmotility
Very low residual postrelaxation lower esophageal sphincter (LES) pressures less than 30 mmHg during
wet swallow
Positioning
Although there are many port placement techniques, the sta pled Collis gastroplasty necessitates a left upper
quadrant, endoscopic, angulating stapler by the surgeon's right hand through a 12-mm trocar. Steep reverse
Trendelenburg is the position of choice (FIG 2).
FIG 1 • Esophagram demonstrating tortuous esophagus with shortening, distal narrowing or strictures, and a
type III paraesophageal hiatal hernia.
P.14
Assume extensive mediastinal dissection will be warranted, and therefore, risk of pleural compromise (FIG 3).
The sterile skin preparation must be wide enough on either flank in case tube thoracostomies are necessary
from resultant pneumothorax. However, a red rubber catheter between 10 and 14 Fr may be placed in a
witnessed pleural defect intraabdominally spanning the diaphragm to the hemithorax in question. This reduces
the resultant pneumothorax and peak ventilatory pressures with the aid of lowering insufflation pressures as
well as anesthesia-assisted ventilatory Valsalva.
FIG 2 • Patient positioning for foregut and antireflux procedures and trocar placement. The left upper quadrant
12-mm port is used for the angulated stapler in the surgeon's right hand.
FIG 3 • Demonstration of adequate dissection of the mediastinum with clear visibility of the left and right crura,
aorta posteriorly, and proximal length achieved of the distal esophagus.
TECHNIQUES
MEASUREMENT OF GASTROPLASTY
As mentioned in the “Positioning” section, this is an adjunctive maneuver, and thus, as previously
described, adequate mediastinal, hiatal, and perigastric dissection should have already taken place.
Dissect the fat pad from the GEJ to expose the trajectories of stapler firing (FIG 4).
Remove any orogastric, nasogastric, or bougie first to recreate the nascent relaxed anatomy of the GEJ.
From a posterior gastric approach, pull the left crus to the right, approximating it with the right crus. This
demonstrates the relaxed position of the crura upon closure of the hiatus.
FIG 4 • GEJ fat pad dissection. The fat pad is elevated with an atraumatic grasper by the first assistant
while the surgeon, with his left hand, defines the gastric wall, thus providing countertraction.
P.15
With an open, premeasured grasper, the intraabdominal length for the gastroplasty is then estimated
(FIG 5). A distance from the anterior hiatus to the GEJ of less than 2.5 to 3 cm warrants the Collis
gastroplasty. Measure from the relaxed hiatus 3 cm distally along a trajectory past the GEJ, if a bougie
were inserted endoluminally, and 1 cm laterally. Here, mark with electrocautery the placement of the first
perpendicular staple firing.
FIG 5 • Measurement of intraabdominal length of esophagus. With a closed crura, the minimum distance
between the GEJ and the diaphragm should be at least 2.5 cm, or the approximate length of an opened
atraumatic grasper.
INTRAABDOMINAL RETRACTION AND BOUGIE PLACEMENT

A 48-Fr dilator is placed transorally up to 55 cm from the incisors (FIG 6). This serves as the stent about
which the Collis gastroplasty is performed. The surgeon's left hand retracts the cardia toward the
patient's left shoulder while the assistant retracts the greater curve laterally to the left flank.
FIG 6 • Marking of Collis gastroplasty. With a 48-Fr dilator in place and Penrose drain released, measure
2.5 to 3 cm distal to the closed diaphragm from the angle of His and then due left laterally.
FIRST STAPLE TRAJECTORY

The first stapled trajectory is usually performed with one or two firings of a rotating and articulating
endoscopic stapler with medium-sized loads (3 to 4 mm) using a 45-mm length Endo GIA purple load
(Covidien, Mansfield, MA). With the endoscopic stapler articulated to the maximum degree in the
surgeon's right hand, a 90-degree stapling is performed up to the body of the dilator on the left side of the
patient just distal to the point predetermined and marked with electrocautery (FIG 7A-C).
P.16
FIG 7 • A. First staple trajectory. B. Maximal articulation of the stapler to the surgeon's left, aiming toward
the previously marked spot adjacent to the dilator. This may take one or two firings to approximate the
staple line so it abuts the inserted dilator (C).
SECOND STAPLE TRAJECTORY

The second stapled trajectory is parallel to the dilator and cephalad (FIG 8A,B). Again, one or two
medium-sized staple loads might be needed. Be careful to not include the Penrose drain in the staple
line; it may be placed into the mediastinum temporarily during the second set of staple firings. The proper
Collis gastroplasty juxtaposes the resultant parallel staple line abutting the esophagus (FIG 8C).
FIG 8 • A. Second staple trajectory. B. The vertical staple line is created by firing the gastrointestinal
anastomosis (GIA) stapler parallel and flush against the upward dilator to create a tight tube. C. The
resultant gastric staple line abuts the esophagus.
P.17
REMOVAL OF THE STOMACH WEDGE
Remove the wedge of stomach through any means, whether directly through the trocar, via an
endoscopic bag, or by removing the entire trocar. This concludes the Collis gastroplasty portion of the
procedure.
COMPLETION OF THE FUNDOPLICATION
Perform the intended complete or partial wrap as described in other chapters, along with crural closure.
Whether a complete (Nissen; 360 degrees) or partial (Toupet; 270 degrees) fundoplication is performed
(FIG 9), the stapled wedge Collis gastroplasty should eventually orient the staple line posteriorly as
assessed on EGD.
FIG 9 • Completion of the antireflux procedure (fundoplication).
PEARLS AND PITFALLS
Inadequate ▪ It is sometimes disconcerting to staple onto an endoluminal foreign body (dilator),

first staple but it is virtually impossible to staple across a 48-Fr dilator. Failure to staple up to and
firing abutting the dilator will result in a floppy distal esophagus and decrease the efficacy
of the fundoplication.
Use of short ▪ The region of the esophageal hiatus is tight quarters. The articulating stapler of 45
staple loads mm is preferred over a longer stapler because of the steep angulation needed in
for first staple these tight spaces. Multiple firings may be needed.
firing
Mismeasure of ▪ Key to the measurement of true intraabdominal length is the natural lay of the
intraabdominal esophagus in the steep reverse Trendelenburg position. Do not insert a dilator,
length nasogastric, or orogastric tube during this step. Remember to close the crura
manually and assess the lay of the esophagus before measuring this length.
Inadequate ▪ Inadequate mediastinal dissection results in incomplete abdominal length of the

mediastinal esophagus. Hence, the use of a Collis gastroplasty, and therefore risk of staple line
dissection leak, can be avoided with intraoperative diligence.
Pneumothorax ▪ Prep into the field the bilateral lower chest cavities that would access each
hemithorax in case a percutaneous tube thoracostomy is needed. Our first
recommendation, however, if peak ventilatory pressures are high from a
pneumothorax, is to decompress the affected side with the placement of a red rubber
catheter through a working 12-mm port and lay it from the hemithorax in question with
the opposite end intraabdominally. The anesthesiologist can assist with manual
bagging Valsalva maneuvers. If this step is refractory, place the tip of the red rubber
catheter intrathoracically and pull the end through a trocar port into a bowl of sterile
saline, desufflate the abdomen, and again, ask the anesthesiologist to assist with
Valsalva.
Left lateral ▪ Upon full dissection, the wedge removed should lie on the left lateral aspect along
wedge the GEJ, that is, the angle of His, in a plane parallel to the operating table.
P.18
POSTOPERATIVE CARE
Nasogastric tube decompression is not routine. Even if injury or perforation occurs to the stomach during
dissection, as long as the tissue is repaired properly and a resultant negative intraoperative leak test
(methylene blue infusion through the intraoperative orogastric tube or EGD air insufflation in pooled
intracorporeal saline in Trendelenburg position) occurs, nasogastric decompression is not a necessity.
With extensive mediastinal dissection and stapled gastroplasty, the risk of (missed) perforation and leak
should be assessed. Strict nil per os (NPO) status overnight, followed by a postoperative day (POD) 1 water-
soluble contrast esophagram is performed to assess leak as well as functional clearance of contrast material.
If negative, the patient is advanced to a clear liquid diet on POD 1 and discharged on either the eve of POD 1
or on POD 2 with a full liquid or pureed diet.
Acid suppression therapy is warranted as the gastroplasty involved gastric mucosa in the region of the newly
reconstructed GEJ.
OUTCOMES
The use of the Collis gastroplasty is usually relegated to the foreshortened esophagus during antireflux
surgery, with etiology including large type III paraesophageal her nias and acid-related strictures. This
procedure has histor ically evolved, especially with the advent of laparoscopy. The outcomes of the
procedure are difficult to quantify in terms of efficacy because the procedure is often combined with
fundoplication (partial and complete) and/or hiatal hernia repair (types I to IV). In general, in experienced
hands, the rate of recurrence of hernia, postoperative leak rate, and stricture are low8,9 and can be
quantified as low as 0% in 4-year follow-up to low double-digit percentages in longer studies.
COMPLICATIONS
Recurrent hiatal hernia
“Slipped” Nissen Postoperative staple line leak
Leak from extensive mediastinal dissection
REFERENCES
1. Collis JL. An operation for hiatus hernia with short oesophagus. Thorax. 1957;12(3):181-188.
2. Terry ML, Vernon A, Hunter JG. Stapled-wedge Collis gastroplasty for the shortened esophagus. Am J
Surg. 2004;188(2):195-199.
3. Johnson AB, Oddsdottir M, Hunter JG. Laparoscopic Collis gastroplasty and Nissen fundoplication. A new
technique for the management of esophageal foreshortening. Surg Endosc. 1998;12(8):1055-1060.
4. Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic Collis gastroplasty is the treatment of choice for
the shortened esophagus. Am J Surg. 1996;171(5):477-481.
5. O'Rourke RW, Khajanchee YS, Urbach DR, et al. Extended transmediastinal dissection: an alternative to
gastroplasty for short esophagus. Arch Surg. 2003;138(7):735-740.
6. Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: pathophysiology, incidence, presentation,
and treatment in the era of laparoscopic antireflux surgery. Ann Surg. 2000;232(5):630-640.
7. Limpert PA, Naunheim KS. Partial versus complete fundoplication: is there a correct answer? Surg Clin
North Am. 2005;85(3):399-410.
8. Durand L, De Antón R, Caracoche M, et al. Short esophagus: selection of patients for surgery and long-
term results. Surg Endosc. 2012;26(3):704-713.
9. Nason KS, Luketich JD, Awais O, et al. Quality of life after collis gastroplasty for short esophagus in
patients with paraesophageal hernia. Ann Thorac Surg. 2011;92(5):1854-1860; discussion 1860-1861.
Chapter 3
Laparoscopic Mesh Hiatal Hernia Repair
Ellen H. Morrow
Brant K. Oelschlager
DEFINITION
A hiatal hernia is an enlarged diaphragmatic hiatus, allowing for passage of the stomach or other organs
into the chest.
Hiatal hernia is traditionally divided into several types; the principle difference is sliding versus
paraesophageal. The sliding type is much more common. This is type I.
Paraesophageal is type II. This involves herniation of the stomach above the gastroesophageal (GE)
junction, which remains in the abdomen.
Type III is a combination of types I and II, with the GE junction in the chest, but with stomach herniating
above it. This is also referred to as a paraesophageal hernia (PEH) and is much more common than a
type II.
A type IV PEH involves herniation of additional organs other than stomach such as the transverse colon.
DIFFERENTIAL DIAGNOSIS
The type of hiatal hernia should be discerned as described under definition and differentiated from other
nonhiatal diaphragmatic hernias.
This is a diagnosis that is often made with imaging prior to surgical referral. If imaging has not yet been
performed, there are other entities that could have similar clinical presentation.
These include gastroesophageal reflux disease (GERD), gastritis, peptic ulcer disease, chronic
mesenteric ischemia, angina, myocardial infarction, or aortic dissection.

Like type I hernias, these patients may present with GERD symptoms (e.g., heartburn, regurgitation,
symptoms related to aspiration, etc.); however, at least half of patients will not complain of significant GERD.
Patients will often present with a history of postprandial abdominal or chest pain, early satiety, dysphagia, and
regurgitation. Symptoms are frequently related to the volume of food they have consumed. They may have
associated weight loss.
PEHs can also present with respiratory symptoms such as dyspnea or cough. Anemia is a common presenting
symptom of a large hiatal hernia and is often the only finding in a gastrointestinal (GI) workup.
Rarely, PEHs can present with acute obstruction.
This is often caused by gastric volvulus.
This will present with increased severity of symptoms; complete intolerance to oral intake; severe pain; and
occasionally, even systemic inflammatory response or sepsis if the stomach becomes ischemic.
There are not generally physical findings specific to this condition.
The patient can be examined for changes associated with GERD in the oropharynx.
Abdominal exam may reveal some epigastric tenderness.
There may be signs of weight loss or overall frailty.
There may be diminished breath sounds.

The workup for hiatal hernia is similar to the GERD workup.
An esophagram is often the most valuable study; this provides images of the hernia in a dynamic fashion using
fluoroscopy (FIG 1). This is the best study for getting an overall size and position of the stomach within the
hernia.
Hernias are frequently diagnosed on computed tomography (CT) for abdominal pain, although this is not the
initial test to obtain if you are most suspicious of hiatal hernia. It will, however, usually make the diagnosis and
can rule in or out other things.
Upper endoscopy can be helpful for visualizing the size of the hernia and more for examining the mucosa for
associated conditions.
Cameron's erosions are linear erosions that can be found in the stomach related to constriction by the
diaphragm.
Changes related to associated GERD can also be seen in the esophagus such as erosive esophagitis and
Barrett's esophagus.
Any neoplastic lesion should be ruled out prior to operative repair.
FIG 1 • Upper GI study demonstrated large hiatal hernia with stomach in the chest.
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Manometry is valuable in planning the antireflux procedure that will be performed in conjunction with repair of
the hernia. Normal motility will allow for creation of a full wrap, as opposed to partial.
pH testing is not generally required, unless the patient is presenting primarily with GERD symptoms. In this
case, it may be useful as a baseline.
SURGICAL MANAGEMENT
Indications for repair of hiatal hernias:
Sliding hiatal hernias (type I) should not be repaired unless the indication is associated GERD, in which
case, they should be repaired at the time of planned fundoplication.
PEHs (types II to IV) should generally be repaired if symptomatic. In younger (<60 years of age) and
healthier patients, repair of even relatively asymptomatic hernias is indicated given the risk of incarceration,
although this risk is smaller than once thought.
Mesh hiatal hernia repairs generally need to be considered only in patients with PEHs (larger hernias).
Many patients with hiatal hernias are elderly, and they may have serious comorbidities or frailty. In these
patients, a thorough medical evaluation should be completed prior to any elective hernia repair.
Some of them may be too frail or high risk for a full hiatal hernia repair with fundoplication but are very
symptomatic and need intervention. In these patients, it may be more prudent to plan for a shorter procedure
without full dissection of the hernia sac; hernia reduction with gastrostomy tube gastropexy may be more
appropriate in these patients.
Positioning
As for other foregut procedures, patients should be in low lithotomy with a beanbag support and both arms
tucked (FIG 2).
The patient will be in steep reverse Trendelenburg for most of the case.
The surgeon can operate from the foot of the table, with the assistant on the patient's left.
FIG 2 • Patient positioning for hiatal hernia repair; low lithotomy. The surgeon stands between the patient's legs
with the assistant on the patient's left.
TECHNIQUES
SETUP AND PORT PLACEMENT
After sterile prep, the upper abdomen is draped. Equipment for laparoscopy is passed off and secured.
The peritoneal cavity is accessed using a Veress needle, and pneumoperitoneum is obtained.
An 11-mm cutting optical trocar is inserted in the left subcostal position.
Additional ports are placed under direct vision as follows (FIG 3):
Camera port (11 mm) in epigastric position; a 5-mm port can also be placed here depending on
surgeon preference for scope size.
Assistant (5 mm) port in left lateral position Surgeon's left hand port (5 mm) in right upper quadrant
A Nathanson liver retractor is then placed in the upper midline for retraction of the left lobe.
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FIG 3 • Port placement for hiatal hernia repair.
REDUCTION
The stomach and any other hernia contents are reduced into the abdominal cavity as possible; with a
PEH, the stomach will almost never fully reduce and the surgeon should not attempt to do so. Just
reduce the stomach that is free and not attached within the mediastinum.
MOBILIZATION
The short gastric vessels are ligated with an electrical or ultrasonic sealing device in order to mobilize the
fundus fully. Begin ligation near the inferior border of the spleen (see FIG 3).
Care must be taken to also divide any attachments or vessels between the fundus and the
retroperitoneum as adhesions are common.
DISSECTION OF HIATUS AND HERNIA SAC
The phrenoesophageal membrane and hernia sac are divided at the muscular edge of the crus.
Once the crus is visualized, the surgeon can be assured that all layers of the sac have been divided. In
this way, the surgeon begins to develop a plane outside of the hernia sac and not within it.
The attachment of the sac to the hiatus is divided until it is freed circumferentially. After this is complete,
the sac is released from the mediastinum, with care to avoid the pleura (FIGS 4 and 5). This is facilitated
with the use of gentle traction and the diffusion of carbon dioxide (CO2) from the pneumoperitoneum.
The appropriate plane should appear areolar and largely avascular.
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FIG 4 • Line drawing (A) and intraoperative photo (B) of mediastinal dissection. The herniated stomach is
seen on the left side of the screen. Electrocautery is used to divide the sac, revealing an areolar plane in
the mediastinum outside the sac.
FIG 5 • A large hiatal hernia defect. Dissection of the sac was begun from the patient's left side. The sac is
still connected to the herniated stomach in the central anterior mediastinum.
ESOPHAGEAL MOBILIZATION
A Penrose drain is then placed around the distal esophagus and used to place downward and alternating
lateral traction on the esophagus as it is circumferentially mobilized in the mediastinum.
Care is taken to ligate or cauterize small vessels in the mediastinum as needed.
Mobilization is continued until the GE junction lies in the abdomen without tension, preferably with 3 cm of
esophagus in the abdomen.
In the setting of a large hiatal or PEH, the esophagus is always relatively foreshortened. If aggressive
mobilization of the mediastinal esophagus is performed, in our experience, adequate esophageal length
can be obtained. If not, then an esophageal lengthening procedure will be needed (see Chapter 2).
A lighted bougie is then placed into the esophagus and stomach by the anesthesia team. Careful
communication between the anesthesia and surgical teams is required to avoid complications during
placement of the bougie. The
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anesthetist should be able to see one of the laparoscopy monitors. If there is any question as to the
location of the esophagus earlier in the procedure, the lighted bougie can be helpful in locating it.
The hernia sac is then amputated and removed. The anterior vagus nerve should be identified and
preserved here as long as adequate esophageal mobilization has been obtained. This is done by only
removing the anterior sac to the left of the vagus nerve.
Adequate removal of the hernia sac facilitates the fundoplication later.
If esophageal mobilization has been inadequate, the vagus can be ligated here,1 or a Collis or wedge
gastroplasty can be performed.2
CRURAL CLOSURE
The crura are reapproximated using permanent suture (FIG 6).
Most of the closure should be posterior, as the muscle is more robust there.
Occasionally, adequate closure cannot be achieved with only posterior suturing due to the size of the
defect; in this case, a relaxing incision or anterior sutures may be required.
A relaxing incision can be made on the right side of the right crus to release the right crus toward the left
and allow for hiatal closure.
FIG 6 • Primary repair of the crural defect posteriorly with interrupted sutures.
MESH PLACEMENT
A biologic mesh is then cut to cover the defect, usually in a U or C shape.
This is introduced through an 11-mm port and placed flat against the hiatus.
Permanent sutures are then used to secure the superior aspects of the mesh to the crus on either side
(FIG 7).
The mesh can be completely secured with suture, or the remaining fixation can be performed with fibrin
glue.
If a relaxing incision was necessary, it should also be covered by the mesh.
FIG 7 • View of mesh placement from the patient's left side. It is secured with suture superiorly and fibrin
glue inferiorly. The mesh covers the posterior defect.
FUNDOPLICATION
Full fundoplication should be performed as long as the patient's esophageal motility allows, to treat reflux
and to prevent reherniation. Fundoplication technique is described in another chapter (FIG 8).
Intraoperative endoscopy should be performed at the conclusion of the case to confirm wrap positioning
and location of the GE junction in the abdomen.
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FIG 8 • Line drawing (A) and intraoperative photo (B) of full fundoplication.
PEARLS AND PITFALLS
Indications ▪ Only symptomatic (GERD associated) sliding hernias should be repaired.

▪ All PEHs (types II to IV) can be considered for repair given the risks of volvulus and
obstruction.
Patient ▪ In elderly or infirm patients, consider gastropexy as an alternative to PEH repair.

selection ▪ In morbidly obese patients, consider laparoscopic sleeve gastrectomy or gastric
bypass as an alternative operation.3
Dissection ▪ Full dissection around the sac must be accomplished. Divide the sac off of the crus
and then maintain an areolar plane in the mediastinum
Esophageal ▪ Must be carried superiorly into the mediastinum to ensure adequate intraabdominal
mobilization esophageal length (3 cm).
Mesh ▪ After primary repair of a large hiatal defect, mesh reinforcement may be used. Biologic
placement mesh has fewer potential complications4 but may have a higher recurrence rate.5
POSTOPERATIVE CARE
The patient generally has an overnight stay in the hospital.
Patients should be given an incentive spirometer, have chemical deep vein thrombosis (DVT) prophylaxis, and
prompt Foley catheter removal.
Patients can be given clear liquids on the night of surgery and the diet can be advanced the following day.
They should be discharged on a pureed diet and should progress to soft diet over the next month. Pills should
be crushed or converted to elixirs for 1 month.
Patients should anticipate at least 2 more weeks of recovery at home, depending on their age and
comorbidities.
Activity is largely unrestricted, but heavy lifting or other Valsalva maneuvers should be avoided to keep the
intraabdominal pressure down and avoid early hernia recurrence.
OUTCOMES
A recent randomized controlled trial of laparoscopic PEH repair with and without biologic mesh
demonstrated a lower recurrence rate at 6 months with biologic mesh.5
This difference in outcomes did not persist when patients were reexamined with upper GI series at a
median follow-up time of 5 years.6
At that time, the recurrence rate was found to be the same between the two groups; there was a 50%
radiographic recurrence rate.
Most of these recurrences were small and did not correlate with patient symptoms except a mildly
increased rate of heartburn.7
Despite the high rate of radiographic recurrence, all symptoms were improved at long-term follow-up.
Only 3% of patients in this trial ultimately required reoperation for hernia recurrences.
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COMPLICATIONS
As with any major abdominal surgery, complications can include bleeding, infection (either at the surgical
site or elsewhere), or thromboembolic events.
Complications that are particular to PEH repair can include postoperative respiratory compromise.
Changing pulmonary physiology after reduction of the herniated stomach, general anesthesia, and
postoperative abdominal pain can lead to increased dyspnea and oxygen requirement during the
immediate postoperative period.
This generally stabilizes enough for discharge within 1 to 2 days or the patient can be discharged on a
short course of home oxygen.
Pneumothorax can occur intraoperatively during mediastinal dissection. The pleura should be repaired to
prevent further insufflation of the pleural cavity with CO2. Once the pleura is closed and the abdomen is
desufflated, the CO2 is reabsorbed quickly and decompression is not generally required.
Following fundoplication, there can be some dysphagia during the early postoperative period. This can
generally be managed with dietary modification. Bloating can also be a complaint early on.
Hernia recurrence is a potential complication. Recurrence was covered in the “Outcomes” section.
REFERENCES
1. Oelschlager BK, Yamamoto K, Woltman T, et al. Vagotomy during hiatal hernia repair: a benign
esophageal lengthening procedure. J Gastrointest Surg. 2008;12:1155-1162.
2. Luketich JD, Grondin SC, Pearson FG. Minimally invasive approaches to acquired shortening of the
esophagus: laparoscopic Collis-Nissen gastroplasty. Semin Thorac Cardiovasc Surg. 2000;12(3): 173-178.
3. Cuenca-Abente F, Parra JD, Oelschlager BK. Laparoscopic sleeve gastrectomy: an alternative for
recurrent paraesophageal hernias in obese patients. JSLS. 2006;10:86-89.
4. Tatum RP, Shalhub S, Oelschlager BK. Complications of PTFE mesh at the diaphragmatic hiatus. J
Gastrointest Surg. 2008;12:953-957.
5. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis reduces recurrence after laparoscopic
paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006;244(4): 481-490.
6. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after
laparopscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized
trial. J Am Coll Surg. 2011;213:461-468.
7. Oelschlager BK, Petersen RP, Brunt LM, et al. Laparoscopic paraesophageal hernia repair: defining long-
term clinical and anatomic outcomes. J Gastrointest Surg. 2012;16:453-459.
Chapter 4
Transthoracic Hiatal Hernia Repair
Jules Lin
Mark Orringer
DEFINITION
The combined Collis-Nissen transthoracic hiatal hernia repair described in this chapter involves
mobilization of the distal esophagus, herniated stomach and hernia sac, preservation of the vagus
nerves, and a fundoplication through a left posterolateral thoracotomy with an esophageal lengthening
procedure when necessary (to allow a 3- to 5-cm tension-free intraabdominal segment of distal
“esophagus”).
The two major categories of hiatal hernias include sliding (type I) and paraesophageal (type II, pure
paraesophageal hernia with the gastroesophageal junction fixed at the hiatus; type III, combined hiatal
hernia where the cardia is above the diaphragm and the fundus is herniated alongside the esophagus;
and type IV, with herniation of the stomach along with the colon, small bowel, or spleen) (FIG 1).1,2 and 3
FIG 1 • The various types of hiatal hernias are illustrated: type I, sliding hiatal hernia; type II, pure
paraesophageal hernia with the gastroesophageal junction fixed at the hiatus; type III, combined hiatal
hernia with the cardia above the diaphragm and the fundus herniated along the esophagus; and type IV,
with herniation of the stomach along with the colon, small bowel, or spleen.
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A detailed history and physical must be performed focusing on heartburn and reflux symptoms, response to
medical treatment as well as the characteristics and degree of dysphagia, regurgitation, pain, bloating, or
anemia. In a series of 240 patients with a paraesophageal hernia, Patel et al.4 found that 68% of patients had
reflux symptoms, 67% abdominal or chest pain, 33% anemia, and 33% dysphagia. The absence of severe
reflux symptoms in most patients with paraesophageal hiatal hernias does not diminish the seriousness of this
problem with its unpredictable potential for strangulation, perforation, bleeding, and aspiration pneumonia.
More subtle symptoms may include early satiety and/or left shoulder and back pain with eating, loud
borborygmi often heard across the room by the patient's family, or acute shortness of breath with bending
forward.
Any previous chest or abdominal operations or endoscopic dilations should be noted.
The history should include the patient's current functional status and exercise tolerance.
A complete physical examination should be performed with attention to auscultation of the heart and lungs and
palpation of the abdomen.
Routine laboratory studies, including a complete blood count and a basic chemistry panel, should be included
as part of the preoperative evaluation.

A chest x-ray (FIG 2) may show a mediastinal air fluid level, suggesting the presence of a paraesophageal
hernia.
A barium swallow (FIG 3) should be performed to delineate the esophageal and gastric anatomy and may
show reflux, although this is not a reliable finding. Accompanying esophageal dysmotility from the
“accordioned” esophagus is common. The esophagram can also be useful when obstruction from gastric
volvulus is suspected (FIG 4).
FIG 2 • Chest x-ray demonstrates an air fluid level (arrowhead) consistent with a type III hiatal hernia.
FIG 3 • Barium swallow demonstrating a type III paraesophageal hernia.
An esophagoscopy (FIG 5) should be performed to evaluate for evidence of esophagitis, Barrett's mucosa,
esophageal carcinoma, or esophageal shortening. Suspicious areas should be biopsied. The gastric mucosa
should also be examined for Cameron erosions, especially when there is a history of anemia. Caution should
be exercised to avoid excessive air insufflation during flexible esophagogastroscopy in the patient with a
paraesophageal hiatal hernia lest the intrathoracic stomach becomes overdistended, resulting in
hemodynamic instability.
For patients complaining of persistent nausea, a gastric emptying study may be obtained to evaluate for
gastroparesis.
When there is no hiatal hernia or a small sliding hiatal hernia, esophageal manometry and 24-hour pH probe
monitoring with impedance are performed, with antireflux medications discontinued for 72 hours, to document
the presence of gastroesophageal reflux, association with the patient's symptoms, and to evaluate for
esophageal dysmotility. However, in the presence of a paraesophageal hernia, we do not routinely perform
these studies. Many of these patients will have some degree of dysmotility in the presence of a chronic hiatal
hernia that frequently improves after hiatal hernia repair. The presence of a symptomatic hiatal hernia is a
mechanical issue, and the indication for repair is the paraesophageal hernia itself regardless of the presence
of acid reflux.
Patients suspected of having an incarcerated hiatal hernia (FIG 4) with severe epigastric pain and
regurgitation should undergo an esophagram and nasogastric tube decompression followed by an emergent
hiatal hernia repair.
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FIG 4 • A. Chest x-ray and (B) barium esophagram showing an incarcerated type III hiatal hernia with complete
obstruction requiring emergent repair.
SURGICAL MANAGEMENT
Indications
Sliding hiatal hernias are repaired when there has been incomplete control of reflux symptoms despite
medical therapy (Table 1) and after confirmation of abnormal acid reflux on 24-hour pH probe. Other
indications include complications of gastroesophageal reflux disease (GERD)—recurrent aspiration, the
development of a reflux stricture, and recurrent bleeding from esophagitis.
Paraesophageal hernias are more likely to present with obstructive symptoms due to the chronic gastric
volvulus and repair is generally recommended in the functional patient.3
There has been controversy regarding the optimal surgical approach (laparoscopic vs. transthoracic), the
need for an antireflux procedure, and the assessment of esophageal
shortening.1,5,6,7,8,9,10,11,12,13,14,15,16,17,18 and 19 The pneumoperitoneum used during laparoscopic
repair displaces the diaphragm upward, making intraoperative assessment of esophageal shortening
more challenging. In addition, performing a lengthening procedure laparoscopically is more difficult due to
the angle of the approach. Taking adequate bites of the attenuated crura is also more difficult due to the
tension induced by the pneumoperitoneum, which could contribute to hernia recurrence after
laparoscopic repair. A transthoracic approach with an esophageal lengthening procedure, similar to a
relaxing incision for an inguinal hernia repair, may be optimal even for a small sliding hiatal hernia in
morbidly obese patients due to the increased risk of recurrence. In a series of 240 patients with
paraesophageal hiatal hernias, documented acid reflux decreased from 88% preoperatively to 4% after a
transthoracic Collis-Nissen procedure, whereas Williamson et al.6 reported an 18% incidence of
postoperative reflux after a selective approach to adding an antireflux procedure. As a
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result, we advocate an antireflux procedure with all paraesophageal hiatal hernia repairs.4,6
FIG 5 • Esophagoscopy with retroflexed views showing (A) a hiatal hernia, (B) erosive gastropathy, and
(C) an intact Nissen fundoplication.
Table 1: Indications for Transthoracic Hiatal Hernia Repair
Sliding hiatal hernia
Reflux symptoms with incomplete control on medical therapy

Complications of gastroesophageal reflux
Recurrent aspiration
Development of a reflux stricture
Recurrent bleeding from esophagitis
Confirmation of acid reflux on 24-hour pH probe
Paraesophageal hernia
Repair should be considered in all physically fit patients due to risk of strangulation,
perforation, or bleeding.
Esophageal lengthening procedure
Intraoperative assessment of esophageal shortening after complete mobilization of the

hernia
Obesity
Reflux esophagitis or stricture
With larger paraesophageal hernias, transthoracic Collis-Nissen repair remains the standard against
which other approaches must be compared.4
Preoperative risk assessment determines whether a patient will tolerate a thoracotomy based on exercise
tolerance and pulmonary function testing (PFT) if there is a substantial smoking history or shortness of breath.
Patients with cardiovascular risk factors or symptoms should undergo preoperative cardiac evaluation.
Patients should be informed of changes in their diet after undergoing a fundoplication, including avoiding large
pills and carbonated drinks and the possibility of gas bloat and dumping syndrome.
In the preoperative area, the history and physical should be reviewed and consent should be obtained. The
operative site on the left chest should be appropriately marked.
For pain control, an epidural catheter can be placed in the preoperative area, or a paraspinous catheter can
be inserted prior to thoracotomy closure.
Once in the operating room (OR), a flexible esophagoscopy should be performed to evaluate the anatomy and
any esophageal mucosal lesions. Overdistention of the stomach with air insufflation must be avoided. After the
scope is removed, a 16-Fr nasogastric tube is placed to decompress the stomach.
Single-lung ventilation is achieved with either a left-sided double lumen endotracheal tube or a bronchial
blocker.
Positioning
The patient should be placed in the right lateral decubitus position (FIG 6). The arms should be placed in an
arm holder in neutral position. The bed is flexed and the patient should be secured with all pressure points
padded.
Following positioning, the endotracheal tube position should be confirmed again by the anesthesiologist.
FIG 6 • The patient is placed in the right lateral decubitus position. The chest is entered through a standard
posterolateral 6th or 7th intercostal space thoracotomy.
TECHNIQUES
THORACOTOMY
A standard posterolateral thoracotomy is generally performed through the 6th intercostal space, although
the 7th intercostal space can be used with smaller hiatal hernias.
The serratus anterior muscle can be spared, although dividing the muscle can provide more anterior
exposure when needed and results in little, if any, functional impairment.
After carefully counting the ribs to confirm the intercostal space, the chest is entered. If a paraspinous
catheter will be used for postoperative pain control, a posterior pleural flap can be raised at this time to
prevent tearing the pleura. Chest retractors such as a Finochietto or Rienhoff are used to provide
exposure.
Exposure and Dissection of the Esophagus and Stomach
The dome of the diaphragm is retracted downward to improve exposure using cloth-covered Harrington
retractors. The inferior pulmonary ligament is divided, and the mediastinal pleura is opened (FIG 7A).
The esophagus is identified by palpating the previously placed nasogastric tube and dissected free from
surrounding tissues. Care is taken to identify and preserve the anterior and posterior vagus nerves,
which, along with the esophagus, are encircled with a Penrose drain that is used to provide tension on
the esophagus as needed (FIG 7B).
The hernia sac is dissected from the right pleura, taking care not to enter the right chest.
With upward traction on the Penrose drain, the hernia sac overlying the cardia is incised. The peritoneal
cavity is entered anterolateral to the cardia, and the phrenoesophageal attachments and hernia sac
surrounding the cardia are divided (FIG 8A,B).
The cardia is retracted anteriorly and the peritoneum medial to the cardia is incised, entering the lesser
sac. The cephalad portion of the lesser curvature is mobilized
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by partially dividing the gastrohepatic ligament, which allows the fundus to be passed posterior to the
upper stomach for the fundoplication. These attachments are divided between clamps using 2-0 silk ties
and may contain the ascending branch of the left gastric artery (FIG 8C,D). A finger is swept
circumferentially underneath the diaphragm, confirming mobilization of the cardia away from the hiatus
(FIG 8E).
FIG 7 • A. After the inferior pulmonary ligament is taken down with electrocautery, the mediastinal pleura
is opened to the level of the interior pulmonary vein exposing the distal esophagus. B. The esophagus
(asterisk) is mobilized, taking care to preserve the anterior and posterior vagus nerves, which are
encircled along with the esophagus using a Penrose.
Four to six short gastric vessels are then divided between clamps and ligated with 2-0 silk sutures (FIG
9). Care must be taken to avoid excess tension on the stomach to prevent splenic injury. The short
gastric vessels must be carefully tied. Once the vessels retract underneath the diaphragm, bleeding may
be difficult to recognize and could require a laparotomy for control.
The hernia sac is resected with electrocautery, taking care not to damage the blood supply to the
proximal lesser curvature of the stomach. The gastroesophageal fat pad is excised to expose the
gastroesophageal junction, taking care to protect the anterior and posterior vagus nerves (FIG 10).
Placement of the Crural Sutures
The mobilized fundus is then reduced through the hiatus.
An Allis clamp is placed on the tendinous portion of the medial crus. The esophagus is retracted
anteriorly. Using a spoon retractor to protect the intraabdominal contents, interrupted no. 1 silk sutures
are placed through the medial crus of the diaphragm approximately 1 cm apart starting posteriorly and
proceeding toward the esophagus (FIG 11A). Sutures must be passed through the strong tendinous
portion of the crus, which is identified by lifting the Allis clamp. All sutures are placed in the medial crus,
snapped, and placed in an Allis clamp to keep them in order.
FIG 8 • A. With upward traction on the Penrose drain encircling the esophagus and countertraction on
the diaphragm, the phrenoesophageal ligament is incised. (continued)
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FIG 8 • (continued) B. The peritoneal cavity is entered and the left lobe of the liver is visible. The
phrenoesophageal attachments and peritoneum surrounding the cardia are divided, exposing the lateral
crus (arrowhead) (stomach, asterisk; diaphragm, double asterisk). C. The gastroesophageal junction is
then retracted anteriorly and the medial crus exposed by incising the peritoneum along the posteromedial
aspect of the cardia. D. The high lesser curvature is mobilized by partially dividing the gastrohepatic
ligament (dotted line), which allows the fundus to be passed posterior to the upper stomach for the
fundoplication. These attachments are carefully ligated and may contain the ascending branch of the left
gastric artery. (continued)
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FIG 8 • (continued) E. A finger is swept circumferentially along the underside of the hiatus to confirm that
the cardia has been completely mobilized.
The sutures are then each reloaded and passed through the lateral crus (FIG 11B). Again, the
intraabdominal contents are protected with the spoon retractor and the spleen is displaced away from the
lateral crus using a Harrington retractor, pulling downward on the dome of the diaphragm. The crural
sutures are not tied at this point and are snapped and placed in an Allis clamp to keep them in order.
Esophageal shortening is often present with large hiatal hernias, increasing the risk of a recurrent hernia,
and is best assessed intraoperatively.8,9,18 If the esophagogastric junction and distal 3 cm of esophagus
do not reduce beneath the diaphragmatic hiatus without tension, an esophageal lengthening Collis
gastroplasty is performed as described in the following text.
Collis Gastroplasty and Nissen Fundoplication
A Maloney esophageal bougie (54 Fr in women and 56 Fr in men) is then placed by the first assistant or
anesthesiologist (FIG 12A). It is essential at this stage to communicate with the person passing the
bougie to ensure that the surgeon's hand is palpating and guiding the bougie as it is being passed to
prevent perforation. The bougie is advanced until 6 in remains outside of the mouth as long as it is
advancing without resistance.
With upward traction on the fundus, which is mobilized back through the hiatus and into the chest, the
dilator is displaced against the lesser curvature of the stomach. An angled ductus clamp is used to help
apply the 3.5-mm gastrointestinal anastomosis (GIA) surgical stapler to the stomach adjacent to the
dilator and parallel to the lesser curvature, lengthening the esophageal tube by approximately 5 cm (FIG
12B). Care should be taken not to apply the stapler either too tightly against the bougie, narrowing the
gastroplasty tube or, so loosely, creating a pouch that empties poorly.
The staple suture line is reinforced with two running 4-0 polydioxanone (PDS) Lembert sutures, each
proceeding from the apex of the gastroplasty incision to either the stomach or esophagus (FIG 12C).
Hemoclip markers are placed at the new esophagogastric junction for localization on imaging.
The elongated gastric fundus is passed posteriorly to the left of the gastroplasty tube and positioned for
the
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Nissen fundoplication. A 2- to 3-cm long fundoplication is constructed using interrupted 2-0 silk sutures
placed 1 cm apart, with each stitch passing from the gastric fundus to the gastroplasty tube and then to
gastric fundus again (FIG 13A,B).
FIG 9 • The gastric fundus is retracted with a Babcock clamp and four to six short gastric vessels are
ligated and divided (arrowhead), mobilizing 10 to 15 cm of the greater curvature.
FIG 10 • The fat pad (arrowhead) must be dissected from the anterolateral aspect of the esophagogastric
junction to allow accurate localization of the gastroesophageal junction for the Collis gastroplasty and
Nissen fundoplication (stomach, asterisk; esophagus, arrow). Care must be taken to identify and
preserve the anterior vagal nerve.
FIG 11 • A. An Allis clamp is placed on the tendinous portion of the medial crus (arrowhead). The
esophagus is retracted anteriorly. Sutures must be passed through the strong tendinous portion of the
crus, which is identified by lifting the Allis clamp. The sutures are placed through the medial crus starting
posteriorly and proceeding toward the esophagus, spacing the sutures 1 cm apart (stomach, asterisk;
diaphragm, double asterisk). (continued)
FIG 11 • (continued) B. The sutures are then each reloaded and passed through the lateral crus
(asterisk). The intraabdominal contents are protected with the spoon retractor and the spleen is
displaced away from the lateral crus using a Harrington retractor, pulling downward on the dome of the
diaphragm (esophagus, arrowhead).
After tying these fundoplication sutures, the silk suture line is oversewn with a 4-0 PDS running Lembert
suture to minimize the risk of a leak from the fundoplication sutures (FIG 13C).
Completion of the Hiatal Hernia Repair
The esophageal dilator is removed and a 16-Fr nasogastric tube is placed.
FIG 12 • If esophageal shortening is present, a Collis gastroplasty is performed. A. An esophageal bougie

(54 to 56 Fr) is placed with the surgeon's hand palpating and guiding the bougie as it is being passed to
prevent perforation. (continued)
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FIG 12 • (continued) B. The esophageal dilator is displaced against the lesser curvature (arrowhead) of
the stomach and an angled ductus clamp is used to help apply the 3.5-mm GIA stapler to the stomach
adjacent to the dilator and parallel to lesser curvature, lengthening the esophageal tube by approximately
5 cm. C. The staple line is oversewn with two running 4-0 PDS Lembert sutures, each proceeding from
the apex of the gastroplasty incision to either the stomach (arrow) or esophagus (arrowhead). Hemoclip
markers are placed at the new esophagogastric junction.
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FIG 13 • A. The fundus (asterisk) is passed behind the gastroplasty tube (arrowhead). B. A floppy 2- to
3-cm Nissen fundoplication is performed with 2-0 silk sutures placed 1 cm apart, passing through the
fundus (asterisk), gastroplasty tube (arrowhead), and the gastric fundus again (double asterisk).
(continued)
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FIG 13 • (continued) C. The suture line is oversewn with a 4-0 PDS running Lembert suture (asterisk).
The fundoplication is reduced through the hiatus and is secured to the undersurface of the diaphragm
with three interrupted 2-0 Prolene horizontal seromuscular mattress “Belsey” sutures, which are passed
through the diaphragm around the circumference of the hiatus (FIG 14B,C). Care must be taken during
passage of the most anteromedial suture to prevent inadvertent injury to the heart and pericardial
tamponade.
The posterior crural sutures are tied until the diaphragmatic hiatus permits the passage of an index finger
alongside the distal esophagus (FIG 15A,B). The Belsey sutures are then tied, and the completed
fundoplication should rest below the diaphragm without tension (FIG 15C).
Hemoclips are used to mark the hiatus for localization on imaging.
Thoracotomy Closure
If a paraspinous catheter will be used for pain control, a pleural flap is raised posteriorly. A paraspinous
catheter is placed percutaneously under the flap and secured to the skin with 2-0 nylon suture. The
pleural flap is reapproximated to the chest wall with 4-0 Vicryl, allowing local anesthetic to be infused
directly to the affected intercostal nerves.
A 28-Fr chest tube is inserted through a low intercostal incision, advanced to the apex, secured to the
skin, and connected to underwater seal drainage. The ribs are reapproximated with interrupted no. 2
Vicryl sutures placed around the 6th rib and through holes drilled in the 7th rib using a microdrill to avoid
nerve entrapment against the lower rib.
The wound is then closed in layers reapproximating the serratus and latissimus muscles with running 2-0
Vicryl, the subcutaneous tissues with 2-0 Vicryl, and the skin with a running 4-0 Monocryl subcuticular
suture.
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FIG 14 • A. The previously placed silk crural sutures are retracted upward and the fundoplication
(arrowhead) is reduced below the diaphragm (lateral crus, arrow). B,C. The fundoplication is secured to the
undersurface of the diaphragm (asterisk) with three interrupted 2-0 Prolene horizontal seromuscular
mattress sutures (arrowhead), which are passed through the stomach (arrow) and then the diaphragm
around the circumference of the hiatus.
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FIG 15 • A. The crural sutures (arrow) are tied until the diaphragmatic hiatus permits the passage of an
index finger (B) alongside the distal esophagus. The Belsey sutures (arrowheads) are then tied securing
the fundoplication to the undersurface of the diaphragm (A). C. The completed fundoplication is shown
resting below the diaphragm without tension.
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PEARLS AND PITFALLS
Preoperative ▪ Discuss and modify risk factors for recurrent hernia preoperatively, especially weight
evaluation loss with a goal body mass index (BMI) <32.
▪ A transthoracic approach with an esophageal lengthening procedure, similar to a
relaxing incision for an inguinal hernia repair, may be optimal even for small sliding
hiatal hernias in morbidly obese patients due to the increased risk of recurrence.
Positioning ▪ Due to the position of the liver, the hiatus cannot be adequately approached through
the right chest. All transthoracic hiatal hernia repairs should be approached through a
left thoracotomy even when the hernia is in the right chest.
Incisions ▪ For smaller hernias, the hiatal hernia repair may be easier to perform through the 7th
intercostal space, but the lower the interspace incision, the greater the degree of
postthoracotomy pain because more chest wall sensory nerves are divided.
Intraoperative ▪ Using a stockinette, a cloth-covered Harrington retractor is used to retract the

diaphragm downward to improve exposure of the hiatus, and a spoon retractor is
useful to protect the intraabdominal contents when placing the crural sutures.
▪ The anterior attachments of the high lesser curvature may contain the ascending
branch of the left gastric artery and should be ligated and divided.
▪ A counterincision parallel to and 1 to 2 cm from the hiatus can be made in the
diaphragm if additional exposure is needed during a redo hiatal hernia repair.
▪ It is essential to communicate with the person passing the bougie to ensure that the
surgeon's hand is palpating and guiding the bougie as it is being passed to prevent
perforation.
▪ Care should be taken during formation of the Collis gastroplasty not to apply the
stapler either too tightly against the bougie, narrowing the gastroplasty tube or, so
loosely, creating a pouch that empties poorly.
▪ We do not recommend the routine use of mesh due to the risk of esophageal
erosion. A transthoracic approach allows adequate bites to be taken of the crura,
which are then tied without undue tension.
▪ Hemoclip markers are placed at the new gastroesophageal junction and the
diaphragmatic hiatus for localization on imaging. The distance between the two levels
of clips represents the intraabdominal length of the distal “neoesophagus.”
Closure ▪ The ribs are reapproximated with interrupted no. 2 Vicryl sutures placed around the
6th rib and through holes drilled in the 7th rib using a microdrill to avoid nerve
entrapment against the lower rib.
▪ A chest x-ray is obtained in the OR at the end of the case to confirm reexpansion of
the lungs and to evaluate for a right pneumothorax or effusion, which may require
chest tube placement if the right pleura was entered.
POSTOPERATIVE CARE
The nasogastric tube is placed to low continuous suction. On postoperative day 2, the nasogastric tube is
placed to gravity and removed on postoperative day 3 if tolerated and the output remains less than 200 mL per
shift. The patient is then started on clear liquids with no pills. On postoperative day 4, the diet is advanced to
full liquids and then a soft diet.
The chest tube is placed to 20 cm of water suction. Chest tubes may be removed on postoperative day 2 once
the drainage has decreased to less than 60 mL per shift.
Patients should be given an adequate pain control regimen and encouraged to ambulate and use the incentive
spirometer.
On postoperative day 5, a barium swallow is obtained to assess that contrast flows freely through the
esophagus and into the stomach and duodenum and that the fundoplication is intact below the diaphragm.
Patients are seen by a dietician for education on a post-Nissen fundoplication diet. They are discharged on a
soft diet for 2 to 3 weeks and reminded to avoid large pills and carbonated beverages.
Most patients are discharged home between postoperative days 5 and 7. At discharge, the importance of
avoiding risk factors associated with hernia recurrence, including heavy lifting, constipation, or chronic
coughing, is emphasized.
Mild dysphagia occurs in less than 10% of patients and usually improves over 4 to 6 weeks as the
postoperative edema subsides.2
OUTCOMES
Transthoracic hiatal hernia repair remains the standard against which other approaches are compared.
Patel et al.4 described 240 patients undergoing repair of a paraesophageal hernia (92% type III and 8%
type IV) with an antireflux procedure in all patients and a Collis gastroplasty in 96%. Five patients (2.1%)
required an emergent repair. There were three perioperative deaths (1.7%), and the median length of
stay was 7 days.4 Early complications included recurrent hernia (four patients), leak (three patients),
excessive narrowing of the hiatus (three patients), and bleeding (one patient). Eighty-six percent of
patients were satisfied at last follow-up, with a mean follow-up of 42 months. An anatomic recurrence was
found in 23 patients (10%), with four requiring early repair and four requiring late reoperation.
Allen et al.9 reported transthoracic hiatal hernia repairs in 147 patients with 81 patients (68.1%)
undergoing a Collis-Nissen, 19 (16.0%) a Belsey-Mark IV, 17 a Nissen (14.3%), and 2 a Harrington repair
(1.7%). There were no operative deaths, and complications occurred in 32 patients (26.9%). With a
median follow-up of 42 months, results were excellent in 69 patients (60%), good in 38 patients (33%),
fair in 6 patients (5.2%), and poor in 2 patients (1.7%). Of five patients who underwent emergent repair,
three had gastric necrosis and one died.
Maziak et al.5 described 94 patients with massive, incarcerated paraesophageal hernias. Organoaxial
volvulus was present in 50% of patients. A gastroplasty was performed in 75 patients (80%) because of a
shortened esophagus. There were two operative deaths. The mean follow-up was 94 months, with 72
patients (80%) free of symptoms and 13 patients (13%) having inconsequential symptoms. Three
patients (4%) required medical therapy or esophageal dilations and two patients had recurrent hernias or
severe reflux successfully treated with a reoperation.
Rogers et al.20 reported a series of 60 patients with a paraesophageal hernia. Thirteen patients
underwent emergent repair. A transthoracic hiatal hernia repair was performed in all patients with an
antireflux procedure added selectively. There was one death after an emergent repair and one
recurrence (1.5%). Seven patients (12%) required a single esophageal dilation and two patients (3%)
developed symptomatic reflux.
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COMPLICATIONS
Bleeding
Splenectomy
Pericardial tamponade
Right pneumothorax or pleural effusion
Damage to the vagus nerves resulting in gastric outlet obstruction or dumping syndrome
Gastric leak
Persistent dysphagia requiring dilations
Recurrent hernia
REFERENCES
1. Stirling MC, Orringer MB. Surgical treatment after the failed antireflux operation. J Thorac Cardiovasc
Surg. 1986;92(4):667-672.
2. Orringer MB, Sloan H. Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann
Thorac Surg. 1978;25(1):16-21.
3. Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results
with 1,030 patients. J Thorac Cardiovasc Surg. 1967;53(1):33-54.
4. Patel HJ, Tan BB, Yee J, et al. A 25-year experience with open primary transthoracic repair of
paraesophageal hiatal hernia. J Thorac Cardiovasc Surg. 2004;127(3):843-849.
5. Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac
Cardiovasc Surg. 1998;115(1):53-60; discussion 61-62.
6. Williamson WA, Ellis FH Jr, Streitz JM Jr, et al. Paraesophageal hiatal hernia: is an antireflux procedure
necessary? Ann Thorac Surg. 1993;53(3):447-451; discussion 451-452.
7. Geha AS, Massad MG, Snow NJ, et al. A 32-year experience in 100 patients with giant paraesophageal
hernia: the case for abdominal approach and selective antireflux repair. Surgery. 2000;128(4):623-630.
8. Altorki NK, Yankelevitz D, Skinner DB. Massive hiatal hernias: the anatomic basis of repair. J Thorac
Cardiovasc Surg. 1998;115(4):828-835.
9. Allen MS, Trastek VF, Deschamps C, et al. Intrathoracic stomach. Presentation and results of operation. J
Thorac Cardiovasc Surg. 1993;105(2):253-258; discussion 258-259.
10. Schauer PR, Ikramuddin S, McLaughlin RH, et al. Comparison of laparoscopic versus open repair of
paraesophageal hernia. Am J Surg. 1998;176(6):659-665.
11. Horgan S, Eubanks TR, Jacobsen G, et al. Repair of paraesophageal hernias. Am J Surg.
1999;177(5):354-358.
12. Dahlberg PS, Deschamps C, Miller DL, et al. Laparoscopic repair of large paraesophageal hiatal hernia.
Ann Thorac Surg. 2001;72(4):1125-1129.
13. Swanstrom LL, Jobe BA, Kinzie LR, et al. Esophageal motility and outcomes following laparoscopic
paraesophageal hernia repair and fundoplication. Am J Surg. 1999;177(5):359-363.
14. Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective
followup reveals high recurrence rate. J Am Coll Surg. 2000;190(5):553-560.
15. Wiechmann RJ, Ferguson MK, Naunheim KS, et al. Laparoscopic management of giant paraesophageal
herniation. Ann Thorac Surg. 2001;71(4):1080-1086.
16. Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication failures: patterns of failure and
response to fundoplication revision. Ann Surg. 1999;230(4):595-604; discussion 604-606.
17. Yau P, Watson DI, Jamieson GG, et al. The influence of esophageal length on outcomes after
laparoscopic fundoplication. J Am Coll Surg. 2000;191(4):360-365.
18. Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: pathophysiology, incidence, presentation,
and treatment in the era of laparoscopic antireflux surgery. Ann Surg. 2000;232(5):630-640.
19. Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair of giant paraesophageal hernia: 100
consecutive cases. Ann Surg. 2000; 232(4):608-618.
20. Rogers ML, Duffy JP, Beggs FD, et al. Surgical treatment of para-oesophageal hiatal hernia. Ann R Coll
Surg Engl. 2001;83(6): 394-398.
Chapter 5
Laparoscopic Nissen Fundoplication
Elizabeth A. Warner
Brant K. Oelschlager
DEFINITION
Gastroesophageal reflux disease (GERD), as defined by the Montreal Consensus Group in 2006, is
caused by gastric reflux, causing troublesome symptoms and/or complications to the patient that
adversely affect their well-being.1 Symptoms can include heartburn, acid brash, regurgitation, dysphagia,
noncardiac chest pain, and pulmonary symptoms such as cough and hoarseness. Complications include
esophagitis, Barrett's esophagus, esophageal stricture, and aspiration pneumonia.
GERD results from incompetency or dysfunction of the lower esophageal sphincter (LES). Important
factors for adequate LES function include esophageal contraction, gastric cardia sling fibers,
diaphragmatic crus, and intraabdominal position of the LES complex. Hiatal hernias efface the natural
valve anatomy, allowing the GE junction to be displaced into the chest, exposing the LES to negative
intrathoracic pressure and increased gastroesophageal reflux. A certain amount of gastroesophageal
reflux is physiologic and not pathologic. However, once symptoms become troublesome to the patient, a
diagnosis of GERD can be made.
GERD can also be due to inadequate esophageal motility resulting in poor clearance of physiologic
reflux. Similarly, delayed gastric emptying can lead to GERD due to the increased volume and duration of
gastric contents that can potentially reflux into the esophagus.
A fundoplication is the use of the gastric fundus to recreate the LES valve function. Various
fundoplication configurations exist (e.g., Nissen, Dor, Toupet) and differ by the number of degrees that
encircle the esophagus, the location of the wrap, and the approach used to create the fundoplication.
Peptic ulcer disease
Esophageal motility disorder (e.g., achalasia)
Malignancy (e.g., esophageal or gastric) Anatomic abnormality (e.g., hiatal hernia)
Eosinophilic esophagitis
Coronary artery disease
Biliary colic
Pancreatitis
Functional heartburn
Hypersensitive esophagus
Functional dyspepsia
Other functional bowel diseases (i.e., inflammatory bowel syndrome [IBS])
The most common gastroesophageal reflux symptoms reported are heartburn, acid regurgitation, and
dysphagia. There is a growing awareness of more atypical presentations, most of which are related to
laryngeal or pulmonary manifestations such as cough, chest pain, hoarseness, wheezing, globus sensation,
and aspiration.2
It is important to ask the patient to explain the sensations they are having when they use the term
“heartburn.” Heartburn, as related to GERD, is a retrosternal burning or caustic sensation. Some patients
incorrectly use the term heartburn to describe epigastric pain (associated with peptic ulcer disease,
gastritis, and functional dyspepsia), right upper quadrant pain (from cholelithiasis or other hepatobiliary
diseases), or chest pain (from coronary artery disease). It is helpful to ask patients to point on their body as
to where they have discomfort when they note that they have heartburn. Classic heartburn does not radiate
to the back nor is it usually described as a pressure sensation.
Regurgitation symptoms can include gastric fluid regurgitation, known as water brash, and/or partially
digested food. Regurgitation of food particles can also be associated with esophageal clearance problems
such as an esophageal diverticulum or achalasia.
Dysphagia from a reflux-associated stricture is usually worse with solids than liquids. If both are equally
bothersome, a neuromuscular disorder must also be considered.
Airway-related symptoms (e.g., cough, wheezing, voice changes) can be present alone or in conjunction
with esophageal symptoms.
Disease states that are sometimes related to GERD are idiopathic pulmonary fibrosis, asthma, and recurrent
pneumonia.
Patients presenting to a surgeon to discuss GERD treatment have often already trialed antacid medications. It
is important to query the patient's response to these medications. If the patient does not have at least
symptomatic improvement to antacid therapy, alternative diagnoses should be considered. Heartburn will
almost always improve with antacid therapy, at least partially, within days to a few weeks. Similarly, they will
notice worsening of heartburn symptoms with cessation of antacid therapy. Airway symptoms may take longer
(2 to 3 months) and may not respond at all (even when GERD is the etiology).
Physical examination findings are often limited in a patient with GERD. In all patients with gastroesophageal
complaints, it is important to query about weight loss and hematemesis and to examine for lymphadenopathy,
as these could represent an underlying malignancy.

Diagnostic testing to confirm objective evidence of abnormal gastroesophageal reflux is imperative before
considering surgical management for GERD. A recent study revealed that 42% of patients referred for
antireflux surgery had a normal pH study when tested objectively.3 The following studies are
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essential to confirm the diagnosis of GERD, the underlying functionality of the LES and esophagus, and
investigate any anatomic considerations necessary for successful operative outcomes:
FIG 1 • Sample of 24-hour pH tracing demonstrating significant acid reflux with good symptom correlation.
pH monitoring (FIG 1) assesses distal esophageal pH over a period of time (routinely 24 to 48 hours) and a
composite DeMeester score is calculated. An abnormal DeMeester score is greater than 14.7.4 Factors
contributing to this score include percent total time pH less than 4, percent upright time pH less than 4,
percent supine time pH less than 4, number of reflux episodes, number of reflux episodes more than 5
minutes, and longest reflux episode.
Upper endoscopy evaluates for esophageal injury and Barrett's esophagus secondary to GERD while
excluding malignant pathology with biopsies as necessary. Endoscopy allows the surgeon to evaluate for
the presence of a hiatal hernia as well as to visually inspect the LES.
Esophageal manometry (FIG 2) assesses LES pressure and relaxation as well as esophageal motility.
Patients with esophageal motility disorders can easily be mislabeled as having GERD based on symptoms.
Understanding a patient's esophageal motility is necessary to plan successful antireflux surgery.
Esophagogram evaluates gastroesophageal anatomy and abnormalities such as hernia, stricture,
diverticula, motility, or tumors.
Ancillary tests that may also be useful include laryngoscopy, gastric emptying scintigraphy, and impedance
testing.
FIG 2 • Normal high-resolution manometry.

SURGICAL MANAGEMENT
There is rarely an absolute indication for antireflux surgery in a patient with GERD. Medical management,
including acid suppression therapy and lifestyle modifications (e.g., dietary changes, weight loss), is usually
sufficient to manage most patients’ GERD symptoms. Many factors must be considered in making the decision
to proceed with antireflux surgery. These include symptom severity, symptom control with medical therapy,
complications of GERD (e.g., severe esophagitis, esophageal stricture, Barrett's esophagus, chronic
respiratory complaints), and the generalized health of the patient.
Patients best suited for an antireflux procedure are those with documented and confirmed GERD for whom
medical and lifestyle changes are not providing adequate quality-of-life improvement. When the quality-of-life
impairment justifies accepting the risk of surgery, antireflux surgery is indicated.
Positioning
Patient can be positioned in either modified lithotomy position or supine depending on surgeon preference.
Lithotomy position requires more time and equipment and has more risks of nerve injury. However, lithotomy
position provides superior ergonomics for the surgeon. Both arms should be tucked to not interfere with
instrumentation and the patient should be adequately stabilized on the bed to safely accommodate steep
reverse Trendelenburg (which allows organs to naturally fall away from the hiatus and left upper quadrant).
Standard trocar placement includes three working trocars, a fourth trocar for the camera, and a fifth for liver
retraction. FIG 3 illustrates standard trocar placement, surgeon, and assistant positioning.
Elevation of the left lateral lobe of the liver is necessary to visualize the esophageal hiatus. This is most
commonly accomplished with a retraction device of the surgeon's choice.
FIG 3 • Typical port placement for laparoscopic foregut surgery using a split-leg approach.
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TECHNIQUES
TAKE DOWN THE LEFT PHRENOGASTRIC LIGAMENT
After obtaining laparoscopic access to the abdomen and placement of trocars and the liver retractor, the
phrenogastric ligament is divided, exposing the left crus. This is most easily accomplished by traction on
the gastroesophageal (GE) junction fat pad and the gastric fundus (FIG 4). Many surgeons start on the
right side by dividing the gastrohepatic ligament and right phrenoesophageal ligament. We have found
that it is safer to first approach the hiatus from the left, which provides better visualization, but both
approaches are acceptable.
FIG 4 • The dissection begins on the left side.
LIGATE AND DIVIDE THE SHORT GASTRIC VESSELS

The short gastric vessels between the greater curvature of the stomach and the spleen are ligated and
divided from the gastric midbody to the angle of His (FIG 5). The most superior short gastric vessels can
be difficult to expose. Care must be taken to avoid capsule tears to the spleen during this maneuver.
More posterior short gastric vessels and retroperitoneal adhesions must also be released to facilitate full
mobilization of the fundus (FIG 6).
FIG 5 • A. The short gastric vessels are placed on tension to allow for safe division without injury to the
stomach. B. The short gastric vessels are divided close to the greater curve of the stomach.
FIG 6 • The most upper short gastric vessel is posterior and should be divided to free the fundus.
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EXPOSE THE ENTIRE LEFT CRUS
The left phrenoesophageal membrane is opened along its length (FIG 7).
FIG 7 • After division of the short gastric vessels, the peritoneal attachments along the left crus are incised.
OPEN GASTROHEPATIC LIGAMENT

The right crus is exposed by opening the gastrohepatic ligament widely, taking care to avoid injury to
nerve of Latarjet (FIG 8).
FIG 8 • The gastrohepatic ligament is divided with cautery, exposing the caudate lobe of the liver.
ENTER THE RIGHT PHRENOESOPHAGEAL MEMBRANE

The right phrenoesophageal membrane is identified overlying the right crus and is divided to expose the
crural fibers beneath. The right phrenoesophageal membrane is opened along its length (FIG 9).
FIG 9 • The peritoneal attachments along the right crus are incised.
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CONNECT LEFT AND RIGHT HIATAL DISSECTIONS
The left and right dissections of the phrenoesophageal membrane are connected both anteriorly and
posteriorly with caution so as not to injure the anterior and posterior vagus nerves. A Penrose drain is
placed around the esophagus to aid in gastroesophageal junction retraction and esophageal exposure
(FIG 10).
FIG 10 • At least 3 cm of esophagus are mobilized into the abdominal cavity.
ESOPHAGEAL MOBILIZATION
The areolar connective tissue surrounding the esophagus is exposed and dissected free by retracting the
GE junction with the Penrose drain to mobilize adequate intraabdominal esophageal length (minimum of 3
cm) (FIG 10). The anterior and posterior vagus nerves as well as the pleura are protected during this
dissection.
POSTERIOR CRUS REAPPROXIMATION
The right and left crura are reapproximated posteriorly with heavy permanent suture (FIG 11) so that the
hiatus comfortably accepts a 52-Fr intraesophageal bougie.
FIG 11 • A posterior cruroplasty is performed with 0-0 silk sutures.
POSTERIOR STOMACH WALL MARKING STITCH

Construction of the fundoplication itself is the single critical step where errors are made that affect the
short- and long-term success of the operation. To combat this, we place a loose stitch on the posterior
gastric wall to mark the proposed site for the first stitch of the fundoplication. Ideally, this stitch is placed 3
cm distal to the GE junction and 2 cm from the greater curvature (FIG 12).
FIG 12 • A marking stitch is placed on the posterior gastric wall to identify the portion of the fundus to be
brought to the right of the esophagus.
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PASS THE FUNDUS POSTERIOR TO THE GASTROESOPHAGEAL JUNCTION
The GE junction is then retracted with the Penrose drain and the posterior gastric fundus is grasped from
the patient's right and brought posterior to the GE junction (FIG 13). (Note: If the previously placed
marking stitch was well placed, it will become visible as the fundus is passed from the patient's left to the
right and will serve to mark the location of the first fundoplication stitch to be placed.)
FIG 13 • The fundus is brought posterior to the esophagus.
IDENTIFY AND GRASP THE ANTERIOR STOMACH

An optimal fundoplication will be achieved by symmetric geometry. This is accomplished by identifying the
place on the anterior gastric wall that is of similar distance from the GE junction and the greater curvature
as the previously placed posterior gastric wall marking stitch (FIG 14). Once this location is identified,
both the anterior and posterior gastric walls are approximated around the distal esophagus at the 10
o'clock position. The wrap should be snug without excessive redundancy but not too tight either.
FIG 14 • The relationship of the stomach to the esophagus for the fundoplication.
FUNDOPLICATION CREATION
Once symmetric fundoplication geometry is confirmed, four seromuscular permanent sutures are placed
from anterior fundus to posterior fundus to secure the fundoplication over a total of 3 cm. Once the first
seromuscular stitch is placed, the Penrose drain is removed and a 52-Fr intraesophageal bougie is
guided into the stomach to aid in fundoplication sizing. To orient the fundal folds appropriately for the
second, third, and fourth fundusto-fundus stitches, grasp the first fundus-to-fundus stitch and retract it
cephalad to the right crus (FIG 15). This will result in appropriate alignment of the fundal suture line at
the 10 o'clock to 11 o'clock positions (FIG 16).
FIG 15 • The first stitch of the fundoplication is placed most cephalad.
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FIG 16 • The completed fundoplication with the suture line at the 11 o'clock position.
FUNDOPLICATION ANCHORING
The fundoplication is then anchored with separate stitches to the right and left crura as well as
esophagus (fundus-esophagus-crus) to anchor the fundoplication in the abdomen and prevent herniation.
Caution must be used so as not to tear the esophageal or crural fibers with these stitches. A final stitch
from the posterior fundus to the crural closure can be placed to prevent posterior herniation. (The
anterior space is protected by the left lateral lobe of the liver.)
INTRAOPERATIVE ENDOSCOPY
Intraoperative endoscopy is used to confirm a wellpositioned fundoplication prior to desufflation of the
abdomen and removal of trocars.
PEARLS AND PITFALLS
Indications ▪ Objective evidence of abnormal gastroesophageal reflux by 24-hour pH monitoring

is essential to consider antireflux surgery because symptoms alone can be
misleading.
▪ Additional mandatory preoperative studies for operative planning: esophageal
manometry, upper endoscopy, and esophagogram.
Hiatus ▪ Either a left-to-right or a right-to-left hiatal dissection is acceptable. We prefer

dissection starting the dissection on the left as it minimizes the risk of inadvertently tearing short
gastric vessels and splenic injury when working from the right.
▪ Mediastinal esophageal mobilization is necessary to gain adequate intraabdominal
esophageal length for proper fundoplication creation.
Fundoplication ▪ A 52-Fr intraesophageal bougie is necessary to calibrate the fundoplication size.

calibration ▪ The first fundoplication stitch is easier without the bougie in place. After the first
stitch, advancing the bougie into the stomach must be done with caution as the
bougie can perforate the GE junction.
Fundoplication ▪ An ideal fundoplication will lay so that the suture line is at the 10 o'clock to 11
orientation o'clock positions on the esophagus.
POSTOPERATIVE CARE
Postoperative dietary modifications: Clear liquids are started postoperatively and are advanced to full liquids
the following day. The patient is typically discharged on the first postoperative day. Over 2 weeks, diet is
advanced to a soft and then finally a regular diet as the patient's dysphagia resolves.
Other postoperative instructions: To decrease postoperative bloating, no straws are used and carbonated
beverages are avoided.
Activity restrictions: No lifting greater than 10 to 15 lb or aggressive physical activity is strictly observed for 6
weeks to avoid stress to the diaphragmatic sutures.
P.49
OUTCOMES
Long-term outcomes (median 69-month follow-up) for laparoscopic antireflux surgery reveal 90% of
patients have resolved or improved heartburn and regurgitation. Seventy-five percent of patients have
resolved or improved dysphagia. Sixty-nine percent of patients have resolved or improved cough and
hoarseness.
Postoperative side effects include new-onset bloating (9%), diarrhea (11%), and dysphagia (2%).
Ninety percent of patients report that they were happy with their decision to undergo laparoscopic
antireflux surgery.2
COMPLICATIONS
Splenic or liver injury
Hollow viscus perforation
Dysphagia
Pneumothorax
REFERENCES
1. Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal
reflux disease: a global evidencebased consensus. Am J Gastroenterol. 2006;101:1900-1920.
2. Oelschlager BK, Quiroga E, Parra JD, et al. Long-term outcomes after laparoscopic antireflux surgery. Am
J Gastroenterol. 2008;103(2): 280-287.
3. Bello B, Zoccali M, Gullo R, et al. Gastroesophageal reflux disease and antireflux surgery—what is the
proper preoperative work-up? J Gastrointest Surg. 2013;17(1):14-20.
4. Johnson LF, DeMeester TR. Twenty-four hour pH monitoring of the distal esophagus. A quantitative
measure of gastroesophageal reflux. Am J Gastroenterol. 1974;62:325-332.
Chapter 6
Redo Fundoplication
C. Daniel Smith
DEFINITION
A variety of fundoplication procedures are used today (Table 1), primarily to treat gastroesophageal reflux
disease (GERD).
The 360-degree fundoplication (Nissen fundoplication) is the most popular of the various fundoplication
techniques.
Although fundoplication, when done by an experienced surgeon, results in control of GERD and
significant improvement in quality of life in the majority of patients, this operation does fail, necessitating
further surgery or a redo fundoplication.1,2 and 3
Broadly speaking, there are three reasons that an operation will fail to control a patient's symptoms
and/or GERD.
Errors in workup or patient selection
Errors in operative management
Natural history of the particular antireflux operation or condition being treated
Fundoplication failure is defined as either recurrence of the condition or symptoms that necessitated the
fundoplication (e.g., recurrent GERD or recurrent hiatal hernia) or the development of new symptoms not
present preoperatively (e.g., dysphagia, nausea, or regurgitation).
One typically sees failure of a fundoplication in a few distinct patterns.4,5 and 6 These are outlined in
Table 2 and FIGS 1 and 2.
When considering these reasons for failure, hiatal hernia is the most common cause (44% of cases).
Wrap disruption or breakdown is the next leading cause, accounting for 16% of failures. Slipped wraps
account for 11.7% of failure, and finally, wraps improperly positioned at the time of their initial
construction is found in 3.9% of cases.7
Wrap or crural stenosis is a rare cause of failure and often times hard to determine as a primary etiology
of failure.
If mesh was used at the initial operation, a distinctly different pattern of failure and management strategy
is needed.8

Common symptoms of failure of fundoplication are outlined in Table 3.
Recurrent GERD is the most common (59%) and dysphagia (31%) the next most common. Although these
symptoms can occur with any or all of the patterns of failure, there are patterns of symptoms that correlate
highly with a given mechanism of failure (FIG 3).
Table 1: Fundoplication Procedures
360-degree fundoplication (Nissen fundoplication)
180-degree posterior fundoplication (Toupet fundoplication)
180-degree anterior fundoplication (Dor fundoplication)
Posterior gastropexy (Hill procedure)
Transthoracic posterior plication (Belsey procedure)
Table 2: Patterns of Fundoplication Failure
Wrap disruption or loosening
Wrap migration or slip
Hiatal herniation or reherniation
Wrap or crural stenosis
Wrap too loose or misplaced at the initial operation
Gross anatomic abnormalities such as hiatal hernia or severe wrap/crural stenosis are more likely to present
with symptoms related to poor esophageal transit and emptying. These symptoms commonly include
dysphagia, chest pain, and regurgitation.
The wrap that has loosened or come undone more commonly presents with recurrent GERD symptoms, often
identical to those being experienced before the first antireflux procedure. Commonly, this includes typical
symptoms such as heartburn, regurgitation, and chest pain but can also be more atypical symptoms such as
cough, laryngitis, or asthma. Again, the relationship and similarity of symptoms to those before the initial
operation is strongly predictive of wrap disruption or loosening.
A slipped wrap will often have a broad constellation of symptoms with more prevalence of nausea and
epigastric pain than the other presentations.
A favorable response to antisecretories and postural regurgitation predicts wrap loosening or incompetence,
whereas poor tolerance of heavy dense foods or weight loss predicts hiatal herniation or esophageal outlet
issues. Improvement
P.51
with dilation supports esophageal outlet restriction. Failure of symptoms to respond to any intervention is more
likely with wrap slippage.
FIG 1 • Common anatomic patterns of antireflux surgery failure: (A) fundoplication disruption, (B) tight
fundoplication or crural stenosis, (C) slipped fundoplication, and (D) hiatal herniation.
FIG 2 • Illustration of incorrectly created fundoplication compared to correct creation.
A confusing presentation is the patient with early postprandial bloating or meal-induced diarrhea. With this
symptom constellation, one should be suspicious of vagal nerve injury or inflammation (dysfunctional gastric
emptying). This symptom complex in the absence of an obvious anatomic abnormality or a positive pH test
should lead one to pursue further workup rather than a redo antireflux operation.
FIG 3 • A-D. Symptoms of antireflux surgery failure correlated with anatomic pattern of failure. SOB, shortness of
breath.
Table 3: Common Symptoms of Fundoplication Failure
Heartburn
Chest pain
Regurgitation
Dysphagia
Nausea
Bloating
Shortness of breath (SOB)
Aspiration

Testing for suspected fundoplication failure falls into testing to secure a diagnosis or reason for failure and
testing for operative planning. An algorithm for the workup of patients suspected to have failed a prior
fundoplication is shown in FIG 4.
Establishing the Diagnosis

In pursuit of a diagnosis of failure, the workup should start with an anatomic assessment. This usually includes
an upper endoscopy (esophagogastroduodenoscopy [EGD]) and contrast esophagram.
Often, a contrast esophagram is all that is needed to identify the pattern of failure. FIG 5 depicts the
esophagram findings corresponding to the various patterns of failure.
Alternatively, an EGD may clearly show an anatomic abnormality. The common endoscopic findings of failure
are outlined in Table 4.
In many cases, if the presenting symptoms correlate with findings on an esophagram or EGD, this is all that is
needed to diagnose failure and the need for reoperation.
If recurrent GERD is the dominant presentation, then pH testing should be obtained.
P.52
FIG 4 • Flowchart of workup for possible antireflux surgery failure. PEH, paraesophageal hernia; EMS,
esophageal motility study; GES, gastric emptying study.
FIG 5 • A-D. Contrast swallow examples for each common anatomic pattern of failure.
Table 4: Endoscopic Findings of Failed Fundoplication
Viewing Location Findings (Pattern of Failure)
Retroflex view of distal Gastric folds extending into wrap (slipped/misplaced fundoplication)
esophagus Esophagogastric junction does not hug scope (loose or undone
fundoplication)
Gastric mucosa extending above hiatal indentation (hiatal hernia)
Forward view of distal Narrowing that does not accept scope (tight wrap or crural stenosis)
esophagus Esophagitis/esophageal ulcers (loose or undone fundoplication)
Constriction on proximal stomach below constriction of wrap (hiatal
hernia)
Constriction of wrap distal to esophagogastric junction (slipped or
misplaced wrap)
P.53
Planning for Operative Management
With a diagnosis of fundoplication failure secured, further testing may be indicated to help plan the most
effective reoperative strategy.
The most common conditions associated with failure that need to be investigated are esophageal motility
problems and impairment in gastric emptying. All patients should undergo an esophageal motility study and a
gastric emptying study before redo surgery.
Impairment in esophageal motility may indicate the need for a partial 270-degree fundoplication rather than a
360-degree fundoplication. Classically, a partial fundoplication should be considered if normal esophageal
peristalsis is present in less than 70% of swallows or esophageal body pressure is less than 30 mmHg.
Delayed gastric emptying may require the addition of a gastrostomy tube to provide gastric decompression in
the early postoperative period, thereby preventing gastric distension-induced crural or wrap disruption.
SURGICAL MANAGEMENT
Redo fundoplication can be both rewarding and challenging. Although the right diagnosis and proper
preparation are important, they are no substitute for experience with all manner of foregut surgery. Redo
fundoplication should not be undertaken by a general surgeon who occasionally performs elective
fundoplication.
For a skilled laparoscopic surgeon, almost all redos can be approached laparoscopically. Early conversion to
an open approach is more likely in the following situations:
Multiple prior foregut procedures, especially prior open repairs
Hiatal hernia with a significant amount of the stomach incarcerated in the chest, especially if mesh was
used
Prior operations that were complicated by postoperative leak, fistula, or early reoperation
In these situations where one may predict a higher likelihood of conversion, it is prudent to be prepared for not
only an open approach but also a thoracoabdominal approach.
EGD should be available intraoperatively for all redos, and an EGD performed by the surgeon before
scrubbing provides valuable firsthand anatomic information that is useful intraoperatively. Leaving the scope in
the stomach allows intraoperative identification of key anatomic structures such as the squamocolumnar
junction or the location of the fundoplication.
Positioning
A split-leg approach is used in nearly all cases (FIG 6). If conversion to an open approach is anticipated, one
arm should be tucked so that a table-mounted retraction system can be secured at the patient's shoulder, well
away from the surgeons' standing position at the patient's side for open access.
FIG 6 • Patient positioning for reoperative antireflux operation.
TECHNIQUES
GAINING ABDOMINAL ACCESS AND PORT PLACEMENT
If the prior fundoplication was performed laparoscopically, it is reasonable to attempt abdominal access
by passing a Veress needle through an area in the upper abdomen free of prior incisions. The safest
means of access is a visualized access using an open technique.
A five-trocar technique as depicted in FIG 7 is used.
FIG 7 • Illustration or photo of trocar placement on abdomen.
P.54
IDENTIFY AND EXPOSE HIATAL ANATOMY
The dissection commences by approaching the esophageal hiatus from the left. The greater curve of the
stomach is found and followed upward toward the angle of His while using a tissue-sealing device to
divide any remaining short gastric vessels or vascularized scar tissue (Table 5).
Once the base of the left crus is found, the left crus is cleared of adhesions up to and around the crural
arch as far as possible (FIG 8). Often, the left lobe of the liver is fused to the fundus starting along the
crural arch limiting how much crural arch can be exposed at this point in the operation.
The mediastinum is entered from the left as far posterior as possible. Usually, this opens a plane just
anterior to the aorta and behind the esophagus (FIG 9). This plane is often very friendly allowing the
posterior mediastinum to be cleared proximally and to the right, over the top of the aorta toward the spine.
A 1/2-in Penrose drain cut 6-in long can be left in the posterior mediastinum (FIG 10) to be found later
when the mediastinum is entered from the right posteriorly.
With at least 1/2 of the esophageal hiatus exposed from the left, the more complicated dissection of the
right crus can be undertaken more safely with some awareness of the esophageal hiatus relationship to
the scar plate that tends to envelop the right side of the hiatus.
Starting distal along the lesser curve of the stomach and well below the adhesions of the left lobe of the
liver to the anterior surface of the stomach will often reveal a friendly dissection plane leading under the
caudate lobe of the liver and to the base of the right crus (FIG 11).
Table 5: Sequence for Successful Hiatal Dissection
Start along greater curve of stomach.

Divide any remaining short gastric vessels (ideally none are encountered).
Expose left crus from base through arch.
Enter mediastinum from left and posterior to hiatal content.
Dissect further proximal into mediastinum and from left to right along plane anterior to aorta
until over spine
Leave left side of hiatus and develop plane between anterior surface of stomach and
undersurface of liver to find caudate lobe of liver.
Following lower edge of caudate lobe of liver, expose right crus from base to arch (often need
to free wrap adhesions to right crus).
Enter mediastinum from right and complete retroesophageal window.
Encircle esophagus with Penrose drain to manipulate and control esophagus during rest of
mediastinal dissection and esophageal mobilization.
After hiatus completely dissected and esophagus mobilized, take down prior wrap by releasing
anterior fusion/sutures and dissect wrap from esophagus
Intraoperative endoscopy to identify location of squamocolumnar junction (adequate
esophageal length) and wrap has been completely taken down (retroflexed view)
FIG 8 • Photo of left crus exposure.

FIG 9 • Posterior mediastinum opened from left.
FIG 10 • Penrose drain left in mediastinum from left.
P.55
FIG 11 • Approaching the base of right crus along caudate lobe of liver.
Once the base of the right crus is exposed, the mediastinum is entered from the right and the Penrose
drain left in the mediastinum from the right is retrieved (FIG 12). At this point, the Penrose drain can be
brought around the entire hiatal contents and used as a retractor to facilitate the remainder of the hiatal
dissection.
This technique of starting on the left and using the crura as the edges of dissection assures safe isolation
of hiatal content thereby minimizing the risk of esophagogastric perforation or vagal nerve injury (FIG 13).
At this point, an EGD is useful to confirm anatomy, assess for any unsuspected perforation, and help
localize the fundoplication in preparation for undoing the fundoplication.
FIG 12 • Penrose drain retrieved from right.
FIG 13 • Completed hiatal dissection.
UNDO PREVIOUS FUNDOPLICATION

Finding the inferior edges of the fundoplication where it drapes over the proximal stomach, especially on
the left side of the gastric cardia, allows the edge to be traced toward the anterior fusion of a 360-degree
fundoplication. A similar exposure on the left can also be accomplished, but the left lower edge of the
fundoplication tends to be more fused along the neurovascular bundles of the lesser curve.
Once the anterior fusion of the fundoplication is found, it can be isolated and either released with the aid
of electrocautery or separated by firing a linear cutting stapler between the two limbs (FIG 14).
FIG 14 • Exposed anterior fusion of wrap.
P.56
With the anterior portion of the fundoplication released, the right limb is dissected away from the lesser
curve of the stomach and right side of the esophagus and returned to its normal location in the left upper
quadrant (FIG 15). As the fundoplication is dissected away posteriorly, the posterior vagus nerve should
be sought and protected.
FIG 15 • Gastric fundus returned to normal location.
With the fundoplication completely undone, an EGD is again performed to assure that the wrap is
completely mobilized and assess for any perforation. This is done by submerging the area of the
gastroesophageal junction (GEJ) under saline while inflating the lumen of the esophagus and stomach
with air and looking for an air leak externally.
RECONSTRUCT ESOPHAGEAL HIATUS
The esophageal hiatus is reconstructed using permanent sutures to approximate the crura posteriorly.
Pledgets can be used to limit the sawing effect of the suture over time (FIG 16).
If the hiatal defect is large, the intraabdominal pressure is decreased to 10 to 12 mmHg, thereby
unloading the pressure on the diaphragm and crural repair.
Several anterior crural sutures may be needed if the defect is large and the posterior-only closure is
creating an angle at the GEJ.
The crural reconstruction should result in the crura effacing the esophagus circumferentially without
impinging.
FIG 16 • Hiatal reconstruction.
P.57
REDO FUNDOPLICATION
A standard technique for fundoplication can be used.9,10 This entails a 360-degree fundoplication if there
is adequate fundus and the preoperative esophageal motility is adequate (peristalsis in 70% or more of
swallows or esophageal body pressure of 30 mmHg or greater). A 270-degree fundoplication should be
used if these criteria are not met (Table 6).
Table 6: Options for Redo Fundoplication
Reconstruction Option Uses
360-degree fundoplication Adequate fundus and normal esophageal motility
270-degree fundoplication Poor esophageal motility or inadequate fundus for 360-degree

fundoplication
No fundoplication Tight wrap or hiatal stenosis with inadequate fundus for any
fundoplication
Proximal divided Recurrent GERD following multiple prior antireflux operations

gastroplasty/gastrectomy with and/or no fundus for redo fundoplication with/without injury to
Roux-en-Y gastrojejunostomy gastric cardia/fundus during redo
Esophagogastric myotomy Pseudoachalasia

with/without partial
fundoplication
Esophagectomy with gastric Severe pseudoachalasia with massive esophageal dilation

pull-up or colon interposition
Roux-en-Y Recurrent GERD following multiple prior antireflux operations

esophagojejunostomy and injury to gastric cardia or distal esophagus during redo
GERD, gastroesophageal reflux disease.
Fundoplication should be calibrated by completing the wrap around a 56- to 60-Fr dilator placed across
the GEJ (FIG 17). It is best if the fundus is positioned for the fundoplication before this dilator is placed;
otherwise, the wrap can be very difficult to bring around the esophagus posteriorly with the dilator in
place.
Two to three permanent sutures that include the anterior esophagus are placed to produce a 2-cm long
fundoplication.
FIG 17 • Completed redo fundoplication.
ASSESS FOR POTENTIAL COMPLICATIONS

One final EGD is recommended to assess the location of the wrap and look for any potential
complications. A retroflex view is very helpful to assure that the wrap is on the distal esophagus and not
the proximal stomach (the appearance of gastric folds extending up and into the wrap suggests a wrap
that is too low).
CONSIDER ADJUNCTS
If the hiatal dissection or undoing the wrap was particularly difficult, a gastrostomy tube can be used to
allow gastric decompression and possible gastric feeds while waiting for proximal gastrointestinal (GI)
function to return and normalize.
P.58
PEARLS AND PITFALLS
Indications for ▪ Functional reasons for symptoms after fundoplication (e.g., misdiagnosed
surgery and GERD, other GI problems, vagal nerve injury) cannot be corrected with
diagnosis of failure surgery.
▪ Without evidence of an obvious anatomic failure or confirmation of recurrent
GERD by pH testing, surgery should be avoided.
Preoperative testing ▪ Preoperative tests are intended to assure that correct redo technique is
performed (e.g., total vs. partial fundoplication).
▪ Skipping testing may compromise redo success.
Identify and expose ▪ Injury to the liver, lesser curve of the stomach, the wrap, and the esophagus
hiatal anatomy is more likely if dissection is started on the right.
▪ Starting on the left allows exposure of the hiatus before working in the more
anatomically congested right side.
Intraoperative ▪ Liberal use of intraoperative endoscopy to guide dissection by frequently

testing assessing anatomy
▪ Assess for potential luminal injury penetration.
Surgical technique ▪ A standardized technique adhering to key technical principles will help assure
successful outcomes (Table 7).
Postoperative care ▪ Managing nausea to prevent retching starts in the operating and recovery
room and is critical to minimizing trauma early postoperative that could disrupt
the redo.
▪ Gastric decompression avoids gastric distension that could disrupt a wrap or
cruroplasty.
▪ Tube access to the stomach may allow nonoperative management of a small
leak found postoperatively.
POSTOPERATIVE CARE
Postoperative management after reoperative antireflux surgery mirrors the care of any foregut surgery patient.
A oneto two-night stay is pretty typical if the redo is laparoscopic, extra days if open. Key aspects of
postoperative care are oral intake and return to activity.
A preventable cause of antireflux surgery failure is early postoperative retching. The two most common
reasons for early postoperative retching are nausea and dietary indiscretion.
Patients should receive preemptive nausea control and antiemetics and be counseled carefully about
maintaining a liquid and soft food diet for at least 1 month after surgery.
Instructing patients to ingest only pourable liquids for the first week after surgery provides a simple rule to
follow, and then providing a detailed menu of acceptable soft foods for another 3 weeks will help effect
compliance with the postoperative diet.
Too rapid advancement to activity that will result in increased intraabdominal pressure can put sutures and the
reconstructed anatomy at risk. A full 30 days of limiting lifting to no more than 30 lb and no vigorous exercise
during this time provides simple guidelines for patients to follow.
Setting appropriate expectations for patients with regard to their overall recovery, diet progression, and
resolution of preoperative symptoms is important. Dysphagia may linger for more than 4 weeks after a redo
and preparing patients for this likelihood will allow them to accept this more readily.
Table 7: Standard Technique for Redo Fundoplication Success
Full hiatal dissection (reduce and resect any hiatal hernia sac)
Adequate esophageal mobilization—3-4 cm of esophagus below diaphragm
Divide all short gastric vessels (be sure to mobilize fundus posteriorly to find and divide any high
posterior vessel[s]).
Resect any epiphrenic fat (careful to not undermine the anterior vagus).
Determine esophageal length and location of EGJ (use endoscopy if unsure).
Careful handling of crura during dissection and closure
Decrease pneumoperitoneum to unload the diaphragm during closure.
Anterior crural stitch if large hiatal defect
Calibrate wrap (assure the fundus is in contact with the esophagus circumferentially—you can
make a wrap too loose).
Use gastrostomy tube for gastric decompression if large hiatal hernia or excessive manipulation of
stomach/area of vagal nerves.
Avoid postoperative nausea (use preemptive antiemetics).
EGJ, esophagogastric junction.
Early dilation may improve the dysphagia, but it also increases the risk of recurrent GERD and therefore
should be avoided if possible. We reserve dilation within the first 3 months after any antireflux operation for
only those patients whose difficulty swallowing makes it hard to handle their own saliva or maintain hydration.
OUTCOMES
The outcomes of redo fundoplication can be comparable to primary antireflux surgery, and in patients
suffering with significant and debilitating symptoms, the operations can return patients to a nearly normal
quality of life with low morbidity and virtually no mortality11 (Table 8).
The patient requiring multiple reoperations for failed fundoplication is a special situation that deserves
special mention. When undertaking a fourth redo, the failure rate jumps from around 7% to over 17%.7
We will rarely simply undertake a redo after three prior attempts. A divided gastroplasty and Roux-en-Y
reconstruction for recurrent severe GERD, an esophagogastric myotomy for pseudoachalasia or
esophagectomy for severe pseudoachalasia with massively dilated esophagus, or an
esophagojejunostomy for poor esophageal emptying with severe GEJ distortion is instead advised.
COMPLICATIONS
Complications can best be understood, identified, and managed considering their occurrence.
Intraoperative
Bleeding
Liver injury
Esophagogastric perforation
Pneumothorax
Vagal nerve injury
Postoperative
Pneumonia
Esophageal obstruction (edema) with inability to swallow
Delayed gastric emptying
Atelectasis and hypoxemia
P.59
Table 8: Outcomes of Redo Fundoplication
Author Date No. Patients Mortality Morbidity Success Follow-up (Mon)
Vignal 2012 47 0 4.3% 78% 24
Musunuru 2012 38 0 18.4% 63% 35
Frantzides 2009 68 0 5.9% 86% 27
Smith 2005 259 0 15.4% 89% 14
Khajanchee 2007 176 0 9.8% 75% 9
Byrne 2005 118 0 1.7% 84% 12
Légner 2011 106 0 35.8% 90% 22
Dallemagne 2011 129 0 7% 83% 75
P.60
REFERENCES
1. Dallemagne B, Perretta S. Twenty years of laparoscopic fundoplication for GERD. World J Surg.
2011;35:1428-1435.
2. Morgenthal CB, Lin E, Shane MD, et al. Who will fail laparoscopic Nissen fundoplication? Preoperative
prediction of long-term outcomes. Surg Endosc. 2007;21:1978-1984.
3. Oelschlager BK, Ma KC, Soares RV, et al. A broad assessment of clinical outcomes after laparoscopic
antireflux surgery. Ann Surg. 2012; 256:87-94.
4. Broeders JA, Roks DJ, Draaisma WA, et al. Predictors of objectively identified recurrent reflux after primary
Nissen fundoplication. Br J Surg. 2011;98:673-679.
5. Engström C, Cai W, Irvine T, et al. Twenty years of experience with laparoscopic antireflux surgery. Br J
Surg. 2012;99:1415-1421.
6. Salminen P, Hurme S, Ovaska J. Fifteen-year outcome of laparoscopic and open Nissen fundoplication: a
randomized clinical trial. Ann Thorac Surg. 2012;93:228-233.
7. Smith CD, McClusky DA, Rajad MA, et al. When fundoplication fails: redo? Ann Surg. 2005;241:861-869;
discussion 869-871.
8. Parker M, Bowers SP, Bray JM, et al. Hiatal mesh is associated with major resection at revisional
operation. Surg Endosc. 2010;24: 3095-3101.
9. Dallemagne B, Arenas Sanchez M, Francart D, et al. Long-term results after laparoscopic reoperation for
failed antireflux procedures. Br J Surg. 2011;98:1581-1587.
10. Légner A, Tsuboi K, Bathla L, et al. Reoperative antireflux surgery for dysphagia. Surg Endosc.
2011;25:1160-1167.
11. van Beek DB, Auyang ED, Soper NJ. A comprehensive review of laparoscopic redo fundoplication. Surg
Endosc. 2011;25:706-712.
Chapter 7
Laparoscopic Partial Fundoplication for Gastroesophageal Reflux
Disease
Marco E. Allaix
Marco G. Patti
DEFINITION
Gastroesophageal reflux disease (GERD) is a chronic condition resulting from the reflux of gastric
contents into the esophagus and is associated with a spectrum of symptoms, with or without tissue
injury.1,2
Several conditions, including irritable bowel syndrome, achalasia, gallbladder disease, coronary artery
disease, or psychiatric disorders can present with heartburn as the main symptom.

Heartburn, regurgitation, and dysphagia are considered typical symptoms of GERD.
GERD can also cause atypical symptoms such as cough, wheezing, chest pain, hoarseness, and dental
erosions.

Clinical history, based on symptoms only, has a low diagnostic accuracy of GERD in about 30% of patients.3
Upper endoscopy is often the first test performed to confirm the diagnosis of GERD. However, about 50% of
patients with clinical symptoms of GERD do not have endoscopic sign of esophagitis.3 In addition, endoscopic
evaluation is highly operator dependent, especially in the assessment of low-grade esophagitis.4 Therefore,
the major role of endoscopy is to detect Barrett's esophagus (usually present in 1% to 5% of patients with
GERD) and to exclude gastric and duodenal pathology.
Barium swallow is useful for detecting and characterizing the type and size of a hiatal hernia; for determining
the location and size of a stricture; and for evaluating length, diameter, and function of the esophagus. This
test, however, is not diagnostic of GERD as a hiatal hernia or reflux of barium can be present in the absence
of abnormal reflux or absent in the presence of clinically significant GERD.
Esophageal manometry provides information about the lower esophageal sphincter (LES) in terms of resting
pressure, length, and relaxation and the amplitude and propagation of esophageal peristaltic waves. In
addition, manometry is essential for proper placement of the pH probe for ambulatory pH monitoring (5 cm
above the upper border of the LES).
24-hour ambulatory pH monitoring is considered the gold standard for the diagnosis of GERD (FIG 1). Its role
is key in the workup as it determines the presence and amount of abnormal reflux and it establishes a
temporal correlation between symptoms and episodes of reflux (particularly important when cough or chest
pain are present).5 An abnormal score not only confirms the diagnosis but also is an independent predictor for
the successful outcome of antireflux surgery.6 Finally, pH monitoring is mandatory for the proper evaluation of
patients who have recurrent symptoms after antireflux surgery.7
Combined multichannel intraluminal impedance and pH testing (MII-pH) detects episodes of reflux,
regardless of the pH of the refluxate, by identifying changes inducted by the presence of liquids and gas in the
esophagus. The episodes are classified as acid, weakly acid, or nonacid on the basis of concomitant pH
monitoring. This test is useful in identifying bile reflux and does not require cessation of proton pump inhibitors
for testing.
SURGICAL MANAGEMENT
A laparoscopic fundoplication is currently considered the procedure of choice for the treatment of GERD.
Even though several eponyms are used to describe different antireflux procedures, we believe that it is more
important to focus on the technical elements that make a fundoplication effective and long lasting.
The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented
by the preoperative manometry. In the United States, a partial fundoplication is proposed only to patients with
very impaired or absent esophageal peristalsis in order to reduce the risk of postoperative dysphagia (FIG 2).
A careful symptomatic evaluation testing is performed in every patient before surgical intervention.
FIG 1 • Ambulatory 24-hour pH monitoring.
P.62
FIG 2 • High-resolution esophageal manometry: ineffective esophageal motility.
Positioning
After induction of general endotracheal anesthesia, the patient is positioned in low lithotomy position with the
lower extremities extended on stirrups with knees flexed 20 to 30 degrees. Alternatively, a split-leg table may
be used.
To avoid sliding as a consequence of the steep reverse Trendelenburg position used during the entire
procedure, a beanbag is inflated to create a “saddle” under the perineum.
Because increased abdominal pressure from pneumoperitoneum and the steep reverse Trendelenburg
position decrease venous return, pneumatic compression stockings are always used as prophylaxis against
deep venous thrombosis.
An orogastric tube is placed to keep the stomach decompressed during the procedure.
A Foley catheter is inserted at the beginning of the operation and removed at the end.
The surgeon stands between the patient's legs. The first and second assistants stand on the right and left
side of operative table (FIG 3).
FIG 3 • Position of the patient and surgical team in the operating room.
TECHNIQUES
PLACEMENT OF PORTS
Five 10-mm trocars are used for the procedure (FIG 4).
The first incision is made in the midline 14 cm distal to the xiphoid process and a Veress needle is
introduced into the peritoneal cavity. The peritoneal cavity is initially insufflated to a pressure of 15
mmHg. Subsequently, under direct vision, an optical port with a 0-degree scope (port 1) is placed.
Once this port is placed, the 0-degree scope is replaced with a 30-degree scope and the other trocars
are inserted under laparoscopic vision.
FIG 4 • Placement of the ports (1-5).
Port 2 is placed in the left midclavicular line at the same level of port 1. It is used by the assistant for
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traction on the gastroesophageal junction and to take down the short gastric vessels.
Port 3 is placed in the right midclavicular line at the same level of the other two ports. A retractor is
used through this port to lift the left lateral segment of the liver to expose the gastroesophageal
junction. The retractor is held in place by a self-retaining system fixed to the operating table.
Ports 4 and 5 are placed under the right and left costal margins so that their axes and the camera form
an angle of about 120 degrees. These ports are used by the operating surgeon for the insertion of
graspers, scissors, and dissecting and suturing instruments.
The instrumentation necessary for laparoscopic partial fundoplication is reported in Table 1.
Table 1: Instrumentation for Laparoscopic Partial Fundoplication
Five 10-mm ports
0- and 30-degree scope
Graspers and needle holder
Babcock clamp
L-shaped hook cautery with suction-irrigation capacity
Scissors
Laparoscopic clip applier
Electrothermal bipolar vessel-sealing system
Liver retractor
Suturing device
2-0 silk sutures
Penrose drain
56-Fr esophageal bougie
DISSECTION
The gastrohepatic ligament is divided, beginning the dissection above the caudate lobe of the liver,
where the ligament is thinner, and continuing toward the diaphragm until the right pillar of the crus is
identified (FIG 5).
The right pillar of the crus is separated from the esophagus by blunt dissection until the left crus is
recognized and the posterior vagus nerve is identified (FIG 6).
Subsequently, the peritoneum and the phrenoesophageal membrane overlying the esophagus are
divided, and the anterior vagus nerve is identified.
The left pillar of the crus is then separated from the esophagus and dissected toward the junction with
the right pillar of the crus (FIG 7).
FIG 5 • Gastrohepatic ligament division.

FIG 6 • Dissection of the right pillar of the crus.
FIG 7 • Dissection of the left pillar of the crus.
DIVISION OF THE SHORT GASTRIC VESSELS

The short gastric vessels are taken down all the way to the left pillar of the crus, starting from a point
midway along the greater curvature of the stomach (FIG 8).8
FIG 8 • Division of short gastric vessels.
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CREATION OF A WINDOW AND PLACEMENT OF A PENROSE DRAIN AROUND THE
ESOPHAGUS
The esophagus is retracted upward with a Babcock clamp applied at the level of the esophagogastric
junction.
A window is opened by a blunt and sharp dissection under the esophagus, between the gastric fundus,
the esophagus, and the left pillar of the crus (FIG 9).
The window is enlarged, and a Penrose drain is passed around the esophagus.
Any hiatal hernia is completely reduced and a minimum of 3 cm of intraabdominal esophageal length is
achieved.
FIG 9 • Creation of a window between the gastric fundus, the esophagus, and the left pillar of the crus.
CLOSURE OF THE CRURA

Interrupted 2-0 silk sutures that are tied intracorporeally with an Endo Stitch device (Covidien, Norwalk,
CT) are used to close the diaphragmatic crura (FIG 10a).
Retraction of the esophagus upward and toward the patient's left with the Penrose drain provides proper
exposure.
The first stitch should be placed just above the junction of the two pillars.
Additional stitches are placed 1 cm apart, and a space of about 1 cm is left between the uppermost stitch
and the esophagus.
FIG 10 • Crura closure (a); posterior partial fundoplication (b); two coronal stitches placed between the top
of the wrap, the esophagus, and the right or left pillar of the crus (c); and one additional stitch placed
between the right side of the wrap and the closed crura (d).
INSERTION OF THE BOUGIE INTO THE ESOPHAGUS AND THROUGH THE ESOPHAGEAL
JUNCTION
The orogastric tube is removed, and a 56-Fr bougie down the esophagus through the esophagogastric
junction is inserted.9
The crura must be snug around the esophagus but not too tight: A closed grasper should slide easily
between the esophagus and the crura.
PARTIAL FUNDOPLICATION
Partial posterior fundoplication
The gastric fundus is gently pulled under the esophagus with two graspers.
The right and left sides of the wrap are separately sutured to the esophagus, leaving 80 to 120
degrees of the anterior esophageal wall uncovered.
Three 2-0 silk sutures are placed on each side between the muscular layers of the esophageal wall
and the gastric fundus (FIG 10b).
Two coronal stitches are then placed between the top of the wrap, the esophagus, and the right or left
pillar of the crus (FIG 10c).
One additional stitch is placed between the right side of the wrap and the closed crura (FIG 10d).
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The resulting wrap measures about 240 to 280 degrees.
Partial anterior fundoplication (See Chapter 9 for more details.)
It is a 180-degree anterior fundoplication.
Two rows of sutures (2-0 silk) are used. The first row is on the left side of the esophagus and has
three stitches. The top stitch incorporates the fundus of the stomach, the muscular layer of the left side
of the esophagus, and the left pillar of the crus.
The second and third stitches incorporate the gastric fundus and the muscular layer of the left side of
the esophagus.
The fundus is then folded over the esophagus so that the greater curvature of the stomach is next to
the right pillar of the crus.
The second row of sutures on the right side of the esophagus consists of three stitches between the
fundus and the right pillar of the crus.
Finally, two additional stitches are placed between the fundus and the rim of the esophageal hiatus to
eliminate any tension from the fundoplication.
PEARLS AND PITFALLS
Indications ▪ A careful evaluation, including manometry, 24-hour pH monitoring, upper

endoscopy, and barium swallow must be done.
Placement of ports ▪ Extreme care must be taken when positioning port 1, because the site of
insertion is just above the aorta.
▪ We recommend using an optical trocar with a 0-degree scope to obtain
access.
▪ If port 3 is too low, the left lateral segment of the liver will not be properly
retracted, resulting in inadequate exposure of the esophagogastric junction.
▪ If port 2 is too low, the esophagogastric junction or the upper short gastric
vessels will be difficult to reach.
▪ If ports 4 and 5 are too low, the dissection at the beginning of the
procedure and the suturing at the end will be challenging.
▪ If port 3 is too medial, the liver retractor may interfere with the instrument
used through port 4.
Dissection ▪ An accessory left hepatic artery originating from the left gastric artery is
frequently present in the gastrohepatic ligament. If this vessel limits the
exposure, it may be safely divided.
▪ The electrocautery should be used with extreme caution. Because of the
lateral spread of the monopolar current, vagus nerves may be damaged
even without direct contact. A bipolar instrument represents a safer
alternative.
Short gastric vessels ▪ Bleeding, either from the short gastric vessels or from the spleen, and
division damage to the gastric wall are possible complications.
▪ Excessive traction and division of a vessel not completely coagulated are
usually the main causes of bleeding.
▪ A burn caused during dissection of the short gastric vessels or traction
applied with the graspers or the Babcock clamp are the most common
mechanisms of damage to the gastric wall.
Creation of a window ▪ Left pneumothorax and perforation of the gastric fundus are two main
and placement of a complications that can occur during this step of the procedure.
Penrose drain around ▪ Left pneumothorax is usually created when the dissection is performed in
the esophagus the mediastinum above the left pillar of the crus rather than between the crus
and the gastric fundus.
▪ Proper identification and dissection of the left pillar of the crus are crucial.
▪ Perforation of the gastric fundus is usually caused by pushing a blunt
instrument under the esophagus or by using monopolar electrocautery for
dissection.
Closure of the crura ▪ The bougie is not placed inside the esophagus during this step of the
procedure in order to have a proper exposure for suturing.
Insertion of the bougie ▪ The most serious complication during this step is an esophageal
into esophagus and perforation.
through esophageal ▪ Lubrication of the bougie and instruction to the anesthesiologist to advance
junction the bougie slowly and to stop if any resistance is encountered help to
prevent this complication.
▪ All instruments must be removed from the esophagogastric junction and the
Penrose drain must be opened. In this way, the creation of an angle between
the stomach and the esophagus, which increases the risk of perforation, is
prevented.
Partial fundoplication ▪ Atraumatic graspers must be used to reduce the risk of injury to the gastric
wall.
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POSTOPERATIVE CARE
Patients are usually discharged after 23 to 48 hours.
Patients start clear liquids and then a soft diet the morning after surgery.
They are instructed to avoid meat, bread, and carbonated beverages for the following 2 weeks.
The time to full recovery ranges between 2 and 3 weeks.
OUTCOMES
Long-term studies conducted in United States have reported a less effective control of GERD with a
partial fundoplication rather than a total fundoplication.10,11 and 12
At 5-year follow-up, recurrence of GERD confirmed by pH monitoring is reported in more than 50% of
patients after partial fundoplication.10
COMPLICATIONS
Esophageal or gastric perforation can be caused either by traction or by an inadvertent electrocautery
burn during any step of the dissection.
A leak usually manifests itself during the first 48 hours.
Peritoneal signs will be present if the spillage is limited to the abdomen; shortness of breath and a pleural
effusion will be noted if spillage also occurs in the chest.
The site of the leak must always be confirmed by a contrast study using a water-soluble contrast agent.
Optimal management consists of a reoperation and direct repair. An esophagectomy may be indicated in
case of a too extensive damage or when the extent of the inflammatory reaction makes the direct repair
impossible. Wide drainage, feeding jejunostomy tube, and use of a covered esophageal stent may also
assist in healing the injury when it cannot be directly repaired.
Gastroesophageal junction and wrap slippage into the chest rarely occurs when coronal suture is placed
and the crura are closed.8 The main symptoms of recurrence are dysphagia and regurgitation. A barium
swallow confirms the diagnosis.
The incidence of paraesophageal hernia may be increased if the closure of the crura is not performed or
if it is too loose.8
REFERENCES
1. Moraes-Filho J, Cecconello I, Gama-Rodrigues J, et al. Brazilian consensus on gastroesophageal reflux
disease: proposals for assessment, classification, and management. Am J Gastroenterol. 2002;97:241-248.
2. Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal
reflux disease: a global evidencebased consensus. Am J Gatreoenterol. 2006;101:1900-1920.
3. Patti MG, Diener U, Tamburini A, et al. Role of esophageal function tests in the diagnosis of
gastroesophageal reflux disease. Dig Dis Sci. 2001;46:597-602.
4. Amano Y, Ishimura N, Furuta K, et al. Interobserver agreement on classifying endoscopic diagnoses of
nonerosive esophagitis. Endoscopy. 2006;38:1032-1035.
5. Patti MG, Arcerito M, Tamburini A, et al. Effect of laparoscopic fundoplication on gastroesophageal reflux
disease-induced respiratory symptoms. J Gastrointest Surg. 2000;4:143-149.
6. Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis of factors predicting outcome after
laparoscopic Nissen fundoplication. J Gastrointest Surg. 1999;3:292-300.
7. Galvani C, Fisichella PM, Gorodner MV, et al. Symptoms are a poor indicator of reflux status after
fundoplication for gastroesophageal reflux disease: role of esophageal function tests. Arch Surg. 2003;
138:514-518.
8. Patti MG, Arcerito M, Feo CV, et al. An analysis of operations for gastroesophageal reflux disease.
Identifying the important technical elements. Arch Surg. 1998;133:600-606.
9. Patterson EJ, Herron DM, Hansen PD, et al. Effect of an esophageal bougie on the incidence of
dysphagia following Nissen fundoplication: a prospective, blinded, randomized clinical trial. Arch Surg. 2000;
135:1055-1061.
10. Horvath KD, Jobe BA, Herron DM, et al. Laparoscopic Toupet fundoplication is an inadequate procedure
for patients with severe reflux disease. J Gastrointest Surg. 1999;3:583-591.
11. Oleynikov D, Eubanks TR, Oelschlager BK, et al. Total fundoplication is the operation of choice for
patients with gastroesophageal reflux and defective peristalsis. Surg Endosc. 2002;16:909-913.
12. Patti MG, Robinson T, Galvani C, et al. Total fundoplication is superior to partial fundoplication even
when esophageal peristalsis is weak. J Am Coll Surg. 2004;198:863-869.
Chapter 8
The Minimally Invasive Surgical Approach to Gastroesophageal
Reflux Disease
W. Scott Melvin
Luke M. Funk
DEFINITION
Endoscopic therapies for gastroesophageal reflux disease (GERD) include transoral incisionless
fundoplication (TIF) and the application of radiofrequency energy to the lower esophageal sphincter
(LES). Minimally invasive LES augmentation surgery involves the placement of a magnetic band across
the LES. All three therapies are designed to reduce GERD symptoms by minimizing the reflux of gastric
contents into the esophagus and are alternatives to traditional surgical fundoplication techniques.
Typical GERD symptoms
Achalasia
Biliary colic/cholecystitis
Esophageal cancer, esophagitis, esophageal motility disorders
Gastritis
Hiatal hernia
Helicobacter pylori infection
Irritable bowel syndrome
Atypical GERD symptoms
Coronary artery disease
Asthma
Bronchogenic carcinoma

History taking should focus on identifying both typical and atypical symptoms associated with GERD.
Typical symptoms include heartburn, regurgitation, water brash (salty taste related to salivary secretion),
and dysphagia.
Atypical symptoms include dyspnea, cough, wheezing, chest pain, recurrent pneumonias, hoarseness, and
dental erosions.
Response to antireflux medications, such as proton pump inhibitors and H2 blockers is important to illicit, as
the majority of patients with typical GERD symptoms will respond to these medications. Failure to respond to
these medications should heighten the surgeon's concern that the patient's symptoms may be unrelated to
GERD.
Once the diagnosis of GERD is confirmed with objective testing, several key points should be discussed with
the patient:
Medical therapy, including lifestyle modifications (i.e., diet modification, weight loss, smoking cessation) and
antireflux medications, should control typical GERD symptoms for most patients. Surgical intervention is
indicated for GERD patients who (1) cannot take antireflux medications due to side effects, (2) would prefer
not to take antireflux medications due to cost or lifestyle impact, or (3) continue to experience symptoms
despite antireflux medications.
Laparoscopic gastric fundoplication (i.e., Nissen fundoplication) is considered to be the gold standard
surgical therapy for the treatment of GERD. Endoscopic therapies and laparoscopic LES augmentation
surgery should probably be reserved for GERD patients who are candidates for surgical intervention and
(1) would prefer a less invasive option than laparoscopic fundoplication surgery or (2) would be considered
too high risk for laparoscopic fundoplication due to comorbidities or previous abdominal surgery, including
prior laparoscopic fundoplication.
Of the three procedures discussed in this chapter, laparoscopic LES augmentation surgery is the only one that
requires general anesthesia, although TIF also involves general anesthesia in the vast majority of cases.
Conscious sedation is usually adequate for radiofrequency therapy. Thus, poor candidates for general
anesthesia (i.e., those with cardiopulmonary conditions such as severe chronic obstructive pulmonary disease
[COPD] or congestive heart failure [CHF]) may be better candidates for radiofrequency therapy. The presence
of these comorbid conditions should be sought out in the history. Additional contraindications for these
procedures are listed in Table 1.
Because there are few physical exam findings associated with GERD, the physical exam should focus on
conditions that might suggest an alternative explanation for the
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patient's symptoms. These include recent weight loss or progressive inability to tolerate solids and liquids
(malignancy), atypical symptoms associated with exertion (coronary artery disease or asthma), or diarrhea
(irritable bowel syndrome).
Table 1: Contraindications for Undergoing Treatment
For all three procedures
Barrett's esophagus
Dysphagia (i.e., multiple times per week)
Esophageal dysmotility, strictures, varices
Esophagitis (grade C or D esophagitis according to the Los Angeles classification)
Hiatal hernia (>2-3 cm)

Obesity (BMI >35)
Specific to transoral incisionless fundoplication
Inability to tolerate general anesthesia
Specific to laparoscopic LES augmentation surgery
Inability to tolerate general anesthesia
Titanium, stainless steel, nickel, or ferrous allergy
Patients who may need to undergo an MRI (LINX considered not safe for MRI)
BMI, body mass index; LES, lower esophageal sphincter; MRI, magnetic resonance imaging.
The presence of abdominal surgical scars or abdominal wall hernias is important to identify if laparoscopic
LES augmentation surgery is being considered as they may make access to the peritoneal cavity and the
gastroesophageal (GE) junction challenging.
Laparoscopic LES augmentation surgery, which involves placement of a magnetic device around the GE
junction, is considered not safe for magnetic resonance imaging (MRI). Patients should be aware of this
contraindication prior to surgery.

Establishing GERD as the etiology of the patient's symptoms is critical before proceeding with any
intervention. Patients may have subjective complaints of heartburn or dysphagia that are unrelated to their
reflux disease. The four diagnostic tests that are most commonly used to establish a diagnosis are upper
endoscopy, barium esophagram, pH testing, and manometry.
Upper endoscopy (esophagogastroduodenoscopy [EGD])
All patients undergoing an antireflux procedure should have an EGD.
EGDs can identify the presence of hiatal hernias and rule out other pathology, which may be contributing to
the patient's symptoms, such as peptic ulcer disease or malignancy.
GERD-related complications such as esophagitis, Barrett's esophagus, and esophageal strictures can also
be identified (FIG 1).
Ambulatory pH testing
This is considered to be the gold standard test for diagnosing the presence of symptomatic GERD.
Patients should typically not be taking their antireflux medications when the study is performed.
pH testing can be performed via catheter-based systems (i.e., 24-hour pH probe testing) or wireless
systems (i.e., 48-hour Bravo testing).
Both catheter-based and wireless systems allow for the quantification of six variables including
total/upright/supine time that the pH is less than 4, number of reflux episodes, number of episodes longer
than 5 minutes, and longest episode. These variables can be combined to calculate the “DeMeester score,”
which is used by many surgeons as definitive evidence for the presence of GERD.1
FIG 1 • The presence of Barrett's esophagus is a contraindication to TIF, radiofrequency energy application,
and laparoscopic LES augmentation surgery.
Barium esophagram
This is a dynamic fluoroscopic study that characterizes both anatomic and functional aspects of the
esophagus. It involves multiple swallows of barium and bariumcoated solid food.
The two most important things to characterize with a barium esophagram are the position of the GE junction
relative to the diaphragmatic hiatus and overall esophageal motility. The presence of a large hiatal hernia
(FIG 2) or significant esophageal dysmotility is a contraindication for any of the three procedures.2
Esophagrams can also identify the presence of reflux that is characterized by the spontaneous reflux of
barium back into the esophagus. However, they are less sensitive than pH studies and thus a negative
finding here does not rule out GERD.
Video recording of this study is crucial because it allows the surgeon to actively assess esophageal
peristalsis and the functional significance of hiatal hernias.
Manometry
Esophageal manometry uses pressure transducers within a transnasal catheter to provide data regarding
the LES resting pressure, LES abdominal and total length, and adequacy of LES relaxation. It also
characterizes esophageal motility by quantifying the amplitude, duration, and propagation of each
contraction.
The presence of significant esophageal dysmotility is a contraindication for all three procedures.
Multichannel impedance testing and gastric emptying studies are also used on occasion to identify nonacidic
GERD and assess gastric functionality, respectively.
FIG 2 • A lateral view of a barium esophagram. A large hiatal hernia is present with a significant portion of the
stomach herniated into the chest. A small distal esophageal diverticulum is seen. All three procedures would be
contraindicated in the presence of this hernia.
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TECHNIQUES
TRANSORAL INCISIONLESS FUNDOPLICATION
Approved by the U.S. Food and Drug Administration (FDA) in 2007, the only TIF device that is currently
available for use in the United States is the EsophyX device (EndoGastric Solutions, Redmond, WA).
EsophyX re-creates the LES by plicating the distal esophagus and the gastric cardia together, thus
creating an antireflux valve similar to that of a laparoscopic Nissen fundoplication.
The device consists of a handle, an 18-mm diameter shaft, a tissue invaginator composed of holes in the
side of the device (which are connected to a suction device), an articulating arm, which approximates
gastric and esophageal tissue and deploys the tissue fasteners, a helical screw, two stylets, and 20
polypropylene H-fasteners (10 plication sets) (FIG 3).
At our institution, general anesthesia is administered and the procedure is performed in the operating
room.
Nasotracheal intubation is performed so the oropharynx can be used entirely for the EsophyX device. A
bite block is placed to protect the teeth from the device and scope.
Two physicians perform the procedure. One manipulates the endoscope while the other controls the
device.
Positioning
After intubation, the patient is placed into the left lateral decubitus position with the head elevated slightly
(FIG 4).
FIG 3 • A. EsophyX device with the articulating arm fully extended. B. Articulating arm is flexed with the H
fasteners visible between the shaft and the distal end of the articulating arm. The helical retractor is
visible as well (images © 2015 EndoGastric Solutions, Inc).
FIG 4 • With the patient in the left lateral decubitus position and a nasotracheal tube present, a bite block
is placed to facilitate passage of the endoscope and subsequently the EsophyX device.
Prophylactic antibiotics are administered before the procedure begins because transluminal fasteners are
placed, which may increase the risk of postoperative infections.
Placement of the Transoral Incisionless Fundoplication Device into the Stomach
Preprocedure endoscopy is performed to verify anatomic landmarks.
A 56-Fr bougie is inserted into the esophagus and then removed to facilitate subsequent passage of the
EsophyX device (FIG 5).
The EsophyX device is lubricated and a standard endoscope is threaded through the device (FIG 6).
Both are placed through a bite block and advanced through the esophagus into the stomach.
The scope is advanced into the gastric lumen and then retroflexed to examine the GE junction. Using a
standard, high-flow insufflator, the stomach is insufflated with
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carbon dioxide to a pressure of 15 mmHg via the working channel of the endoscope. Once the
articulating arm is visualized within the stomach, the scope is withdrawn into the device, the articulating
arm is flexed, and the scope is then advanced back into the retroflexed position within the gastric lumen
(FIG 7).
FIG 5 • Passage of a large Bougie after diagnostic endoscopy facilitates advancement of the EsophyX
device into the stomach and minimizes the likelihood of esophageal injury during passage of the device.
FIG 6 • A. The endoscope is passed through the handle of the EsophyX device and can be seen exiting
the distal end of the device (B). The articulating arm is fully extended in this image. Once the scope and
device are advanced into the stomach, the scope is withdrawn into the body of the device and the
articulating arm is flexed. The scope is advanced back into the stomach and retroflexed to obtain a view
of the GE junction.
Using the retroflexed view, the GE junction is envisioned as a clock face with the 12 o'clock position
located at the lesser curvature, the 6 o'clock position at the greater curvature, and the 9 o'clock position
located along the posterior gastric wall (FIG 8).3
Anterior Rotational Plication Fasteners
The closed articulating arm is placed at the 12 o'clock position (FIG 9A). The helix retractor portion of the
device is also at the 12 o'clock position and advanced into the squamocolumnar junction (FIG 9B). The
entire device is then advanced distally a couple of centimeters and rotated clockwise on the screen. This
allows the articulating arm to be opened and the helical retractor disengaged from the articulating arm.
FIG 7 • The articulating arm of the device is flexed within the gastric lumen. The arm will subsequently be
rotated into the 12 o'clock position at the lesser curve to facilitate placement of the helix retractor.
The articulating arm is then rotated back to the 6 o'clock position, partially closed, and pulled back 1 to 2
cm (FIG 9C). The GE junction is advanced caudally by applying tension to the helical retractor.
The stomach is then desufflated and the articulating arm is rotated toward the 1 o'clock position. This
maneuver rotates the fundus anteriorly around the esophagus thereby initiating the fundoplication.
Externally, the handle of the device is rotated approximately 180 degrees (FIG 10). This has been
described in the literature as the “Bell Roll maneuver.” 3
The helical retractor and articulating arm are secured in place and the suction is applied.
FIG 8 • Using a clock face to describe the anatomy of the GE junction in a retroflexed view, the lesser
curvature is at 12 o'clock while the greater curvature is a 6 o'clock.
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FIG 9 • A. With the articulating arm at 12 o'clock, the helix retractor is placed into the squamocolumnar
junction. B. The helix retractor can be seen as a thin, horizontally oriented wire entering the gastric
lumen. The device is then advanced distally into the stomach and rotated clockwise on the screen so that
the articulating arm is at 6 o'clock (C).
FIG 10 • The articulating arm is rotated counterclockwise back toward the 1 o'clock position (the tip is
thus not visible in this view). The fundus is thus anteriorly rotated around the esophagus. This completes
the anterior portion of the fundoplication.
The first H-fastener set is then deployed.

The stomach is then reinsufflated to visualize deployment of a pair of H fasteners. Two sets of additional
H fasteners are subsequently placed at varying distances from the GE junction.
This will result in the placement of six fasteners 1 to 3 cm above the squamocolumnar junction.
Posterior Rotational Plication Fasteners
The helix retractor portion of the device is maintained at the 12 o'clock position.
The articulating arm is rotated counterclockwise through the lesser curve to the 8 o'clock position,
partially closed, and pulled back 1 to 2 cm. The GE junction is advanced caudally by applying tension to
the helical retractor.
The “Bell Roll” maneuver is again performed, but this time in the clockwise direction (clockwise on the
screen).
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The stomach is desufflated and the articulating arm is rotated clockwise to the 11 o'clock position. This
maneuver rotates the fundus posteriorly around the esophagus (FIG 11).
FIG 11 • To perform the posterior component of the fundoplication, the articulating arm is rotated
clockwise to the 11 o'clock position. This maneuver is a mirror image of the maneuver used to create the
anterior component of the fundoplication.
The first set of posterior rotational plication fasteners is then deployed.

The process is then repeated to place two additional sets of H fasteners at varying distances from the
GE junction.
Anterior Corner Longitudinal Plication
To address a gap in the anterior component of the plication that is often appreciated only after the
anterior and posterior sets have been placed, an anterior corner plication set is often placed.
The articulating arm is rotated counterclockwise through the lesser curve toward the 1 o'clock position.
Tension is applied to the helical retractor caudally and the approximating arm is pulled proximally while
desuf-flating the stomach.
Two additional sets of H-fasteners are deployed around the 1 o'clock position.
Greater Curve Deep Plication
The purpose of this maneuver is to fixate the greater curvature slightly more proximally on the
esophagus. This lengthens the antireflux valve.
The helix retractor is disengaged from the 12 o'clock position and re-engaged at the squamocolumnar
junction at the 6 o'clock position.
The reticulating arm is moved into the 5 o'clock position and one or two sets of fasteners are 2 to 4 cm
proximal to the squamocolumnar junction (FIG 12).
The newly constructed antireflux valve should be 200 to 300 degrees in circumference.
Inspection of the Newly Created Antireflux Valve
The device and endoscope are withdrawn together and then endoscope is removed from the EsophyX
device.
The endoscope is then advanced back into the stomach to allow inspection of the antireflux valve and to
assess for any bleeding or injuries to the esophagus and stomach. The fasteners are visualized in the
distal esophagus (FIG 13).
FIG 12 • The shaft of the device has been pulled back into the esophagus 3 to 4 cm. This allows
placement of the greater curve plication sutures with the articulating arm near the 6 o'clock position. This
move adds length to the antireflux valve.
The fundoplication created by the EsophyX device should have a similar endoscopic appearance as one
created by a laparoscopic Nissen fundoplication.
FIG 13 • Multiple purple polypropylene fasteners are visualized with the distal esophagus after TIF is
completed. These fasteners are not typically seen when retroflexing from within the stomach.
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RADIOFREQUENCY ENERGY APPLICATION TO THE LOWER ESOPHAGEAL SPHINCTER
Approved by the FDA in 2000, the Stretta system (Mederi Therapeutics Inc, Greenwich, CT) is currently
the only device on the market that uses radiofrequency energy for the treatment of GERD.4
The application of radiofrequency energy to the GE junction results in thermal injury and subsequent
scarring, which reduces LES compliance, decreases the number of transient LES relaxations, and
thereby decreases the incidence of reflux symptoms.
The Stretta system is composed of two main components: a radiofrequency generator and a catheter
system that connects to the generator. The catheter system is composed of an outer sheath, a 30-Fr
bougie tip, and four nickel-titanium 22-gauge needle electrodes surrounding a balloon. The system also
includes a channel for suction and another for irrigation (FIG 14).
FIG 14 • A. Schematic representation of the Stretta catheter system. The distal end is composed of a 30-Fr
bougie tip. The nickel-titanium needle electrodes can be seen pointing outward surrounding the balloon. B.
Radiofrequency generator (images © 2015 Mederi Therapeutics Inc).
Conscious sedation is usually adequate for use of the Stretta system. At our institution, Stretta is usually
performed in the endoscopy suite as opposed to the operating room.
Only one physician is typically needed to perform the procedure.
Positioning
After administration of conscious sedation medications, the patient is placed into the left lateral decubitus
position and a bite block is placed.
Placement of the Stretta Device into the Distal Esophagus
A standard endoscope is advanced down to the GE junction. The distance from the patient's lips to the
squamocolumnar junction is measured.
A guidewire is inserted through the working channel of the endoscope and the endoscope is removed.
Under fluoroscopic guidance, the catheter system is then passed over the guidewire into the stomach.
The catheter tip is then positioned 1 cm above the squamocolumnar junction based on measurements
obtained from the endoscopic evaluation.
Application of Radiofrequency Energy
The balloon is inflated to a pressure of 2 lb/in2.

The electrodes are then deployed through the mucosa and into the muscularis propria. Suction and
irrigation are initiated through their respective working channels.
The generator is activated and radiofrequency energy is applied for approximately 90 seconds per
application. During this process, the muscularis propria is heated to a temperature of 85°C, whereas the
esophageal mucosa is maintained below 50°C via cold water that is instilled through the catheter system.
This creates four ablation sites that are distributed 90 degrees apart from each other.
After the 90-second interval is complete, the catheter system is rotated 45 degrees and another cycle of
radiofrequency energy is delivered for 90 seconds. Following this cycle, eight lesions approximately 45
degrees apart are created in a circumferential fashion at that level.
The catheter system is advanced approximately 5 mm and the process is repeated to create another 8
sites of ablation. In total, this process is performed at six levels (from 1 cm proximal to the
squamocolumnar junction to the proximal gastric cardia), creating 48 ablation sites (FIG 15).
The Stretta system is then removed.
Inspection of the Gastroesophageal Junction
The endoscope is advanced back down to the GE junction to allow inspection of the radiofrequency
energy application site (FIG 16).
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FIG 15 • Coronal section through the esophagus with the electrodes positioned 1 cm proximal to the
squamocolumnar junction. Two electrodes can be seen entering the muscularis propria. After the tissue has
been ablated at six levels (indicated by white), the GE junction will eventually scar down as a result of the
thermal injury (images © 2015 Mederi Therapeutics Inc).
FIG 16 • Retroflexed views of the GE junction immediately before (A) and after (B) use of the Stretta device.
LOWER ESOPHAGEAL SPHINCTER AUGMENTATION SURGERY

The only commercially available laparoscopic LES augmentation device in the United States is the LINX
Reflux Management System (Torax Medical, St. Paul, MN). The LINX system is designed to decrease
reflux of gastric contents into the distal esophagus via placement of a flexible, expandable device
consisting of multiple interlinked titanium beads with a magnetic core (FIG 17).
When placed around the GE junction, it enhances the ability of the LES to resist opening and prevent
reflux into the esophagus.
FIG 17 • A. LINX device fully open with sutures at each end. B. Magnetic beads at each end are brought
together. This is the configuration that the device is in when placed around the GE junction.
With the device in place, once a patient swallows and esophageal peristalsis reaches the GE junction,
the pressure of the peristalsis overcomes the magnetic field within the LINX device thereby allowing the
device to open and food to enter into the stomach. The magnetic beads can also separate when
intragastric pressure exceeds the magnetic strength of the beads, which allows the patient to belch or
vomit if/when necessary.
General anesthesia is necessary.
Preoperative prophylactic antibiotics are administered prior to incision to reduce the chance of infection.
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FIG 18 • A 5-mm supraumbilical port, 8-mm left upper quadrant port, 5-mm left upper outer quadrant port,
and 5-mm right upper quadrant port are placed. A bladed 5-mm subxiphoid port is temporarily placed to
facilitate insertion of a liver retractor. The surgeon stands between the patient's legs and uses the 5-mm
right upper quadrant port and 8-mm port. The assistant on the patient's left controls the camera and retracts
the stomach inferiorly via the 5-mm right upper outer quadrant port.
Positioning
The patient can be placed into either the supine or splitleg position on the operating room table.
Port Placement and Initial Dissection
Our technique involves initial placement of a Veress needle in the left upper quadrant. Four ports are
subsequently placed including a 5-mm supraumbilical port, 8-mm left upper quadrant port, 5-mm left
upper outer quadrant port, and 5-mm right upper quadrant port. A 5-mm port is temporarily placed in the
subxiphoid position to facilitate placement of a liver retractor (FIG 18).
FIG 19 • A,B. A blunt grasper in the surgeon's left hand retracts the medial border of the right crus
laterally to open up the retroesophageal plane while the proximal stomach is retracted inferiorly and
laterally. The vagus nerve has been mobilized away from the esophagus to open up the plane for the
sizer to be introduced. (Photo courtesy of Dr. Kyle Perry, The Ohio State University Wexner Medical
Center.)
A 5-mm camera is inserted through the supraumbilical port, which is operated by an assistant surgeon
standing on the patient's left. The operating surgeon stands between the patient's legs and uses the 5-
mm right upper quadrant port and the 8-mm port. The operating surgeon uses a blunt grasper (left hand)
and an ultrasonic dissector (right hand) to enter the lesser sac via the pars flaccida. The left upper outer
5-mm port is used by the assistant surgeon to retract the stomach downward and laterally toward the
spleen to facilitate dissection of the GE junction.
Dissection of Gastroesophageal Junction
The medial border of the right crus of the diaphragm is identified to facilitate the dissection of the
retroesophageal space (FIG 19). The posterior vagal trunk is identified and preserved. The medial border
of the left crus is then identified from the patient's left to further open the retroesophageal space.
The blunt grasper in the surgeon's left hand is then passed through the retroesophageal plane between
the posterior esophageal wall and the posterior vagal trunk, which is preserved. The tip of the grasper
exits the retroesophageal tunnel anterior to the left crus of the diaphragm and is maintained in that
location.
Device Selection and Placement
A Penrose is placed into the upper abdomen and pulled through the retroesophageal tunnel. This serves
as a tract for smooth passage of the sizer.
The sizing instrument is placed into the abdomen through the 5-mm port (surgeon's left hand) and
advanced through the retroesophageal plane from the patient's right to left.
The white portion of the sizing instrument is then tightened around the GE junction cephalad to the
hepatic branches of the anterior vagal trunk. As the circumference
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of the sizer approaches that of the GE junction, the appropriate LINX device size will be indicated on the
sizing device (FIG 20).
The sizing instrument is removed and the LINX device is inserted through the same plane that the sizer
was placed through. The LINX device is then wrapped around the GE junction anteriorly. The sutures at
each end of the device are then secured with a Ti-Knot device or securing the magnetic clasp depending
on the version of the device employed (FIG 21).
FIG 20 • With the sizer gently wrapped around the GE junction anteriorly, the appropriate length of the
LINX device is estimated and the LINX device is modified so that the length of the device matches this
distance. (Photo courtesy of Dr. Kyle Perry, The Ohio State University Wexner Medical Center.)
The abdomen is desufflated, the ports are removed, and the skin incisions are sutured closed.
FIG 21 • The LINX device is in place around the GE junction. The sutures at each are retracted superiorly
and inferiorly to illustrate ideal positioning of the device. (Photo courtesy of Dr. Kyle Perry, The Ohio State
University Wexner Medical Center.)
PEARLS AND PITFALLS
Pitfall Pearl
Transoral incisionless fundoplication
▪ Cervical esophageal injury during ▪ Dilation of the esophagus with a large bougie (i.e., 56 Fr)
placement of the device given the and generous application of lubricant to the device will
relatively large size of the device minimize the likelihood of esophageal injury.
▪ Nasotracheal intubation will help clear the oropharynx for
EsophyX device insertion.
▪ Postoperative bleeding due to helix ▪ Minimize the number of times that the helix retractor is
retractor placement or during fastener deployed (once at the 12 o'clock position and once at the
placement, particularly along the lesser 6 o'clock position should be enough).
curve of the stomach ▪ Minimize fastener placement along the lesser curvature.
▪ Postprocedural EGD will identify early bleeding that may
occur during these steps; if identified, endoclips can be
placed.
▪ Gastric or esophageal perforation ▪ Avoid placement of the fasteners through the

related to fastener placement diaphragmatic crura by ensuring that the fasteners are
deployed below the point where the crura cross the
esophageal wall.
▪ Administer antiemetics aggressively to avoid significant
postoperative retching which may pull on the fasteners.
Radiofrequency energy application

▪ Imprecise radiofrequency energy ▪ Adequate amounts of anxiolytic and narcotic medications
application due to patient movement will help minimize patient movement; if necessary, general
during the procedure anesthesia can be administered.
▪ Overdistention of the stomach from ▪ Monitor the suction return closely to prevent the stomach
excess irrigation fluid from filling up with irrigant; there should be essentially a
1:1 correlation between irrigation and suction fluid.
▪ Uneven energy application via the four- ▪ More than two device rotations per level may be
needle electrodes due to asymmetry of necessary to ensure that the radiofrequency energy is
the GE junction (i.e., if a small hiatal applied at numerous points throughout the circumference
hernia is present) of the esophagus.
Lower esophageal augmentation surgery
▪ Esophageal injury while developing the ▪ Minimize the use of the ultrasonic dissector near the
retroesophageal plane. esophagus.
▪ To minimize bleeding near the posterior vagal trunk,
which may obscure the retroesophageal plane, carefully
and bluntly dissect with a Maryland or blunt grasper.
▪ Postoperative dysphagia due to ▪ Ensure that there is no tension on the sizer when
excessive restriction from the device measuring the circumference around the GE junction.
▪ Device migration ▪ When developing the retroesophageal plane, minimize

the amount of dissection posterior to the GE junction. The
dissection only needs to be wide enough to permit
passage of the sizer.
POSTOPERATIVE CARE
TIF—Patients are admitted postoperatively for overnight observation. A liquid diet is initiated following the
procedure and advanced to a soft solid diet within the next several weeks. Antiemetics are administered
liberally to minimize postoperative retching. Routine postoperative imaging is not obtained.
Radiofrequency energy application—Patients are discharged home on the day of the procedure. They are
kept on a liquid diet for the first several weeks and are subsequently advanced to a soft solid diet. Routine
postoperative imaging is not obtained.
LES augmentation surgery—Patients are admitted to the hospital overnight. During our early experience, as
part of a clinical trial, all patients underwent a routine chest x-ray and barium esophagram to verify correct
position of the device. Routine imaging is not currently obtained. The patient may resume a normal diet
immediately after the procedure.
OUTCOMES
TIF—With the earliest case series being published in 2008,5 truly long-term data regarding TIF are
lacking. In 2012, Trad and colleagues6 published their data which involved 28 patients and a median
follow-up of 14 months. Eighty-two percent of patients remained off their daily antireflux medications,
whereas 68% were satisfied with the results of the procedure.6 Heartburn and regurgitation symptoms
were eliminated in 65% and 80% of patients, respectively.
Radiofrequency energy application—In the earliest multicenter trial conducted in the United States
(involving 47 patients), 87% of patients had discontinued their antireflux medications at 6 months while
quality of life improved and esophageal exposure to acid (pH <4.0) decreased by over 50% (11.7% to
4.8% of the total time).7 Four-year follow-up data from a study published in 2007 found that, along with
sustained improvements in quality of life scores, 85% of patients remained off proton pump inhibitors or
had decreased their use by half.8
Lower esophageal augmentation surgery—In February 2013, the results of a nonrandomized multicenter
trial were published in the New England Journal of Medicine.9 Sixty-four percent of patients had either
normalized or significantly reduced their esophageal acid exposure at 1 year. Ninety-three percent of
patients had significantly reduced their antireflux medication regimen, whereas 92% experienced a
substantial improvement in quality of life.
COMPLICATIONS
TIF
Esophageal laceration/perforation
Postoperative bleeding
Gastric leak, mediastinal abscess
Early fundoplication failure
Radiofrequency energy application
Bloating, dyspepsia
Esophageal ulceration/bleeding
Esophageal perforation
LES augmentation surgery
Bloating, dysphagia
Device migration and/or erosion into the GI tract (to date, none have been reported or published in the
literature)
Allergic reaction to the device (patients with titanium, stainless steel, nickel, or ferrous allergies)
REFERENCES
1. Herbella AM, Peters JH. Anatomic and physiologic tests of esophageal function. In: Soper NJ, Swanström
LL, Eubanks WS, eds. Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia, PA: Lippincott
Williams & Wilkins; 2009:68-82.
2. Howard D, Richards R. Endoluminal therapy for gastroesophageal reflux disease. In: Murayama KM,
Chand B, Kothari SN, et al, eds. Evidence-Based Approach to Minimally Invasive Surgery. Woodbury, CT:
Cine-Med; 2012:29-38.
3. Bell RC, Cadière GB. Transoral rotational esophagogastric fundoplication: technical, anatomical, and
safety considerations. Surg Endosc. 2011;25:2387-2399.
4. Nikfarjam M, Ponsky JL. Endoluminal approaches to gastroesophageal reflux disease. In: Cameron JL,
Cameron AM. Current Surgical Therapy. 10th ed. Philadelphia, PA: Elsevier; 2010:19-21.
5. Bergman S, Mikami DJ, Hazey JW, et al. Endolumenal fundoplication with EsophyX: the initial North
American experience. Surg Innov. 2008:15(3):166-170.
6. Trad KS, Turgeon DG, Deljkich E. Long-term outcomes after transoral incisionless fundoplication in
patients with GERD and LPR symptoms. Surg Endosc. 2012;26:650-660.
7. Triadafilopoulos G, Dibaise JK, Nostrant TT, et al. Radiofrequency energy delivery to the
gastroesophageal junction for the treatment of GERD. Gastrointest Endosc. 2001;53(4):407-415.
8. Noar MD, Lotfi-Emran S. Sustained improvement in symptoms of GERD and antisecretory drug use: 4-
year follow-up of the Stretta procedure. Gastrointest Endosc. 2007;65(3):367-372.
9. Ganz RA, Peters JH, Horgan S, et al. Esophageal sphincter device for gastroesophageal reflux disease. N
Engl J Med. 2013;368(8): 719-727.
Chapter 9
Laparoscopic Heller Myotomy and Anterior Fundoplication for
Esophageal Achalasia
Marco E. Allaix
Marco G. Patti
DEFINITION
Esophageal achalasia is a primary motility disorder characterized by lack of esophageal peristalsis and
failure of the lower esophageal sphincter (LES) to relax properly in response to swallowing.
Benign strictures secondary to gastroesophageal reflux disease (GERD) and esophageal neoplasms may
mimic the clinical presentation of achalasia.
An infiltrating tumor of the gastroesophageal junction can mimic not only the clinical and radiologic
findings of achalasia but also the manometric profile. This condition, defined as “secondary achalasia” or
“pseudoachalasia,” should be suspected and ruled out in patients older than 60 years of age, with recent
onset of dysphagia (less than 6 months), and with excessive weight loss.1

Dysphagia is the main complaint, being reported by about 95% of patients. It is often for both solids and
liquids. Most patients are able to maintain a stable weight due to changes made in their diet.
About 60% of patients experience regurgitation of undigested food. It occurs more frequently in the supine
position and may lead to aspiration that in turn can cause respiratory symptoms, such as cough, hoarseness,
wheezing, and episodes of pneumonia.2
Heartburn is present in about 40% of patients: It is due to stasis and fermentation of undigested food in the
distal esophagus rather than due to gastroesophageal reflux (GER).
Esophageal distention can cause chest pain in up to 40% of patients, and it is usually experienced at the time
of a meal.

A thorough evaluation to establish the diagnosis should be performed in all patients with symptoms suggestive
for achalasia.3 It consists of the following studies:
Upper endoscopy is usually the first test that is performed to rule out the presence of a mechanical
obstruction secondary to a peptic stricture or cancer.
Barium swallow shows a narrowing at the level of the gastroesophageal junction (the so-called bird's beak),
slow esophageal emptying with an air-fluid level, and either absence of or tertiary contractions of the
esophageal wall (FIG 1). It also defines the diameter and the axis of the esophagus (dilated and sigmoid in
long-standing achalasia) and associated pathologic findings, including an epiphrenic diverticulum. The
gastric air bubble is usually absent.
FIG 1 • Barium swallow: dilatation of the esophageal body, retained barium, and distal esophageal
narrowing (bird's beak).
Esophageal manometry is the gold standard for the diagnosis of achalasia. Lack of peristalsis and absent
or incomplete LES relaxation in response to swallowing are the key criteria for the diagnosis. The LES is
hypertensive in only about 50% of patients.3 Recently, a new classification of esophageal achalasia has
been proposed based on high-resolution manometry (HRM): type I, classic, with minimal esophageal
pressurization; type II, achalasia with panesophageal pressurization; and type III, achalasia with spasm (FIG
2).4
FIG 2 • High-resolution esophageal manometry: type II achalasia according to the Chicago classification.
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Ambulatory pH monitoring is important in untreated patients when the diagnosis is uncertain in order to
distinguish between GERD and achalasia. Postoperatively, ambulatory pH monitoring can be performed to
rule out GER that is present in about 30% to 40% of cases after Heller myotomy and is often
asymptomatic.5
SURGICAL MANAGEMENT
A careful systematic evaluation and the tests described before should be performed in every patient before
treatment.
Positioning
After induction of general endotracheal anesthesia, the patient is positioned supine in low lithotomy position
with the lower extremities extended on stirrups, with knees flexed 20 to 30 degrees or straight if using a split-
leg table.
To avoid sliding as a consequence of the steep reverse Trendelenburg position used during the procedure, a
beanbag is inflated to create a “saddle” under the perineum.
Because increased abdominal pressure from pneumoperitoneum and the steep reverse Trendelenburg
position decrease venous return, pneumatic compression stockings are always used as prophylaxis against
deep venous thrombosis.
An orogastric tube is placed to keep the stomach decompressed during the procedure and it is removed
before starting the myotomy.
A Foley catheter is inserted at the beginning of the operation and removed at the end.
The surgeon stands between the patient's legs. The first and second assistants stand on the right and left
side of the operating table (FIG 3).
FIG 3 • Position of the patient and surgical team in the operating room.
TECHNIQUES
PLACEMENT OF PORTS
Five 10-mm trocars are used for the procedure (FIG 4).
The first incision is made in the midline 14 cm distal to the xiphoid process and a Veress needle is
introduced into the peritoneal cavity. The peritoneal cavity is insufflated to a pressure of 15 mmHg.
Subsequently, under direct vision, an optical port with a 0-degree scope (port 1) is placed. Once this
port is placed, the 0-degree scope is replaced with a 30-degree scope and the other trocars are
inserted under laparoscopic vision.
FIG 4 • Placement of the ports.
Port 2 is placed in the left midclavicular line at the same level of port 1. It is used by the assistant for
traction on the gastroesophageal junction and as an instrument to take down the short gastric vessels.
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Port 3 is placed in the right midclavicular line at the same level of the other two ports. A retractor is
used through this port to lift the left lateral segment of the liver to expose the gastroesophageal
junction. The retractor is held in place by a self-retaining system fixed to the operating table.
Ports 4 and 5 are placed under the right and left costal margins so that their axes and the camera form
an angle of about 120 degrees. These ports are used by the operating surgeon.
The instrumentation necessary for the laparoscopic myotomy is reported in Table 1.
Table 1: Instrumentation for Laparoscopic Heller Myotomy and Partial Fundoplication
Five 10-mm ports
0- and 30-degree scope
Graspers and needle holder
Babcock clamp
L-shaped hook cautery with suction-irrigation capacity
Scissors
Laparoscopic clip applier
Electrothermal bipolar vessel-sealing system
Liver retractor
Suturing device
2-0 silk sutures
DISSECTION
The gastrohepatic ligament is divided, beginning the dissection above the caudate lobe of the liver,
where the ligament is thinner, and continuing toward the diaphragm until the right pillar of the crus is
identified and separated from the esophagus by blunt dissection.
Subsequently, the peritoneum and the phrenoesophageal membrane overlying the esophagus are
divided and the anterior vagus nerve is identified (FIG 5A).
FIG 5 • A. Division of the peritoneum and the phrenoesophageal membrane overlying the esophagus with
anterior vagus nerve identification. B. Separation of the left pillar of the crus from the esophagus.
The left pillar of the crus is then separated from the esophagus (FIG 5B).
Blunt dissection is finally performed in the posterior mediastinum, laterally and anteriorly to the
esophagus in order to have about 4 to 5 cm of esophagus without any tension below the diaphragm.
Posterior dissection is necessary only if a partial posterior fundoplication is planned.
DIVISION OF THE SHORT GASTRIC VESSELS
The short gastric vessels are taken down all the way to the left pillar of the crus, starting from a point
midway along the greater curvature of the stomach (FIG 6).6
FIG 6 • Division of the short gastric vessels.
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MYOTOMY
The fat pad should be removed to expose the gastroesophageal junction after identification of the
anterior vagus nerve.
Traction is then applied with a Babcock clamp, grasping below the gastroesophageal junction and pulling
downward and to the left in order to expose the right side of the esophagus.
A myotomy is performed on the right side of the esophagus in the 11 o'clock position using a hook
cautery. The proper submucosal plane is found using the cautery, about 3 cm above the
gastroesophageal junction.
Once the mucosa is exposed, the myotomy is extended proximally for about 6 cm above the
gastroesophageal junction and distally for 2.5 to 3 cm onto the gastric wall (FIG 7).7
The edges of the muscles are then separated with a dissector in order to have 30% to 40% of the
mucosa not covered by muscles.
Intraoperative endoscopy is rarely necessary, particularly when enough experience is present and a long
myotomy onto the gastric wall is performed.
FIG 7 • Esophageal myotomy.
PARTIAL FUNDOPLICATION
The main goal of the surgical treatment is relief of dysphagia while preventing GER.8
A laparoscopic Heller myotomy (LHM) alone is associated with postoperative GER in about 50% to 60%
of patients.9
Better functional results are achieved with a partial fundoplication added to the myotomy compared to a
total fundoplication that is associated with higher rates of postoperative dysphagia.10
Regarding the type of partial fundoplication, no significant differences are evident in terms of control of
GER after the partial anterior and partial posterior fundoplication.5
We prefer the partial anterior fundoplication because it is simpler to perform, as posterior dissection is not
necessary, and because it covers the exposed esophageal mucosa.
Partial Anterior Fundoplication (Dor)
The Dor fundoplication is a 180-degree anterior fundoplication.
Two rows of sutures (2-0 silk) are used. The first row is on the left side of the esophagus and has three
stitches. The top stitch incorporates the fundus of the stomach, the muscular layer of the left side of the
esophagus, and the left pillar of the crus (FIG 8).
FIG 8 • Dor fundoplication: top stitch of the left row of sutures.
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FIG 9 • Dor fundoplication: second and third stitches of the left row of sutures.
The second and third stitches incorporate the gastric fundus and the muscular layer of the left side of the
esophagus (FIG 9).
The fundus is then folded over the exposed mucosa so that the greater curvature of the stomach is next
to the right pillar of the crus.
FIG 10 • Dor fundoplication: right row of sutures.
FIG 11 • Completed Dor fundoplication.
The second row of sutures on the right side of the esophagus consists of three stitches between the
fundus and the right pillar of the crus (FIG 10).
Finally, two additional stitches are placed between the fundus and the rim of the esophageal hiatus to
eliminate any tension from the fundoplication (FIG 11).
Partial Posterior Fundoplication
Some authors argue that the posterior partial fundoplication should be used as it might be more effective
in preventing GER and because it keeps the distal edges of the myotomy separated.11
The posterior fundoplication requires the creation of a posterior window between the left pillar of the crus,
the stomach, and the esophagus followed by the passage of the gastric fundus under the esophagus.
The hiatus is loosely closed posterior to the esophagus.
Subsequently, each side of the wrap is attached to the esophageal wall lateral to the myotomy with three
stitches. The resulting wrap measures about 220 to 240 degrees.
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PEARLS AND PITFALLS
Indications ▪ A careful evaluation including manometry, 24-hour pH monitoring, upper

endoscopy, and barium swallow must be done.
Placement of ▪ Extreme care must be taken when positioning port 1, because the site of insertion
ports is just above the aorta.
▪ We recommend using an optical trocar with a 0-degree scope to obtain access.
▪ If port 3 is too low, the left lateral segment of the liver will not be properly
retracted and exposure of the esophagogastric junction may be inadequate.
▪ If port 2 is too low, the esophagogastric junction or the upper short gastric
vessels may be difficult to access.
▪ If ports 4 and 5 are too low, the dissection at the beginning of the procedure and
the suturing at the end will be challenging.
▪ If port 3 is too medial, the liver retractor may interfere with the instrument used
through port 4.
Dissection ▪ An accessory left hepatic artery originating from the left gastric artery is
frequently present in the gastrohepatic ligament. If this vessel limits the exposure,
it may be safely divided.
▪ The electrocautery should be used with extreme caution. Because of the lateral
spread of the monopolar current, vagus nerves may be damaged even without
direct contact. A bipolar instrument represents a safer alternative.
Short gastric ▪ Bleeding, either from the short gastric vessels or from the spleen, and damage to
vessels the gastric wall are possible complications.
division
▪ Excessive traction and division of a vessel not completely coagulated are the
main causes of bleeding.
▪ A burn caused during dissection of the short gastric vessels or traction applied
with the graspers or the Babcock clamp are the most common mechanisms of
damage to the gastric wall.
Myotomy ▪ In patients who have had previous treatment with botulinum toxin injection, the
myotomy is technically more challenging due to the fibrosis that alters the normal
anatomic planes and may increase the risk of perforation.12
▪ If a mucosal perforation occurs, it can be repaired with 5-0 absorbable material.
▪ In case of bleeding from the cut muscular fibers, gentle compression with a
sponge is recommended rather than the electrocautery, which can cause thermal
damage to the esophageal wall.
Partial ▪ To reduce the risk of postoperative dysphagia due to the fundoplication

anterior
fundoplication ▪ The short gastric vessels should be divided.
▪ The wrap should be performed using the fundus rather than the body of the
stomach.
POSTOPERATIVE CARE
Patients spend an average of 1 to 2 days in the hospital and return to work in 2 to 3 weeks.
Patients are fed the morning of the first postoperative day with clear liquids and then a soft diet.
They are instructed to avoid meat, bread, and carbonated beverages for the following 2 weeks.
Most patients resume their regular activity within 2 to 3 weeks.
OUTCOMES
Long-term follow-up shows that symptoms are improved in 90% to 95% of patients at 5 years and in 80%
to 90% at 10 years.
Most LHM failures present within the first 2 to 3 years of follow-up and may reflect fibrosis of the distal
edge of the myotomy that can be successfully treated in most cases with pneumatic dilatation.
Postoperative GER occurs in about 30% to 40% of patients, and it is usually controlled by acid-reducing
medications.
COMPLICATIONS
Esophageal leak may occur during the first 24 to 36 hours postoperatively, and it is usually the result of a
thermal injury of the esophageal mucosa.
Typical signs and symptoms include pain, fever, and dyspnea. A chest x-ray may show a pleural
effusion.
An esophagogram confirms the location and the extension of the leak.
Treatment options vary based on the time of diagnosis and on the location and extension of the leak.
In case of early diagnosis, small leaks can be repaired directly. If the damage is too extensive or the
inflammatory reaction in case of late diagnosis does not allow a direct repair, an esophagectomy may
be indicated. In selected cases, wide drainage and placement of a feeding jejunostomy tube with or
without the use of an esophageal stent may allow the leak to heal without esophagectomy.
Pneumothorax occurs in case of intraoperative violation of the parietal pleura. Usually, it resolves
spontaneously and does not require tube thoracostomy as the CO2 is rapidly absorbed.
Persistent dysphagia is usually due to technical errors, such as a too short of a myotomy or a too
constricting fundoplication.
Recurrent dysphagia after a symptom-free period may be caused by scar tissue in the distal edge of the
myotomy, postoperative GER, technical errors cited earlier, or esophageal cancer. In either case, a
thorough evaluation is mandatory to rule out malignancies and make a correct diagnosis. Subsequent
treatment is tailored to the results of this workup and includes pneumatic dilatation and/or a reoperation.
REFERENCES
1. Moonka R, Patti MG, Feo CV, et al. Clinical presentation and evaluation of malignant pseudoachalasia. J
Gastrointest Surg. 1999;3:456-461.
2. Khandelwal S, Petersen R, Tatum R, et al. Improvement of respiratory symptoms following Heller myotomy
for achalasia. J Gastrointest Surg. 2011;15:235-239.
3. Fisichella PM, Raz D, Palazzo F, et al. Clinical, radiological, and manometric profile in 145 patients with
untreated achalasia. World J Surg. 2008;32:1974-1979.
4. Bredenoord AJ, Fox M, Kahrilas PJ, et al. Chicago classification criteria of esophageal motility disorders
defined in high resolution esophageal pressure topography. Neurogastroenterol Motil. 2012;24:57-65.
5. Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor versus Toupet fundoplication following
Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc.
2012;26:18-26.
6. Patti MG, Molena D, Fisichella PM, et al. Laparoscopic Heller myotomy and Dor fundoplication for
achalasia: analysis of successes and failures. Arch Surg. 2001;136:870-877.
7. Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia.
Arch Surg. 2003;138:490-497.
8. Patti MG, Herbella FA. Fundoplication after laparoscopic Heller myotomy for esophageal achalasia: what
type? J Gastrointest Surg. 2010;14(9):1453-1458.
9. Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor
fundoplication: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240:405-415.
10. Rebecchi F, Giaccone C, Farinella E, et al. Randomized controlled trial of laparoscopic Heller myotomy
plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg. 2008;
248:1023-1030.
11. Hunter JG, Trus TL, Branum GD, et al. Laparoscopic Heller myotomy and fundoplication for achalasia.
Ann Surg. 1997;225:655-665.
12. Smith CD, Stival A, Howell DL, et al. Endoscopic therapy for achalasia before Heller myotomy results in
worse outcome than Heller myotomy alone. Ann Surg. 2006;243:579-586.
Chapter 10
Radiofrequency Ablation of Barrett's Esophagus
Shajan Peter
C. Mel Wilcox
Klaus Mönkemüller
DEFINITION
Barrett's esophagus (BE) is an acquired condition due to a change in the normal esophageal squamous
epithelium to columnar epithelium containing goblet cells. This metaplastic change can progress to low-
grade dysplasia (LGD) and high-grade dysplasia (HGD), with the latter having a 5% to 10% risk of
developing into esophageal adenocarcinoma.1,2
Radiofrequency ablation (RFA) is a safe and effective endoscopic treatment modality for BE whereby
squamous tissue replaces the ablated metaplastic or dysplastic epithelium. RFA uses a bipolar electrode
array to generate thermal energy to result in tissue dissipation.3

It might be difficult to distinguish symptoms of BE from gastroesophageal reflux disease (GERD) clinically,
although increased duration, severity, and early age of onset for reflux symptoms as well as obesity
predispose to BE occurrence.4
Age older than 55 years, male gender, white ethnicity, or smokers are predisposing factors for BE
development and progression to dysplasia. Genetic influences may play a role, although only a small
proportion (7%) of patients with BE have a documented family history of BE or esophageal cancer.5
Selection of patients for endoscopic treatment of BE requires a multidisciplinary approach consisting of the
endoscopist, pathologist, and the surgeon.
Confirmation of dysplasia (high or low grade) on biopsies or endoscopic mucosal resection (EMR) specimens
is done by a dedicated gastrointestinal (GI) pathologist.6

Detailed endoscopic examination with high-definition white light of the BE segment is essential for
management.
The extent of the BE segment should be defined using the Prague C & M classification including the length of
the circumferential segment (C) and the maximal extent of the BE segment (M)7 (FIG 1).
FIG 1 • Prague C & M classification.
Other imaging modalities that might help in delineating BE are narrow band imaging (NBI), chromoendoscopy,
autofluorescence imaging, and confocal laser endoscopy. These adjuncts aid in directed biopsies.
Any visible lesions in the Barrett's segment should be described using the Paris classification.8
Targeted biopsies are obtained from visible abnormalities, followed by four-quadrant biopsies of every 1 to 2
cm of the BE segment (Seattle protocol) and these should be reviewed by a dedicated GI pathologist.9
Nodular lesions are best staged by an EMR as described in Chapter 11.
ENDOSCOPIC MANAGEMENT
Patients are given standard esophagogastroduodenoscopy (EGD) preprocedure preparation instructions with
specific attention to factors that increase risk of sedation including morbidly obese patients; anatomic variants
such as short neck, cervical osteophytes, cricopharyngeal hypertrophy; and prior history of surgery involving
the GI tract, radiation, or documentation of previous strictures.
No antibiotics are required and it is desirable to minimize or stop antiplatelet/anticoagulation prior to the
procedure.
Equipment lists for circumferential and focal ablation can be found in Tables 1 and 2.
Positioning
The patient is placed in the left lateral decubitus position and prepared as for a routine upper endoscopy.
Table 1: Circumferential Ablation Equipment List
Endoscope and equipment
RFA energy generator console
HALO360 sizing balloon

HALO360 balloon ablation catheter
HALO cap
Gauze
1% N-acetylcysteine solution
Spray catheter
Savary spring-tipped guidewire
From Frantz DJ, Dellon ES, Shaheen NJ. Radiofrequency ablation of Barrett's esophagus. Techniques
Gastrointest Endosc. 2010;12:100-107.
Table 2: Focal Ablation Equipment List
Endoscope and equipment
RFA energy generator
HALO90 ablation device
Gauze
1% N-acetylcysteine solution
Spray catheter
From Frantz DJ, Dellon ES, Shaheen NJ. Radiofrequency ablation of Barrett's esophagus. Techniques
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TECHNIQUES
CIRCUMFERENTIAL ABLATION
Endoscopy with Inspection and Recording the Landmarks
Measurements are taken to map the extent of the BE showing (1) top of intestinal metaplasia (TIM), (2)
proximal contiguous area of BE (M), (3) proximal level at which the BE is circumferential, (4) and the top
of the gastric folds (TGF) (FIG 2).
Careful inspection should be made to rule out prior ulceration, strictures, previous scarring from EMR or
residual nodularity as these may compromise any balloon circumferential ablation. Dilatations should be
performed prior to ablation.
Mucosa is washed with N-acetylcysteine to clear any excess mucus and prepare the tissue for further
ablation.
After adequate inspection and recording landmarks, a guidewire is passed into the gastric antrum and
then the endoscope removed.
Sizing
The sizing balloon is attached to the control unit and then calibrated externally also to rule out any leaks.
It is then introduced over the guidewire into the body of the esophagus, placing it 3 cm proximal to the
TIM measurement.
Serial measurements are taken at 1-cm intervals, starting proximally and proceeding distally by inflating
the device on the pedal provided. The displayed measurements on the console are then recorded by a
technician or nurse. The smallest diameter treatment balloon suggested throughout the sizing is chosen
as appropriate ablation catheter.
Selecting Appropriate Ablation Device
After sizing, the catheter is then removed, keeping the guidewire in place.
The smallest diameter treatment balloon suggested throughout the sizing is chosen as appropriate
ablation catheter and attached to the generator.
FIG 2 • Endoscopic appearance of BE. Yellow oval indicates top of gastric folds, green line to yellow
arrows indicates maximum length of BE, and white line denotes length of circumferential BE.
First Ablation Pass
The Barrx™ 360 RFA Balloon Catheter (Covidien, Mansfield, MA) (FIG 3), consisting of a 3-cm electrode
array encircling a 4-cm long balloon, is then passed over the guidewire into the esophagus (FIG 4A). The
endoscope is intubated alongside the catheter to visualize the proximal end of the balloon, which is then
positioned 1 cm proximal to the TIM.
The balloon is automatically inflated first and then energy delivered by using the foot pedals attached to
the control unit. The uniform energy has a density of 12 J/cm2 and power of 40 W/cm2 ablating to a depth
of 700 to 1,000 μm over 3 cm of array (FIG 4B).
After a second of ablation, the balloon automatically deflates and the circumferential burn is visible.
Depending on the length of the segment, an additional 3 cm of circumferential ablation is performed such
that there is minimal overlap with the previously ablated segment (FIG 4C).
Cleaning Procedure
The balloon catheter is then removed along with the endoscope, leaving the guidewire in place. Outside
the patient, it is inflated and cleaned using damp gauze, removing adherent ablated tissue.
The treated area is then cleaned of the coagulum using a HALO cap attached to the tip of the endoscope
(FIG 5). After reintroduction of the endoscope, the coagulum is gently removed using the edge of the cap,
debriding proximal to distal in a circumferential manner and thereafter cleaning with saline lavage. The
endoscope is removed and then the cap discarded.
Second Ablation Pass
The cleaned ablation catheter device is then introduced over the guidewire with the endoscope and a
second set of ablation is performed as described previously, retreating the area and further coagulating
any superficial blood vessels preventing bleeding.
FIG 3 • Barrx™ 360 RFA Balloon Catheter (© 2014 Covidien).
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FIG 4 • Circumferential ablation. A. Positioning of device. B. First ablation. C. Postablation appearance.
Focal Ablation
The focal ablation is performed for treating shorter segments, tongues and islands of BE, and during
follow-up after an initial circumferential RFA. It may also be of special use in treating areas adjacent to
the squamous-columnar junction.
FIG 5 • Cleaning using HALO cap.
After careful endoscopic examination, the areas are recorded and endoscope removed while externally,
the HALO90 device (array measuring 13 × 20 mm) is attached to the tip of the scope. It is positioned such
that the back of the thumb-shaped array is located at 12 o'clock position on the endoscopic field of view
and can be pivoted easily. It is reintroduced into esophagus after careful intubation.
The esophagus is washed with N-acetylcysteine solution. The targeted area of BE is identified and the
endoscope is angulated such that the ablation device is tightly opposed to the mucosa (FIG 6A).
After maintaining optimal contact, the energy is delivered using the foot pedal using the similar energy
settings previously described. Maintaining the same position, a second pulse of energy is given. The
device is then moved to the next treatment area and previously mentioned steps repeated, treating all
visualized BE (FIG 6B).
The coagulum of desiccated mucosa is then removed using either a HALO cap as previously described
or even the tip of the ablation device could be used to scrape the tissue. After gentle debridement, the
device is then externally cleaned using damp gauze, reintroduced while mounted on the scope and a
second round of two applications per area are performed in an identical manner such that eventually
each targeted area receives a total of four energy ablations.
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FIG 6 • Focal ablation. A. Positioning of device. B. Ablation.
FOLLOW-UP
Endoscopic evaluation of the ablated area is performed 2 months following the procedure, and complete
healing should have occurred by this time (FIG 7).
FIG 7 • Follow-up showing healing.
PEARLS AND PITFALLS
Indications ▪ Careful history, endoscopic findings, and pathologic review of records should
be done prior to selection of patients for ablation.
Selection of ▪ Long-segment circumferential areas should be targeted using the

ablation method circumferential HALO360 device.
▪ Short segment and subsequent sessions or “touch up” of BE can be treated

using the focal HALO90 device.
Circumferential ▪ Endoscopic identification of landmarks and length on segment based on

ablation Prague classification
▪ Sizing of device and selection of balloon ablating catheter
▪ Careful positioning and endoscopic visualization of the catheter and

performing the first ablation pass
▪ Cleaning of device externally while performing debridement of tissue using the

endoscope and cap
▪ Performing the second ablation pass
Focal ablation ▪ Endoscopic identification of landmarks

▪ Attachment of device to endoscope such that it is in 12 o'clock endoscopic
view
▪ Optimal opposition to targeted mucosa and energy delivered using “dual

technique” with continued ablation of all areas
▪ Debridement of tissue, cleaning of device, and second pass of ablation for all
areas
Follow-up ▪ Immediate postprocedure instructions are given regarding food intake, pain
management, and antireflux medications.
▪ Follow-up after 2 months for repeat endoscopy, further ablation, or biopsies.
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POSTOPERATIVE CARE
After RFA treatment, patients may experience chest pain and dysphagia for 3 to 4 days thereafter.
Postoperative care includes a pain management with viscous lidocaine or liquid acetaminophen with narcotic.
A liquid diet is advised for 24 hours after treatment and then to slowly return to normal diet.
A maintenance dose of proton pump inhibitor (PPI) such as esomeprazole 40 mg twice a day during the entire
treatment period for adequate acid suppression is required to promote healing. In addition, sucralfate 1 g four
times a day for 2 weeks is prescribed.
Patients are usually discharged home on the same day as the procedure. On occasion, severe chest pain may
require admission for observation and optimizing pain management.
They are instructed to be followed up for 2 months after the initial ablation when they are reassessed for
further treatment or biopsies if neo-squamous epithelium is seen. Approximately 3.5 treatment sessions may
be necessary to clear all dysplastic BE and this will depend on the length of segment.
OUTCOMES
RFA is effective for treatment of HGD and LGD.3
In a randomized sham-controlled trial, complete eradication for HGD was noted in 81.0% compared to
19.0% in controls. Similarly, disease progression was lower in the ablation group (3.6% vs. 16.3%).10
Patients with LGD achieved eradication in 90.5% of the ablation group as compared to 22.7% of control
group at the end of 12 months. Durability of RFA demonstrated eradication of dysplasia in 98% and 91%
of metaplasia at the end of 3 years since ablation therapy.11
COMPLICATIONS
RFA has a low complication rate with low adverse events. Chest pain and dysphagia are commonly
associated symptoms lasting for a period of 3 to 4 days posttreatment and resolves spontaneously to
baseline.12,13
Strictures can occur on follow-up and the rate varies between 0% and 8%, with longer segments and
preceding EMR to be higher risk factors for developing them. They can, however, be managed by
endoscopic dilatation.
Bleeding is rare (<1%) and encountered especially in patients on antiplatelet or anticoagulation therapy.
No perforations or RFA-related deaths have been reported after RFA. Fever is also a rare complication
and can be managed using antipyretics.
Buried intestinal metaplasia or glands has been of concern postablation and may not be visible
endoscopically. It is less frequently reported after RFA (0.9%) and highlights the need for deep
endoscopic biopsies, which need to be carefully reviewed by the pathologist.14
REFERENCES
1. Shaheen NJ, Crosby MA, Bozymski EM, et al. Is there publication bias in the reporting of cancer risk in
Barrett's esophagus? Gastroenterology. 2000;119:333-338.
2. Hvid-Jensen F, Pedersen L, Drewes AM, et al. Incidence of adenocarcinoma among patients with Barrett's
esophagus. N Engl J Med. 2011;365:1375-1383.
3. American Gastroenterological Association, Spechler SJ, Sharma P, et al. American Gastroenterological

Association medical position statement on the management of Barrett's esophagus. Gastroenterology.
2011;140:1084-1091.
4. Nelsen EM, Hawes RH, Iyer PG. Diagnosis and management of Barrett's esophagus. Surg Clin North Am.
2012;92:1135-1154.
5. Chak A, Ochs-Balcom H, Falk G, et al. Familiality in Barrett's esophagus, adenocarcinoma of the

esophagus, and adenocarcinoma of the gastroesophageal junction. Cancer Epidemiol Biomarkers Prev.
2006; 15:1668-1673.
6. ASGE Standards of Practice Committee, Evans JA, Early DS, et al. The role of endoscopy in Barrett's
esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012;76:1087-1094.
7. Sharma P, Dent J, Armstrong D, et al. The development and validation of an endoscopic grading system
for Barrett's esophagus: the Prague C & M criteria. Gastroenterology. 2006;131:1392-1399.
8. Endoscopic Classification Review Group. Update on the paris classification of superficial neoplastic
lesions in the digestive tract. Endoscopy. 2005;37:570-578.
9. Levine DS, Haggitt RC, Blount PL, et al. An endoscopic biopsy protocol can differentiate high-grade
dysplasia from early adenocarcinoma in Barrett's esophagus. Gastroenterology. 1993;105:40-50.
10. Shaheen NJ, Sharma P, Overholt BF, et al. Radiofrequency ablation in Barrett's esophagus with
dysplasia. N Engl J Med. 2009;360:2277-2288.
11. Shaheen NJ, Overholt BF, Sampliner RE, et al. Durability of radiofrequency ablation in Barrett's
esophagus with dysplasia. Gastroenterology. 2011;141:460-468.
12. Sharma VK. Ablation of Barrett's esophagus using the HALO radiofrequency ablation system. Techniques
Gastrointest Endosc. 2010; 12:26-34.
13. van Vilsteren FG, Bergman JJ. Endoscopic therapy using radiofrequency ablation for esophageal
dysplasia and carcinoma in Barrett's esophagus. Gastrointest Endosc Clin N Am. 2010;20:55-74, vi.
14. Gray NA, Odze RD, Spechler SJ. Buried metaplasia after endoscopic ablation of Barrett's esophagus: a
systematic review. Am J Gastroenterol. 2011;106:1899-1908; quiz 1909.
15. Frantz DJ, Dellon ES, Shaheen NJ. Radiofrequency ablation of Barrett's esophagus. Techniques
Chapter 11
Endoscopic Mucosal Resection for Barrett Neoplasia
Shajan Peter
C. Mel Wilcox
Klaus Mönkemüller
DEFINITION
Barrett esophagus (BE) is a strong risk factor for esophageal adenocarcinoma.1
The annual risk of BE progression to adenocarcinoma ranges from 01.12% to 0.61%.1,2
The traditional treatment of choice for “resectable” esophageal adenocarcinoma is esophagectomy.
However, surgical resection is still associated with significant mortality and morbidity, even in high-
volume centers and especially in elderly or poor surgical candidates.3
Thus, during the last two decades, patients with early cancer or those with high-grade dysplasia have
been successfully treated with endoscopic resection methods.4,5
The most common method used is endoscopic mucosal resection (EMR) or “mucosectomy.” 4,5
The differential diagnosis of mucosal neoplasia of the distal esophagus is narrow. The most common
malignant neoplasia of the distal esophagus is adenocarcinoma, followed by squamous cell cancer.4,5
Proximal stomach cancer such as cardiac or fundic adenocarcinoma extending into the esophagus may
be difficult to differentiate from distal esophageal adenocarcinoma.
Submucosal tumors such as gastrointestinal (GI) tumors, spindle cell tumors, lipoma, and leiomyoma are
easily differentiated from mucosal lesions as these tumors generally have a normal overlying mucosa.

Most patients with Barrett's neoplasia do not have any specific symptoms and BE is discovered incidentally
during an upper GI endoscopy performed for the evaluation of gastroesophageal reflux symptoms, dyspepsia,
or abdominal pain.6
However, Barrett's neoplasia is more common in patients with the following characteristics: male, central
obesity, Caucasian, age older than 50 years, tobacco use, and chronic gastroesophageal reflux disease
(GERD).6
Although reflux of acid is a common occurrence in BE, a high proportion of BE patients deny a history of reflux
symptoms.7
Therefore, any patient undergoing upper endoscopy should be carefully investigated for columnar-lined
epithelium and intestinal metaplasia of the distal esophagus, with special attention to patients with the risk
factors mentioned earlier.

Radiologic studies do not play a role in the evaluation of BE unless there is a stricture present (benign or
malignant). In this instance, a barium esophagogram can be helpful to determine the length and characteristics
of the stenosis.
Although computed axial tomography is useful to evaluate for lung metastasis and mediastinal and perigastric
lymph node involvement in esophageal adenocarcinoma, its role in patients with early Barrett neoplasia is
negligible, as most of these patients have local disease, which does not extend beyond the submucosa of the
esophagus.
Patients with Barrett's cancer invading the submucosa (sm1) have a very low risk of lymph node metastasis
and thus are ideal candidates for EMR.4,5 and 6
In the past, endoscopic ultrasound (EUS) was used to determine the depth of GI layers involvement in early
Barrett neoplasia.8
However, the sensitivity and specificity of EUS for early Barrett neoplasia are low and the results can be
misleading.8
The mainstay of diagnosis of BE is with light endoscopy, ideally using high-definition endoscopes and
equipment.9
It is very important to measure the proximal distance of extension of cylindrical-type epithelium into the
esophagus. The extent of BE segment should be defined using the Prague C & M classification including the
length of the circumferential segment (C) and the maximal extent of the BE segment (M).10
The use of various staining agents and dyes (chromoendoscopy) such as methylene blue (FIG 1) and indigo
carmine or agents such as acetic acid (FIG 2) enhances the mucosal pit pattern analysis (see the following
text) and thus facilitates the detection high-grade dysplasia and carcinoma.9
FIG 1 • Chromoendoscopy with methylene blue allows for a better definition of the pit pattern and the detection
of areas of dysplasia and carcinoma. The absence of colorant points to a suspicious area of dysplastic cells.
This image shows a pit pattern type IIIS.
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FIG 2 • Acetic acid is another useful adjunct to define the mucosal pit pattern. Careful analysis of the pit
pattern of Barrett's epithelium is mandatory to define its type and discover areas of dysplastic cells. This
sample shows a type II pit pattern.
Other imaging modalities that might help in delineating BE are narrow band imaging (NBI) (FIG 3),
autofluorescence imaging, and confocal laser endoscopy.
Magnification endoscopy is also important to characterize the mucosal surface and pit pattern (FIG 4).
The most widespread classification used to categorize the pit pattern in BE is the Endo classification (adapted
from S. E. Kudo).11
This classification categorizes the opening of the pits into round (I), stellar or asteroid (II) (see FIG 2), tubular
elongated (IIIL), tubular short or round (IIIS) (see FIG 1), gyrus or sulcus branched (IV) (see FIG 4), and
irregular or amorphous (V) (FIG 5).
Types I, II, and III pit patterns are “benign,” whereas pit pattern types IV and V are more commonly present in
advanced neoplasia or carcinoma.
Chromoendoscopy is performed to aid in obtaining directed (i.e., targeted) biopsies prior to mucosectomy to
define the precise extent of neoplastic involvement.
Targeted biopsies are obtained from visible abnormalities, followed by four-quadrant biopsies of every 1 to 2
cm of the BE segment (Seattle protocol; see Chapter 10) and these should be reviewed by a dedicated GI
pathologist.
FIG 3 • NBI is one of the many “virtual” chromoendoscopy techniques to evaluate the mucosal and
submucosal surface. This sample shows a pit pattern type IIIL.
FIG 4 • Magnification endoscopy permits the close examination of the mucosa. The pit pattern in this case is
mixed (IIIL and IV).
ENDOSCOPIC MANAGEMENT
The two most important indications for EMR of Barrett's neoplasia are diagnostic and therapeutic.5,6,12
EMR can be generally attempted if the lesions are smaller than 20 mm in diameter.
Endoscopic submucosal dissection (ESD) should be reserved for larger lesions.
However, ESD is a technique that has been mainly used for early squamous cell cancer of the esophagus.
The results of ESD for Barrett neoplasia are still suboptimal.
All patients should undergo a thorough history and physical examination and be classified based on the
American Society of Anesthesiologists (ASA) score.
Interventions in patients with ASA score greater than or equal to 4 are not deemed beneficial, as the risk of
harm outweighs the potential benefits.
Obtaining routine laboratory data such as white blood cell and platelet count, bleeding studies (partial
thromboplastin time [PTT]/international normalized ratio [INR]), and creatinine and electrolytes is mainly
indicated in multimorbid patients or those taking medications that specifically affect any organ or system (e.g.,
anticoagulant, diuretics).
Management of anticoagulants preoperatively should be based on the guidelines established by the American
Society for Gastrointestinal Endoscopy.13
FIG 5 • The abnormal and amorphous pit pattern (type V) with the presence of tortuous or irregular vessels is
suggestive of dysplasia and malignancy.
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In patients with high-risk cardiovascular conditions on warfarin, it is important to bridge this period with the use
of low-molecular or fractionated heparins.13
Prophylactic antibiotics are not recommended before EMR.14
The standard of care is the administration of conscious sedation.4,5,12,15

Exceptions include patients who ingest narcotics or benzodiazepines, multimorbid patients, or heavy alcohol
drinkers. For these groups of patients, we prefer monitored anesthesia care (MAC), use of nurse-assisted
propofol sedation (NAPS), or general anesthesia (GA).
We want to emphasize that a carefully performed EMR in expert hands should take less than 15 minutes.
When performing an EMR, the bulk of time is usually in recognizing and characterizing the lesion. The
resection per se is a focused procedure that should be targeted, efficient and efficacious.
Positioning
The patient is placed in the left lateral decubitus position and prepared as for a routine upper endoscopy.
TECHNIQUES
ENDOSCOPIC MUCOSAL RESECTION TECHNIQUES
Several EMR techniques have been described for removal of focal and diffuse lesions in BE.4,5,12,15
Table 1 lists the essential equipment needed for EMR.
Table 1: Endoscopic Mucosal Resection Equipment List
Endoscope with high-definition white light capabilities
Spray catheter (or biliary cannula) to apply dye for chromoendoscopy

Indigo carmine or methylene blue solution for chromoendoscopy
Duette® EMR kit or esophageal varices banding device
Snares (hexagonal and oval)
Injection needle
Roth Net to retrieve resected specimen
Cork or Styrofoam plates and pins to pin down the specimen
Electrosurgical unit
EMR, endoscopic mucosal resection.
SNARE TECHNIQUE
This is the most “simple” technique to remove a lesion.4,5,15
It entails using an oval or hexagonal electrocautery snare.
However, simple refers mainly to the commonly used instruments to perform an EMR, as it requires high-
level skills and experience to be able to grasp the target lesion and resect it entirely by just using a snare.
It is important to always remove all the air before snaring the lesion. This allows for ensnaring more
tissue.
The assistant holding the snare should carefully close it while the endoscopist aspirates the air and
advances the snare catheter toward the lesion.
The electrocautery used for performing EMR should be predominantly cut or blended.
Coagulation currents tend to produce deep injury and are associated with high risk of perforation.
SUBMUCOSAL INJECTION AND SNARE
A modification of the snare technique is the use of a submucosal cushion below the tissue to be
removed.4,5,12
This “safety” cushion may theoretically decrease the risks of perforation.
By iatrogenically swelling up the mucosa with the injection of substances, it will be harder for the
pathologist to determine the depth of tumor invasion (if present).
We also caution against the use of epinephrine in the solution used to create the submucosal cushion as
the venous irrigation from the distal esophagus returns to the right heart without first-pass metabolism
through the liver via the azygous vein, thus increasing the chance of systemic effects and side effects,
including cardiac ischemia.
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USE OF A TRANSPARENT CAP (“SUCK-AND-CUT” OR INOUE TECHNIQUE)
A transparent cap is attached to the tip of the scope.
The cap is placed perpendicularly against the mucosa, preferentially in the greater curvature of the
stomach. A snare is advanced, opened, and placed around the inner ring of the cap (FIG 6).
Once the snare is partially opened, completely inside the inner part of the cap, the scope is pulled back
into the esophagus and directed toward the lesion of interest.
The lesion is then aspirated inside of the cap and the snare is closed snuggly around the base of the
lesion (FIG 7).
Once the lesion has been caught with the snare, electrosurgical currents are applied and the lesion is
resected (FIG 8).
FIG 6 • A snare is advanced, opened, and placed around the inner ring of the cap.
FIG 7 • Once the lesion has been sucked inside the cap and caught with the snare, electrosurgical currents
are applied and the lesion is resected.
FIG 8 • Successful EMR. The resected site shows the muscularis propria demonstrating an effective
resection of mucosa and submucosa. The aim of any EMR should be an in toto and R0 resection.
USE OF CAP WITH LIGATURE DEVICE (“SUCK-LIGATE-AND-CUT” TECHNIQUE)

With this method, both the mucosa and submucosa are aspirated or “sucked” into a transparent cap
loaded with elastic ligature bands or rings (FIG 9).
This device is essentially the same as the one to perform esophageal variceal ligation.
Whereas some experts use a “multiband” ligator (MBL), using a single-band ligation device is also
possible.
FIG 9 • The mucosa and submucosa are sucked into a transparent cap loaded with elastic ligature bands
or rings.
After placing the bands, the scope is retrieved, the cap is removed, and the scope is reinserted to
perform the EMR.
By aspirating (“sucking”) the tissue into the cap and releasing the ring on its base, a pseudopolyp is
created (FIG 10).
The main advantage of the Duette®-MBL (Cook Medical, Winston Salem, NC) is that a 5-Fr polypectomy
snare can be passed through both the ligator handle and channel of the scope, thus permitting ligation
and subsequent resection using the snare without removal of the endoscope (FIG 11).
FIG 10 • By aspirating (sucking) the tissue into the cap and releasing the ring on its base, a pseudopolyp
is created.
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FIG 11 • The main advantage of the Duette®-MBL (Cook, Winston Salem, NC) is that a 5-Fr polypectomy
snare can be passed through both the ligator handle and channel of the scope, thus permitting ligation
and subsequent resection using the snare without removal of the endoscope.
The “pseudopolyp” is then snared off.

An advantage of using an MBL method is the creation of one or multiple pseudopolyps.
The MBL methods is a great option for (1) removing lesions located in various sites, (2) piecemeal EMR
of a larger lesion, and/or (3) to perform hemi- or full circumferential resection of the distal esophageal
mucosa.15
Resected specimens are collected using the snare Roth Net (US Endoscopy, Mentor, OH) or aspirated
into the inside of the cap of the scope and retrieved out of the esophagus or stomach.
The piece(s) should be fixed onto a piece of cork or Styrofoam before being immersed in 4% formalin
solution and sent for histopathologic assessment.
PEARLS AND PITFALLS
Patient ▪ Careful history, endoscopic findings, and pathologic review of records should
evaluation be done prior to selection of patients for EMR.
Indication ▪ EMR is only indicated for lesions less than 20 mm.
Endoscopy ▪ Endoscopic identification of landmarks and length on segment should be

based on the Prague classification.
▪ Knowledge of chromoendoscopy and advanced endoscopic methods is

essential for a successful EMR.
▪ The chromoendoscopy devices should be ready before the procedure gets

started.
▪ Careful description and documentation of the exact location of the lesion is

mandatory.
▪ Use a diagram to document findings.
▪ Endoscopic photodocumentation is mandatory.
EMR ▪ EMR should be only performed by endoscopists with advanced endoscopic

method/technique training.
▪ Become well-versed in one EMR technique.
▪ Remove the air before ensnaring the lesion.

▪ Be ready for potential complications (bleeding, perforation) and know how to
treat them.
▪ Each resected specimen should be pinned down into cork or Styrofoam and
placed into distinctly labeled formalin containers.
▪ Always have an additional large hexagonal and small oval snare readily
available.
Follow-up ▪ All patients undergoing EMR should be put on long-term proton pump
inhibitors.
▪ All EMR cases should be presented at the pathology conference.
▪ Follow-up endoscopy is mandatory to ensure complete resection and

evaluate for synchronous or metachronous lesions or recurrence.
▪ All patients undergoing EMR should be kept in a registry to ensure quality

care.
POSTOPERATIVE CARE
A liquid diet is administered for 24 hours after treatment and then advanced to regular diet.
All patients undergoing EMR should be on long-term proton pump inhibitors.
The dosage is doubled after EMR and kept at this level for 4 weeks.
Patients are usually discharged home on the same day of the procedure.
Follow-up endoscopy is based on the type and histology of lesion resected.
Long-term follow-up is based on the recommendations of the American College of Gastroenterology and
American Society for Gastrointestinal Endoscopy.
OUTCOMES
EMR is efficacious method to treat BE with high-grade dysplasia and early cancer as long as the lesions
are less than 20 mm.4,5,12,15
In expert hands, complete remissions of more than 95% can be achieved.4,5,12,15
A favorable outcome is dependent on the following “low-risk” criteria: invasion not beyond sm1, absence
of infiltration into lymph vessels and/or veins, histologic grade G1/2, and macroscopic type I/II.
Recurrence or metachronous neoplasia are seen in up to 20% to 30% of patients.
Repeat endoscopic treatment can be performed in almost all patients presenting with metachronous or
recurrent disease.
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Ablative therapy using radiofrequency ablation of the residual or recurrent Barrett segment is possible,
feasible, and effective.
COMPLICATIONS
EMR has low complication rates in expert hands.
Early complications include perforation (<0.5%) and bleeding (5% to 14%).
Moderate or severe post-EMR bleeding can be easily controlled by diluted epinephrine injection
(1:10,000) and/or metal clip application.
Esophageal stenosis is more common in patients undergoing resection of more than 50% of the distal
esophageal circumference
REFERENCES
1. Yousef F, Cardwell C, Cantwell MM, et al. The incidence of esophageal cancer and high-grade dysplasia
in Barrett's esophagus: a systematic review and meta-analysis. Am J Epidemiol. 2008;168:237-249.
2. Hvid-Jensen F, Pedersen L, Drewes AM, et al. Incidence of adenocarcinoma among patients with Barrett's
esophagus. N Engl J Med. 2011;365:1375-1383.
3. Cijs TM, Verhoef C, Steyerberg EW, et al. Outcome of esophagectomy for cancer in elderly patients. Ann
Thorac Surg. 2010;90:900-907.
4. Pech O, Behrens A, May A, et al. Long-term results and risk factor analysis for recurrence after curative
endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in
Barrett's oesophagus. Gut. 2008;57:1200-1206.
5. Manner H, Pech O, May A, et al. Endoscopic resection for early cancers of the esophagus and stomach.
In: Mönkemüller K, Wilcox CM, Muñoz-Navas M, eds. Interventional and Therapeutic Gastrointestinal
Endoscopy. Basel, Switzerland: Karger; 2010:147-155. Frontiers of Gastrointestinal Research; vol 27.
6. Neumann H, Mönkemüller K, Kandulski A, et al. Dyspepsia and IBS symptoms in patients with NERD,
ERD and Barrett's esophagus. Dig Dis. 2008;26:243-247.
7. Wang KK, Sampliner RE. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's
esophagus. Am J Gastroenterol. 2008;103(3):788-797.
8. Zuccaro G Jr, Rice TW, Vargo JJ, et al. Endoscopic ultrasound errors in esophageal cancer. Am J
Gastroenterol. 2005;100:601-606.
9. Pohl J, May A, Rabenstein T, et al. Comparison of computed virtual chromoendoscopy and conventional
chromoendoscopy with acetic acid for detection of neoplasia in Barrett's esophagus. Endoscopy.
2007;39:594-598.
10. Sharma P, Dent J, Armstrong D, et al. The development and validation of an endoscopic grading system
for Barrett's esophagus: the Prague C & M criteria. Gastroenterology. 2006;131:1392-1399.
11. Endo T, Awakawa T, Takahashi H, et al. Classification of Barrett's epithelium by magnifying endoscopy.
Gastrointest Endosc. 2002; 55(6):641-647.
12. Chennat J, Ross AS, Konda VJ, et al. Advanced pathology under squamous epithelium on initial EMR
specimens in patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma:
implications for surveillance and endotherapy management. Gastrointest Endosc. 2009;70(3):417-421.
13. Zuckerman MJ, Hirota WK, Adler DG, et al. ASGE guideline: the management of low-molecular-weight
heparin and nonaspirin antiplatelet agents for endoscopic procedures. Gastrointest Endosc. 2005;61:189-
194.
14. Mönkemüller K, Aqbar Q, Fry LC. Use of antibiotics in therapeutic endoscopy. In: Mönkemüller K, Wilcox
CM, Muñoz-Navas M, eds. Interventional and Therapeutic Gastrointestinal Endoscopy. Basel, Switzerland:
Karger; 2010:7-17. Frontiers of Gastrointestinal Research; vol 27.
15. Seewald S, Akaraviputh T, Seitz U, et al. Circumferential EMR and complete removal of Barrett's
epithelium: a new approach to management of Barrett's esophagus containing high-grade intraepithelial
neoplasia and intramucosal carcinoma. Gastrointest Endosc. 2003;57:854-859.
Chapter 12
Esophagectomy: Transhiatal and Reconstruction
Robert E. Glasgow
DEFINITION
Transhiatal esophagectomy (THE) or esophagectomy without thoracotomy is defined as removal of the
esophagus and upper stomach using an incision in the left anterior neck for purposes of dissection of the
upper third of the esophagus via the thoracic inlet, and an upper midline abdominal incision for purposes
of dissection of the stomach and lower two-thirds of the esophagus and creation of a conduit for
esophageal reconstruction (stomach, colon).
Although THE is usually applied for purposes of treating esophageal and gastroesophageal (GE) junction
carcinoma, THE may also be used for treatment of benign esophageal conditions including end-stage
achalasia and medically/endoscopically recalcitrant esophageal stricture from caustic injection or end-
stage reflux disease and acute perforation.
The remainder of this discussion will focus on the use of THE in the treatment of malignant disease. Most
aspects of the diagnostic workup and operative techniques also apply to the evaluation and treatment of
benign conditions for which THE is being considered.
THE is most commonly used in treatment of esophageal cancer. In particular, adenocarcinomas of lower
third of the esophagus and Siewert types I and II GE junction adenocarcinoma (FIG 1; Table 1) are
optimally suited for this approach.
Squamous cell carcinomas (SCCs) of the lower third of the esophagus may also be approached via THE,
whereas tumors of the middle and upper third of the esophagus usually require transthoracic
esophagectomy (TTE) to allow for direct visualization of the dissection of the involved esophagus.

All patients should undergo a comprehensive medical history with emphasis not only on clinical history
pertinent to the primary indication for consideration of THE but also the pertinent comorbid conditions that
would influence treatment planning. Included in this history is a comprehensive past surgical history. Prior
fundoplication will make dissection of the esophageal hiatus more difficult. Patients with a prior history of
gastric resection, for example, may not be candidates for use of the stomach as a conduit for reconstruction
because of inadequate length or blood supply. Finally, if the colon is to be considered for use for
reconstruction, the influence of prior colectomy on anatomy and blood supply should be very carefully
considered.
FIG 1 • Imaging and diagnostic evaluation of a patient with a localized T3, N1, M0 Siewert type 2 GE junction
adenocarcinoma undergoing consideration for THE. A. Upper endoscopy showing ulcerated mass in the lower
third of the esophagus. B. CT showing an enlarged mass at the lower third of the esophagus. C. PET-CT. D.
Endoscopic ultrasound showing mucosal-based mass invading into the adventitia of the esophagus. E.
Endoscopic ultrasound showing enlarged lymph node fine needle aspiration (FNA) biopsy confirming
adenocarcinoma.
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Table 1: Siewert Classification for Gastroesophageal Junction Adenocarcinoma
Type I: Adenocarcinoma of the lower esophagus with the center located within 1 cm above and 5 cm
above the anatomic EGJ.
Type II: True carcinoma of the cardia with the tumor center within 1 cm above and 2 cm below the
EGJ.
Type III: Subcardial carcinoma with the tumor center between 2 and 5 cm below EGJ, which infiltrates
the EGJ and lower esophagus from below.
EGJ, esophagogastric junction.

From Rüdiger Siewert J, Feith M, Werner M, et al. Adenocarcinoma of the esophagogastric junction:
results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive
patients. Ann Surg. 2000;232(3):353-361.
Whether it be for benign or malignant disease, the principal symptom at the time of presentation for a patient
who would undergo THE is dysphagia. Often, these patients have significant nutritional impairment, most
notably, weight loss.
In patients with adenocarcinoma of the esophagus and GE junction, a history of GE reflux disease should be
elicited as well as a careful history of prior endoscopic and radiographic evaluations. In patients with SCC, a
prior and current history of tobacco and alcohol use should be elicited.
A comprehensive physical examination should be performed with special attention to the cervical and
supraclavicular areas for enlarged lymph nodes, chest exam for possible effusions, and abdominal exam for
palpable masses and periumbilical lymph nodes (Sister Mary Joseph nodule).

Upper Endoscopy with Biopsy
All patients presenting with dysphagia should undergo upper gastrointestinal endoscopy and biopsy with the
goal of making a diagnosis and localizing the site of obstruction (FIG 1).
Multiple biopsies of suspicious areas (nodules, ulceration, stricture, possible Barrett’s) should be obtained.
Endoscopic mucosal resection (EMR) of focal nodules should be performed to provide accurate T staging
and to evaluate degree of differentiation and vascular and/or lymphatic invasion.
For cancer, the location of the tumor as measured from the incisors and GE junction and extent of tumor
length, circumferential involvement, and degree of obstruction should be documented.
Computed Tomography of Chest and Abdomen

Once a diagnosis of cancer is made, a computed tomography (CT) of the chest and abdomen with oral and
intravenous contrast is done.
Tumor location, locoregional involvement or invasion, regional and extraregional lymph node involvement, and
metastatic disease should be evaluated and recorded.
If metastasis is suspected, biopsy of concerning lesions should be undertaken to confirm stage and direct
palliative treatment.
Positron Emission Tomography-Computed Tomography

In patients whom a standard CT of the chest and abdomen is unremarkable, a positron emission tomography-
computed tomography (PET-CT) should be performed again to confirm primary tumor location and extent,
evaluate regional and extraregional nodal involvement, and exclude occult metastases.
Endoscopic Ultrasound
In patients without metastatic disease (stage 4), an endoscopic ultrasound is done to document depth of
invasion of the tumor (T stage) and evaluate mediastinal and perigastric/celiac lymph node involvement (N
stage). Biopsy of suspicious lymph nodes is indicated.
All patients should then be assigned a pretreatment TNM stage to guide treatment planning discussions,
preferably under the direction of a multidisciplinary treatment planning conference attended by surgical,
medical, and radiation oncology.1 The National Comprehensive Cancer Network (NCCN) defines optimal
treatment planning algorithms.2
In considering options for reconstruction, the two most common conduits are the stomach and colon. Although
variations in stomach blood supply are very rare, variations in colonic blood supply are common enough to
justify preoperative evaluation of arterial anatomy and collateral circulation by visceral angiography in planning
choice of conduit.
For purposes of using the stomach as a conduit for esophageal reconstruction, an intact right gastric and,
more importantly, right gastroepiploic artery is imperative (FIG 2).
For purposes of the colon as a conduit for esophageal reconstruction following a THE, an adequate
collateral blood supply via an intact marginal artery is required (FIG 3). Obviously, a colonoscopy to exclude
and/or treat colonic pathology must be done prior to use of the colon.
SURGICAL MANAGEMENT
As THE is a technically complex operation with a high degree of associated morbidity and mortality, this
operation should be done by surgical teams experienced in the perioperative management of these
patients.3,4 and 5 This includes experienced operating room personnel and anesthesiologists.
Patients should undergo preoperative evaluation by the surgical and anesthesia team for purposes of
mitigating perioperative risks in the area of cardiac, pulmonary, and renal comorbidities.
A discussion should be done with the patient as to how pain will be measured and managed following surgery.
Regional anesthetics such as an epidural catheter are very
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helpful in alleviating pain, thereby allowing the patient to be more engaged in early mobilization and physical
therapy.
FIG 2 • Stomach blood supply for purposes of using the stomach as a conduit for reconstruction following
THE. Arrows show lines of division including the short gastric arteries, left gastroepiploic artery, left gastric
artery, and ligation of the right gastric artery at the incisura angularis at the point of origin of the gastric conduit
staple line.
Perioperative antibiotics should be administered within 60 minutes of skin incision and redosed in a timely
manner during the operation. Cefazolin, dosed to weight specifications and redosed every 4 hours, is
recommended. Cefoxitin can also be used and redosed every 3 hours. For patients with a beta-lactam allergy,
clindamycin or vancomycin and aminoglycoside or aztreonam or fluoroquinolone are used. All prophylactic
antibiotics are not necessary beyond surgery completion.6
Perioperative monitoring with an arterial line is helpful especially during blunt mediastinal esophagus
dissection where transient hypotension is common because of decreased venous return and compression on
the heart. Rarely is a central line indicated.
Appropriate deep venous thrombosis prophylaxis is required. Intermittent sequential compression devices
should be placed prior to induction of anesthesia and continued after surgery. Chemical prophylaxis should be
instituted postoperatively once clinically indicated.
Urinary catheters are placed following induction of anesthesia and discontinued within 24 hours of surgery.
Positioning
Patients undergoing THE are positioned supine on the operating room table (FIG 4).
Both arms are tucked and pressure points padded to prevent injury during the course of the operation.
A towel or medium gel roll is placed behind the shoulders to allow for mild extension of the neck. This is of
particular importance in obese, short-necked patients.
The head is rotated 30 degrees to the right to open exposure to the left neck.
Placement of Surgical Incisions

A midline laparotomy from the xiphoid process to the umbilicus is made (FIG 4).
After verifying the patient to be a candidate for resection and verifying that THE can proceed, a 5-cm incision
is made overlying the anterior border of the left sternocleidomastoid muscle with the inferior extent at the head
of the clavicle. Contraindications to THE include difficult mediastinal blunt dissection of the esophagus
because of tumor or treatment effect, excessive mediastinal bleeding with blunt dissection, and inadequate
conduit length for reconstruction.
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FIG 3 • Colon blood supply for purposes of using the colon as a conduit for reconstruction following THE.
FIG 4 • Supine position with location of surgical incisions for THE.
TECHNIQUES
TRANSHIATAL ESOPHAGECTOMY
Abdominal Exploration to Exclude Metastatic Disease
Upon entering the abdomen, visceral and parietal peritoneal surfaces are palpated to exclude occult
peritoneal carcinomatosis. This should include inspection of the lesser sac by opening thru the
gastrocolic omentum.
The liver is palpated for suspicious nodules and biopsy performed. Intraoperative ultrasound can be a
useful adjunct in this step. If indeterminate lesions are noted on preoperative imaging, ultrasound-guided
biopsy is indicated.
Metastatic disease is an absolute contraindication to proceeding with surgical resection.
Exploration of the Esophageal Hiatus to Determine Local Resectability
Prior to proceeding with dissection of the stomach, the esophageal hiatus is explored to make sure the
distal esophagus and GE junction can be dissected free of the
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esophageal hiatus and surrounding abdominal and mediastinal structures. If so, and in the absence of
metastatic disease, resection can proceed.
This dissection and subsequent dissections are facilitated by use of an electrosurgical device such as an
ultrasonic or bipolar scalpel.
The pars flaccida is opened, including division of an accessory or replaced left hepatic artery, if
necessary.
The peritoneum and phrenoesophageal membrane overlying the junction of the right crus of the
diaphragm and esophagus is incised allowing the esophagus to be dissected off the right crus.
The phrenoesophageal membrane just cephalad to the GE fat pad is divided as is the peritoneal
reflection overlying the angle of His.
The esophagus is dissected off the left crus of the diaphragm and esophagus encircled with a 1-in
Penrose drain (FIG 5).
The esophagus and GE junction are then dissected free of the crural confluence of the esophageal
hiatus, and esophagus with associated periesophageal fatty tissue and lymph nodes dissected free of the
esophageal hiatus and underlying aorta.
If the esophagus and GE junction are free of surrounding structures, resection can proceed. If adherent
to or invading the pleura, pericardium, or diaphragm (T4a), resection of these structures can be
performed. If adherent to the aorta, vertebral body, or trachea (T4b), resection should be aborted.
Mobilization of the Stomach and Duodenum
Once it is determined that resection can proceed, the stomach and duodenum are mobilized. Most often,
the stomach is used as the conduit for reconstruction following THE. Therefore, mobilization of the
stomach for purposes of proceeding with the esophagectomy and for purposes of the creation of the
gastric conduit occur simultaneously.
The right gastroepiploic artery and vein are identified along the greater curvature of the stomach. An
adequate pulse in this vessel is imperative if the stomach is to be used for the reconstruction (FIG 6).
These vessels terminate at the bare area roughly one-half the distance along the greater curvature
between the pylorus and GE junction. It is imperative to preserve these vessels as they are the blood
supply to and from the conduit.
FIG 5 • Dissection of the GE junction and encirclement with a Penrose drain to facilitate manipulation.
FIG 6 • Palpation of the right gastroepiploic pedicle along the greater curvature of the stomach to ensure
an adequate pulse to permit use of the stomach as a conduit for reconstruction.
Once these vessels are identified, the gastrocolic ligament is entered several centimeters from the bare
area entering the lesser sac.
Using an electrosurgery device, the gastrosplenic ligament and short gastric vessels are divided
proceeding along the greater curvature toward the esophageal hiatus. Placing a surgical clip on the distal
ends of larger vessels, including the left gastroepiploic artery, can ensure ongoing hemostasis of these
vessels. The posterior leaflet of the gastrosplenic ligament is likewise divided as are the congenital
adhesions of the stomach to the anterior surface of the pancreas. This frees the greater curvature.
Division of the gastrocolic ligament then proceeds distally, paying careful attention to stay at least a few
centimeters away from the right gastroepiploic vessels (FIG 7). Careful attention should be paid to not
placing traction or trauma to these vessels while freeing the stomach from the colon. This is especially
true as one frees the stomach from the anterior surface of the pancreas and approaches the origin of
these vessels from under the duodenal bulb. Traction of the vein, in particular, can traumatize these
vessels resulting in impaired venous outflow and conduit venous congestion.
After freeing the stomach from the colon, a Kocher maneuver is performed to permit mobilization of the
duodenum. An adequate Kocher maneuver permits mobilization of the pylorus to reach the esophageal
hiatus (FIG 8).
At this point, the remainder of the gastrohepatic ligament is divided and left gastric pedicle is identified.
The lymph nodes along the left gastric pedicle and celiac axis and surrounding aorta are dissected free
of the origin of the left gastric artery and included in the surgical specimen. The left gastric artery and
vein are then divided with either a vascular load of a surgical stapler or suture ligated.
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The stomach is now free of its upper attachments and vasculature. If a colon conduit is preferred,
preparation of the colon should proceed. If a gastric conduit is preferred, the gastric conduit is created to
avoid trauma to the conduit during retraction of the stomach necessary for the inferior mediastinal
dissection. This also allows verification of the adequacy of the blood supply to the apex of the conduit
and length of the conduit prior to proceeding with the transhiatal dissection. This will be discussed in the
following text. For this discussion, the mediastinal dissection will be described.
With a Penrose drain around the GE junction for caudal retraction of the stomach and lower esophagus
with associated lymphatic tissue is dissected under direct visualization from the lower mediastinum. This
dissection is facilitated by a medium handheld malleable retractor and the use of an electrosurgical
device. Approximately 5 to 10 cm of mediastinal esophagus can be dissected under direct visualization by
this technique. Mobility of the mediastinal esophagus to assure feasibility and safety of a transhiatal blunt
dissection is verified.
FIG 7 • Mobilization of the greater curvature of the stomach by dividing the gastrosplenic (A) and
gastrocolic ligament (B), being careful to not injure the gastroepiploic pedicle.
FIG 8 • Kocher maneuver to ensure adequate mobility of the pylorus. This is assured if the pylorus can
freely reach to the hiatus without tension.
After the limits of direct visualization are reached, blunt mediastinal dissection can proceed. To assure
proper tactile orientation of the esophagus during blunt dissection, a 44-Fr bougie dilator or equivalent is
placed in the esophagus.
The hand is then first advanced posterior to the esophagus, between the esophagus and aorta. The
surgeon’s fingers are then advanced up this plane with pressure on the bougie containing esophagus to
assure proper tissue plane dissection (FIG 9).
The same dissection is then performed anterior to the esophagus.
If vagal nerve sparing is planned, the vagus nerves are elevated off the esophagus by hooking the
nerves with the index finger and bluntly dissecting them down and off the esophagus where they are then
dissected free from the GE junction and stomach. As this operation is most often performed for
malignancy, division of the vagal nerves is required to assure proper oncologic dissection. The nerves
are then divided at the level of the hiatus with the electrosurgery device.
This completes the abdominal stomach and esophagus mobilization.
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FIG 9 • A,B. Mediastinal mobilization of the esophagus with a hand placed thru the esophageal hiatus from
the abdominal incision and finger placed thru the cervical incision.
Cervical and Upper Mediastinal Esophageal Mobilization

The cervical esophagus is approached thru a 5-cm incision anterior to the left sternocleidomastoid
muscle. The skin, subcutaneous tissues, and platysma are divided with electrocautery (FIG 10).
The thin fascial layer surrounding the anterior border of the sternocleidomastoid muscle is incised with
cautery.
The dissection is carried medial and deep to the sternocleidomastoid muscle. The omohyoid muscle is
identified and divided with cautery. The inferior thyroid artery and middle thyroid vein, if identified, are
ligated with fine silk or absorbable suture.
Dissection is carried medial to the carotid sheath with gentle lateral traction on the sternocleidomastoid
and carotid sheath and medial traction on the trachea and thyroid. The recurrent laryngeal nerve (RLN)
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is identified and preserved adherent to the tracheoesophageal groove. Dissection is carried down to the
prevertebral fascia allowing the surgeon to then pass the index finger between the prevertebral fascia
and esophagus.
FIG 10 • Cervical skin incision and dissection. A. Location of cervical skin incision. B. Dissection thru
platysma.
FIG 11 • Dissection of the cervical esophagus is facilitated by placement of a Penrose drain around the
esophagus after sharply dissecting the esophagus free of other vital cervical structures, including the
RLN.
The cervical esophagus is then sharply dissected from trachea, being careful to not dissect free nor
injure the RLN. Once free of the trachea, a blunt right-angle clamp placed between the trachea and
esophagus, rotated and advanced to the prevertebral fascia facilitates placement of a Penrose drain
around the esophagus (FIG 11).
Upward traction is placed on the cervical esophagus and blunt mediastinal dissection of the upper and
middle third of the esophagus can ensue (FIG 9). The surgeon maintains contact between the volar
aspect of the first two fingers and the esophagus at all times to the proper tissue plane of dissection.
Again, a small-caliber bougie dilator placed in the esophagus facilitates tactile feedback of the
esophagus.
With anterior and upward traction of the cervical esophagus and caudal retraction on the stomach, a
hand is inserted thru the hiatus posterior to the esophagus and is met by fingers inserted thru the neck
incision down the prevertebral plane. Loose areolar attachments are divided until fingers meet.
The same dissection is then performed anterior to the esophagus. When performing this dissection, the
surgeon must maintain constant pressure on the esophagus to avoid injury to the membranous trachea.
Both the anterior and posterior planes can usually be dissected relatively easily.
Having freed the esophagus from its anterior and posterior attachments, the lateral attachments are then
divided. This is often done with a combination of direct downward pressure on these attachments with
the index finger from above or by placing the inferior index finger above the attachment pulling down
along the insertion of the attachment into the esophagus.
Alternatively, the bougie can be removed from the esophagus and the lateral attachments divided under
direct visualization as the esophagus is retracted anteriorly out the cervical incision. Usually, some sort of
bimanual dissection in the posterior mediastinum is required.
At any point where this dissection proves difficult because of difficult adhesions; fused tissue planes
especially in the vicinity of the membranous trachea, carina, and azygous vein; lack of mobility of the
esophagus; or excessive bleeding, the blunt dissection should be abandoned and dissection under direct
visualization performed via an incision in the right chest.
Removal of the Esophagus
After complete mobilization of the esophagus, the cervical esophagus is delivered into the next for several
centimeters and divided leaving approximately 20 cm of length to the esophagus. The remaining
esophagus can subsequently be divided further at the time of anastomosis.
A 1-in Penrose is affixed to the distal esophagus and the stomach and esophagus drawn down thru the
hiatus dragging the Penrose thru the esophageal bed into the abdomen. This will allow the reconstruction
conduit to be attached to the Penrose and delivered cephalad up into the cervical incision for subsequent
anastomosis to the cervical esophagus (FIG 12).
FIG 12 • Removal of the esophagectomy specimen thru the abdominal incision after attaching a Penrose
drain to the cut distal end of the esophagus to guide advancement of the reconstruction conduit back up
thru the esophageal bed in the posterior mediastinum.
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RECONSTRUCTION: GASTRIC CONDUIT
Creation of Gastric Conduit
After mobilization of the stomach, the gastric conduit is created. This is best done prior to completion of
the mediastinal dissection so as to protect the conduit from trauma due to manipulation of stomach during
dissection.
The goals of creating the gastric conduit are as follows:
Create a gastric tube based on the greater curvature blood supply.
Create a gastric tube of sufficient length to reach into the cervical incision.
Divide the proximal stomach at a point assuring negative surgical margin, usually 5 cm distal to the GE
junction along the greater curvature.
Resect the lesser curvature of the stomach to include the lesser curvature lymphatic drainage along
the distribution of the left gastric artery.
Six centimeters from the pylorus along the lesser curvature, roughly corresponding to the incisura
angularis, the lesser curvature neurovascular pedicle is suture ligated. Careful attention is directed at
preserving the integrity of the right gastric artery.
Using a surgical stapling device, the stomach is divided from this point along the lesser curvature parallel
to the greater curvature creating a 5-cm wide gastric tube (FIG 13). The division of the stomach is
completed 5 cm from the GE junction along the greater curvature (FIG 14). For this step, a “thick” load of
the stapling device is recommended.
Length of the conduit is inspected by delivering the conduit over the patient’s torso (FIG 15). The apex
should reach to the sternal notch to be of sufficient length to reach into the cervical incision once brought
thru the esophageal bed.
The conduit should be inspected for viability. If the viability is in question, removal of some of the apex of
the stomach may result in insufficient length forcing conversion to a transthoracic approach where gastric
conduit length is less of a concern.
FIG 13 • The gastric conduit is begun by ligating the lesser curvature neurovascular pedicle then starting
the conduit staple line at the incisura angularis.
FIG 14 • A,B. The staple line proceeds cephalad toward the hiatus giving rise to a 5-cm wide gastric
conduit while removing the lesser curvature of the stomach and straightening the natural curvature of the
stomach to optimize conduit length. The gastric staple line terminates 5 cm from the GE junction along the
greater curvature of the stomach.
Gastric Drainage Procedure

As the vagus nerves will be divided, a gastric drainage is usually necessary either in the form of a
pyloromyotomy or pyloroplasty. With tubularization of gastric conduit, some have omitted this step as
unnecessary.7 In these patients, delayed gastric emptying can be managed postoperatively by
endoscopic balloon dilation or botulinum toxin injection into the pylorus.
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FIG 15 • The completed gastric conduit.
For pyloromyotomy, an incision measuring 1.5 cm along the stomach extending 1 cm along the anterior
surface of the duodenum across the pylorus is made using the needle tip cautery. With a fine mosquito
clamp, the pyloric muscle fibers are divided. An omental patch can be used to patch the exposed
submucosa using a Graham patch technique.
For pyloroplasty, a 4-cm full-thickness longitudinal incision is made beginning 2 cm proximal to the
pylorus on the anterior stomach. This full-thickness incision is then closed transversely with interrupted
full-thickness 3-0 silk suture (FIG 16).
Esophagogastrostomy
The apex of the gastric conduit is then sutured to the end of the Penrose drain. The Penrose is then
drawn up and out the cervical incision delivering the stomach into the neck. Typically, the stomach
reaches with excess length permitting trimming of further stomach off the apex of the conduit. Similarly,
the esophagus can be further trimmed and both additional specimens marked and sent for final proximal
and distal margin analysis.
The cervical anastomosis can be accomplished either by a hand-sewn or stapled approach.8,9
For hand-sewn, two-layer anastomosis is performed with an outer layer of interrupted 3-0 silk suture in a
seromuscular fashion and inner layer of running full-thickness monofilament absorbable suture. Others
have described a single-layer anastomosis using monofilament absorbable running suture.
For a stapled anastomosis, a stay suture of 2-0 silk is placed at the 6 o’clock position of the cervical
esophagus. A 2-cm long longitudinal gastrotomy is made on the anterior surface of the gastric conduit
close to the greater curvature. The 2-0 silk is then placed at the apex of this gastrostomy and tied to
serve as stay suture holding orientation of cervical esophagus and gastric conduit for application of the
stapler. A 45-mm stapler is advanced with one arm in the esophagus and the other in the stomach. The
stapler is directed toward the right ear with the anastomosis placed along the greater curvature of the
stomach. The remaining common enterotomy is closed in two layers with an inner layer of running full-
thickness, 3-0 monofilament suture and an outer later of interrupted 3-0 silk suture in a seromuscular
fashion (FIG 17).
FIG 16 • A Heineke-Mikulicz pyloroplasty is made by making a 4-cm longitudinal incision centered at the
pylorus. This fullthickness incision is closed transversely with interrupted 3-0 silk sutures using a full-
thickness bite.
FIG 17 • A. Linear stapled esophagogastrostomy using a 45-mm line stapler in a side-to-side fashion. B.
Suture closure of the anterior portion of the anastomosis or common enterotomy of the
esophagogastrostomy.
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After completion of the anastomosis, careful caudal traction of the stomach at the hiatus is applied as the
anastomosis is delivered back into the neck behind the trachea and excess redundancy of the conduit in
the chest is straightened out.
Either a nasojejunal feeding tube is placed or surgical jejunostomy tube placed for postoperative
nutrition.
The gastric conduit is anchored to the arch of the hiatus with interrupted 3-0 silk suture to prevent
herniation.
The soft closed suction drain is placed thru the thoracic inlet and delivered out onto the chest wall. The
neck wound is closed by approximating the platysma muscle with interrupted suture and closing the skin
with a running subcuticular suture of 3-0 monofilament absorbable suture. The abdominal wound is
closed per routine.
RECONSTRUCTION: COLON CONDUIT
Mobilization of the Colon
When performing a colon interposition for reconstruction following THE, the stomach is preserved other
than the portion removed to assure adequate distal margins. This would include preservation of the left
gastric artery. To facilitate use of the colon, however, complete gastric mobilization as discussed earlier
is necessary as the preferred route for the colon is retrogastric to decrease tension on the conduit and
blood supply.
Complete colonic mobilization is required including mobilization of both the splenic and hepatic flexures.
This often entails extension of the surgical incision below the umbilicus.
Once mobilization is complete, verification of adequacy of blood supply for the subsequent conduit is
needed even in the setting of preoperative angiography. This can be accomplished by serial ligation of
the ileocolic artery, then right colic artery, and, if necessary, middle colic arteries with Bulldog clamps
(FIG 3).
Angiographic arterial anatomy requirements for a successful left colic-based colon interposition
reconstruction include a patent inferior mesenteric artery, patent ascending branch of the left colic
artery, intact marginal artery anastomosis between the left colic (inferior mesenteric) and middle colic
(superior mesenteric) arteries, single middle colic trunk prior to bifurcation into a right and left branch,
and separate origin of the right colic artery.10
To reach to the neck, a conduit based on the left colic artery branch of the inferior mesenteric artery and,
if possible, middle colic arteries is needed. This entails delivering the colon in an isoperistaltic fashion to
the neck with the cecum or proximal right colon serving as the proximal end of the colon conduit (FIG 18)
If the blood supply is adequate for a left colic vascular based conduit, the ileocolic artery is ligated as low
in the mesentery as possible, as is the right colic artery. The mesentery of the ascending colon is
likewise divided to the level of the middle colic arteries.
The terminal ileum is divided with a surgical stapler.
The cecum is rotated up to the neck to verify adequate conduit length. If not, the middle colic branches
can be divided as well (FIG 19).
FIG 18 • Creation of the colon conduit based on the left colic artery.
Delivery of Colon
Once the colon is mobilized, the colon is delivered thru the hiatus in a fashion similar to the gastric
conduit as discussed earlier. To decrease demands on conduit length, it is optimal to deliver the colon to
the hiatus behind the stomach in a retrogastric position. Alternatively, the colon can be delivered thru a
retrosternal pathway if the posterior mediastinum is no longer a viable option. The disadvantage of this
route is increased demand on conduit and blood supply length.
As there is typically adequate length to the colon conduit, the proximal end of the colon can be amputated
back,
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usually removing the cecum. This has the advantage of decreasing the size differential between the
cervical esophagus and colon as the colon narrows in luminal diameter and becomes thicker and more
muscular. Also, as one moves distally on the colon, the reliance on mesenteric arcades for blood supply
decreases.
FIG 19 • Delivery of the colon thru the mediastinum by rotating the cecum up thru the esophageal bed and
out the cervical incision.
Anastomoses
The esophagus-to-colon anastomosis is accomplished in a similar fashion as described in the section on
the use of the stomach as a conduit for reconstruction. This can be stapled using a linear stapler or hand
sewn in either a one- or two-layer technique. Although circular staplers can be used, conduit length is
often inadequate, making this awkward (FIG 20).
The cervical anastomosis is drawn back in the neck by careful caudal traction on the colon at the hiatus.
FIG 20 • The completed reconstruction with both esophageal to colon and colon to stomach
anastomoses.
The colon is then divided at a point along the posterior stomach to permit a subsequent colon-to-stomach
anastomosis. This is optimally done using a linear stapler joining the colon and stomach in a side-to-side
fashion and closing the common enterotomy with an additional stapler load or hand-sewn closure.
In manipulating the colon for this anastomosis, it is imperative to not disturb the mesentery of the colon
out of concern for disrupting the mesenteric vessels.
Enteric continuity is restored by completing the small bowel-to-colon anastomosis using surgical staplers
in a standard fashion.
A jejunostomy feeding tube is placed for nutritional support as is a cervical closed suction drain.
A gastric drainage procedure is done if vagotomy was performed during the course of esophageal
resection.
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PEARLS AND PITFALLS

Indications ▪ THE should only be performed for curative intent when treating malignancy.
▪ NCCN guidelines should be followed as to preoperative evaluation, staging, and

treatment algorithms.
Approach ▪ THE should only be considered for patients with appropriate pathology (middle,
lower third of the esophagus, and GE junction tumors).
▪ In patients with unfavorable prior surgical history (prior gastric surgery rendering
the gastric conduit inadequate) or locally advanced tumors that require a direct
visualization of mediastinal dissection, a THE is contraindicated in favor of a
transthoracic approach.
Gastric ▪ Avoid any traction or direct trauma to the right gastroepiploic and right gastric
mobilization artery pedicles so as to avoid disrupting these vessels or causing venous injury
with resultant thrombosis as this will lead to graft failure.
▪ Use of an electrosurgical device greatly improves efficiency and effectiveness of

gastric mobilization.
Esophageal ▪ If excessive adhesions are encountered secondary to tumor extension or

dissection treatment effect or excessive bleeding is encountered with blunt dissection of
the esophagus, a TTE should be performed.
▪ A small-caliber bougie dilator (44 Fr) in the esophagus facilitates tactile

localization of the esophagus during blunt dissection.
Reconstruction ▪ Graft failure and anastomotic leak result from ischemia, which is a consequence
of inadequate blood supply, venous congestion, tension on the anastomosis, or
hypoperfusion in the early postoperative period. These factors should be
avoided.
▪ Proper orientation of the conduit with prevention of twisting is made easier by

drawing parallel lines on the Penrose drain and making sure the drain does not
twist as it is pulled out thru the neck delivering the conduit to the cervical
incision.
Anastomosis ▪ Proper orientation of the cervical anastomotic staple lines should be maintained
to maximize perfusion of the gastric wall. This is accomplished by keeping the
esophagogastrostomy staple line as far away from the conduit lesser curvature
staple line.
▪ When placing the anastomosis back in the neck, it should be straightened by

reducing redundancy of the conduit by caudal traction on the conduit at the
hiatus. Avoid placing tension on the anastomosis.
POSTOPERATIVE CARE
Patients recover in the intensive care unit until acute cardiac, respiratory, and volume status issues are
resolved.
As hypoxia and hypotension can lead to hypoperfusion of the reconstruction with anastomotic leak or, in the
worst scenario, conduit necrosis, this should be avoided and quickly remedied if clinically encountered.
As respiratory failure and pneumonia are the most common complications encountered, aggressive
pulmonary care is required. Early ambulation is mandatory.
Fluid overload can lead to hypoxia, pulmonary edema, and dysrhythmia (most often atrial fibrillation).
Enteric nutrition is begun slowly on postoperative day 1.
Patients should be carefully followed for signs of postoperative complications (see the following text) and
evaluation and mitigation strategies employed at the first sign of such issues.
If the patient is medically stable to consider oral intake, a water-soluble contrast study followed by barium is
done on the fourth postoperative day to make sure there is no significant anastomotic leak and the conduit
empties adequately into the small intestine.
If ok, a liquid diet is started and continued for 2 weeks at which time the patient is transitioned to a soft diet for
an additional 2 weeks prior to resuming a normal diet. The rationale for this approach is to avoid food
impaction during the critical period of anastomotic healing. The surgical drain is removed after a negative
study and no evidence of oral fluids in the drain within 48 hours of oral liquid intake.
The feeding tube is discontinued when the patient is able to take adequate oral intake, usually within the first
to second week following surgery.
Patients should be counseled as to how to optimize their fluid and nutritional intake during this period of
transition to regular diet and manage dumping symptoms with dietary and lifestyle modification.
Patients should be advised as to the early signs of anastomotic stricture and need for esophageal dilation.
OUTCOMES
THE is a very morbid, high-risk procedure with very high associated operative morbidity and mortality
(see the following text).
Regarding functional outcome, the best data available are reviews from patients who underwent this
procedure for benign indications and early stage cancer given the longer survival in these patients
compared to patients with cancer.11,12
Symptoms of physical impairment, including GE reflux, dumping, and dysphagia, are very common
after surgery but show gradual improvement toward baseline over the first year, not quite reaching
baseline. Long-term physical impairment is less common after THE compared to TTE.
Overall health-related quality of life (ability to work, social interaction, daily activities, emotional
function, perception of health, energy level, and mental health) decreases after surgery but returns to
baseline national norms within 1 year of surgery.
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Regarding cancer-specific outcome, long-term survival is a function of the underlying biology and stage
of the tumor rather than surgical approach.13,14
COMPLICATIONS
Perioperative complications occur in 40% to 50% of patients and fall into specific categories depending
on the point of time in which they appear following surgery. Reported overall 30-day mortality for THE
ranges from 1% in select single center reports to 10% in nonselective administrative database
reports.13,15,16
Early postoperative period (0 to 2 days)
Technical complications
Bleeding
RLN injury with resultant hoarseness (unilateral) and airway obstruction (bilateral)
Pleural violation with pneumothorax or pleural effusion
Conduit necrosis requiring removal of conduit and cervical esophagostomy
Medical complications
Respiratory complications (respiratory failure, pneumonia)
Cardiac complications (dysrhythmia, myocardial infarction, heart failure)
Urinary tract complications (renal failure or insufficiency)
Intermediate postoperative period (2 to 14 days)
Anastomotic leak manifest as cervical wound infection and drainage or drainage of oral secretions
via closed suction drain.
Conduit necrosis requiring removal of conduit and cervical esophagostomy
Thoracic duct injury with chyle leak, usually manifest by pleural effusion at onset of enteric or oral
nutrition.
Respiratory complications (respiratory failure, pneumonia)
Cardiac complications (dysrhythmia, myocardial infarction, heart failure)
Urinary tract complications (renal failure/insufficiency, urinary tract infection)
Infectious complications, (line infection, organ space infection, wound infection)
Late postoperative period (after 14 days)
Anastomotic stricture
Dumping syndrome
Malnutrition
Cancer recurrence
REFERENCES
1. Edge SB, Byrd DR, Compton CC, et al. AJCC Cancer Staging Manual . 7th ed. New York, NY: Springer;
2010.
2. Ajani JA, Barthel JS, Bentrem DJ, et al. Esophageal and esophagogastric junction cancers. J Natl Compr
Canc Netw. 2011;9(8): 830-887.
3. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States.
N Engl J Med. 2002;346(15):1128-1137.
4. Birkmeyer NJ, Goodney PP, Stukel TA, et al. Do cancer centers designated by the National Cancer
Institute have better surgical outcomes? Cancer. 2005;103(3):435-441.
5. Dimick JB, Wainess RM, Upchurch GR Jr, et al. National trends in outcomes for esophageal resection.
Ann Thorac Surg. 2005;79(1):212-216; discussion 217-218.
6. Cataife G, Weinberg DA, Wong HH, et al. The effect of Surgical Care Improvement Project (SCIP)
compliance on surgical site infections (SSI). Med Care. 2014;52(2 Suppl 1):S66-S73.
7. Arya S, Markar SR, Karthikesalingam A, et al. The impact of pyloric drainage on clinical outcome following
esophagectomy: a systematic review [published online ahead of print February 24, 2014]. Dis Esophagus.
doi: 10.1111/dote.12191.
8. Honda M, Kuriyama A, Noma H, et al. Hand-sewn versus mechanical esophagogastric anastomosis after
esophagectomy: a systematic review and meta-analysis. Ann Surg. 2013;257(2):238-248.
9. Price TN, Nichols FC, Harmsen WS, et al. A comprehensive review of anastomotic technique in 432
esophagectomies. Ann Thorac Surg. 2013;95(4):1154-1160; discussion 1160-1161.
10. Peters JH, Kronson JW, Katz M, et al. Arterial anatomic considerations in colon interposition for
esophageal replacement. Arch Surg. 1995;130(8):858-862; discussion 862-863.
11. de Boer AG, van Lanschot JJ, van Sandick JW, et al. Quality of life after transhiatal compared with
extended transthoracic resection for adenocarcinoma of the esophagus. J Clin Oncol . 2004;22(20):4202-
4208.
12. Darling GE. Quality of life in patients with esophageal cancer. Thorac Surg Clin. 2013;23(4):569-575.
13. Chang AC, Ji H, Birkmeyer NJ, et al. Outcomes after transhiatal and transthoracic esophagectomy for
cancer. Ann Thorac Surg. 2008;85(2):424-429.
14. Hulscher JB, van Sandick JW, de Boer AG, et al. Extended transthoracic resection compared with limited
transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002;347(21): 1662-1669.
15. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends,
lessons learned. Ann Surg. 2007;246(3):363-372; discussion 372-374.
16. Rentz J, Bull D, Harpole D, et al. Transthoracic versus transhiatal esophagectomy: a prospective study of
945 patients. J Thorac Cardiovasc Surg. 2003;125(5):1114-1120.
Chapter 13
Ivor Lewis Esophagectomy
Robert E. Merritt
DEFINITION
An Ivor Lewis esophagectomy is defined as a resection of the esophageal tumor using a laparotomy
incision and a right thoracotomy. The esophagogastric anastomosis is performed in the right thoracic
cavity. This surgical approach is appropriate for patients with resectable tumors in the middle and distal
third of the esophagus as well as the gastroesophageal junction.

Patients who present with esophageal carcinoma should undergo a complete history and physical
examination.
Patients often complain of dysphagia to solid food and liquids. This symptom is related to esophageal
obstruction from a bulky tumor.
Barrett’s intestinal metaplasia or gastroesophageal reflux disease (GERD) may precede the diagnosis of
esophageal cancer.
Significant weight loss is a common symptom of patients with esophageal cancer. The weight loss may be
secondary to poor oral intake related to dysphagia or cancer cachexia.
The cervical lymph nodes and supraclavicular lymph nodes should be thoroughly examined during physical
examination. The cervical and supraclavicular lymph nodes are a common site for metastatic spread from
esophageal carcinoma.

An esophagogastroduodenoscopy (EGD) should be performed on every patient with esophageal carcinoma
(FIG 1). Upper endoscopy allows access to the tumor for diagnosis and determination of the histologic
subtype (adenocarcinoma vs. squamous cell carcinoma). The location of the tumor is also important to
determine whether an Ivor Lewis esophagectomy would be feasible. Esophageal tumors in the proximal third
of the esophagus would require a transhiatal or threefield esophagectomy with a cervical
esophagogastrostomy anastomosis.
Endoscopic ultrasound (EUS) is a critical staging technique for esophageal cancer (FIG 2). The EUS
determines the depth of invasion of the tumor into the esophageal wall (T stage). Esophageal tumors that
penetrate through the esophageal wall are considered locally advanced and have a high propensity to
metastasize to locoregional lymph nodes. Periesophageal lymph nodes that are enlarged can be visualized
with EUS and fine needle aspiration biopsy can be performed to determine locoregional lymph node
involvement. Patients with biopsyproven lymph node involvement will typically be referred for preoperative
chemotherapy or combined chemoradiation.
FIG 1 • An upper endoscopy demonstrating a large distal esophageal carcinoma. An endoscopic biopsy was
consistent with a moderately differentiated adenocarcinoma.
FIG 2 • A. An EUS image demonstrating a T3 esophageal carcinoma with extension into the adventitia. B.
Demonstration of a peritumoral lymph node.
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FIG 3 • A. The first PET image demonstrates a hypermetabolic esophageal carcinoma located in the distal
third of the esophagus. B. The second PET image demonstrates a hypermetabolic cervical lymph node that
represents distant metastatic disease.
All patients who are being considered for esophagectomy should undergo a computed tomography (CT) scan
of the chest, abdomen, and pelvis to evaluate the primary tumor in the esophagus and the locoregional lymph
nodes. The liver, celiac lymph nodes, bone, and adrenal glands are common sites for metastatic disease
secondary to esophageal carcinoma. Positron emission tomography (PET) is an essential staging technique
for esophageal carcinoma (FIG 3). PET scans can detect occult metastatic disease that was not identified on
standard CT scans in about 10% to 15% of cases. This detection of occult metastatic disease will prevent
patients with stage IV esophageal carcinoma from undergoing an unnecessary esophageal resection.
SURGICAL MANAGEMENT
Any patient who is being evaluated for an Ivor Lewis esophagectomy should undergo a complete and thorough
cardiopulmonary evaluation prior to the operation. Cardiac disease and respiratory compromise should be
identified in the preoperative period to properly access perioperative risk of complications and mortality.
Pulmonary function tests should be obtained to measure the forced expiratory volume in 1 second (FEV1) and
diffusion capacity. Patients with a history of chronic obstructive pulmonary disease (COPD) will have
diminished values for FEV1 and diffusing capacity of lung for carbon monoxide (DLCO); therefore, they will be
at increased risk for perioperative respiratory complications.
A transthoracic echocardiogram is obtained to assess the left ventricular ejection fraction left ventricular wall
motion. A treadmill stress test should be obtained when the echocardiogram findings are abnormal.
Prior to surgical resection, a patient’s nutritional status should be optimized. A preoperative feeding access for
enteral nutrition may be necessary in cases of severe malnutrition. A prealbumin level can be measured to
further assess the patient’s nutritional status.
Perioperative antibiotics should be given within 30 minutes of the first incision. Compression boots are placed
on the lower extremities and subcutaneous unfractionated heparin is given to minimize the risk of
postoperative deep venous thrombosis (DVT).
An arterial line and central venous catheter should be placed for intraoperative hemodynamic monitoring.
An epidural catheter should be placed for postoperative pain management. Epidural infusion of local
anesthetic minimizes postthoracotomy pain and allows patients to participate in pulmonary toilet exercises.
Positioning
The Ivor Lewis esophagectomy technique uses two incisions. Patients are positioned in the supine position
first for the midline laparotomy incision (FIG 4). The second portion of the operation is performed through a
right posterior lateral thoracotomy (FIG 5). Patients are positioned in the left lateral decubitus position. A
beanbag is used to help hold patients into position. The operating room bed is flexed to open the rib spaces.
FIG 4 • A midline laparotomy incision is located between the xiphoid and the umbilicus.
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FIG 5 • A standard posterior lateral thoracotomy incision provides excellent exposure of the intrathoracic
esophagus.
TECHNIQUES
MOBILIZATION OF THE GASTRIC CONDUIT
The patient is positioned supine on the operating table. A double lumen endotracheal tube is placed for
single lung isolation. An arterial line, central venous catheter, and epidural catheter are placed by the
anesthesia team. Compression boots and subcutaneous heparin are given for DVT prophylaxis.
A midline laparotomy incision is performed from the xiphoid down to the umbilicus. A full inspection of the
abdominal cavity is performed to rule out tumor dissemination on peritoneal surfaces or liver metastasis.
A Bookwalter retractor is used to provide exposure. The triangular ligament of the left lobe of the liver is
divided and the left lateral segment is retracted cephalad to expose the esophageal hiatus.
The dissection of the gastric conduit begins by entering the lesser sac along the great curvature of the
stomach. The right gastroepiploic artery should be identified and preserved. The greater omentum is
divided along the greater curvature of the stomach with an ultrasonic dissector by divided branches of the
right gastroepiploic arcade and carefully preserving the gastroepiploic trunk (FIG 6).
The gastrocolic omentum is divided toward the duodenum. The stomach is retracted upward and any
adhesions between the stomach and pancreas should be carefully divided (FIG 7). The duodenum is
then mobilized with the Kocher maneuver.
FIG 6 • The division of the gastrocolic ligament along the great curvature of the stomach. The right
gastroepiploic artery is preserved.
FIG 7 • Mobilization of stomach.
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FIG 8 • Division of left gastric artery.
The short gastric vessels are ligated using the ultrasonic dissector. The short gastric vessels should be
ligated close to the spleen to avoid thermal injury to the stomach.
The lesser omentum is then divided toward the esophageal hiatus. A replaced left hepatic artery should
be identified and preserved if present. The right gastric artery can be preserved in most cases when the
anastomosis is performed in the right thorax.
The left gastric pedicle is identified along the lesser curvature of the stomach. The left gastric pedicle is
divided at the origin from the celiac axis using an Endo GIA linear stapler. The surrounding adipose
tissue and lymph nodes should be swept upward prior to ligation of the left gastric pedicle (FIG 8).
FIG 9 • Dissection of the hiatus.
The crura of the diaphragm are identified and the distal esophagus should be visualized. The
phrenoesophageal membrane is then divided to facilitate mobilization of the esophagus around the
esophageal hiatus (FIG 9). The right crus of the diaphragm are divided if necessary to permit four fingers
to fit into the opened esophageal hiatus. This prevents compression of the esophageal conduit and
possible ischemia.
FORMATION OF THE GASTRIC CONDUIT
The Endo GIA linear stapler is used to divide the stomach along the lesser curvature. The staple line is
started along the lesser curvature just proximal to the right gastric artery (FIG 10). The staple line should
end between the cardia and the fundus. The staple line is oversewn with multiple interrupted 3-0 silk
sutures to cover the staple line with serosa. The gastric tube should be 5 to 6 cm in width.
The gastric tube is secured to the remnant of the gastric cardia with two interrupted 0-silk sutures. This
will allow the gastric conduit to be pulled into the chest along with the esophagogastric specimen.
FIG 10 • Left and Right: The formation of the gastric conduit using a linear endoscopic stapler. The
gastric conduit should be 5 to 6 cm in diameter.
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HEINEKE-MIKULICZ PYLOROPLASTY
The pylorus muscle is identified with direct palpation at the border of the antrum of the stomach and the
first portion of the duodenum. The pylorus muscle is incised longitudinally using the cautery and
ultrasonic dissector. The incision is carried through the mucosal layer. The incision is then closed
transversely with interrupted 4-0 Vicryl sutures and second layer of 3-0 silk sutures.
JEJUNOSTOMY FEEDING TUBE
The ligament of Treitz is identified at the root of colon mesentery. The jejunostomy tube is placed in the
proximal jejunum about 30 to 40 cm from the ligament of Treitz. A purse-string suture is placed on the
serosa of the jejunum using a 4-0 chromic suture. A small enterotomy is created within the purse string. A
10-Fr jejunostomy tube is placed through the abdominal wall and into the jejunum. The purse-string
suture is tied and the jejunostomy site is covered with multiple 3-0 silk sutures to imbricate the serosa.
The jejunostomy insertion site is then secured to the abdominal wall with four interrupted 2-0 silk sutures.
The jejunostomy tube site on the abdominal wall should not be twisted to avoid postoperative bowel
obstruction or ischemia.
THORACIC MOBILIZATION OF THE ESOPHAGUS
A right posterior lateral thoracotomy is performed and the right chest is entered through the 5th
intercostal space. The serratus anterior muscle is preserved.
The right lung is isolated with a double lumen chest tube and the right lung is retracted anteriorly.
The inferior pulmonary ligament is incised with cautery and the level 9 lymph nodes are harvested. The
mediastinal pleura along the anterior esophagus is incised with the cautery. The distal esophagus is
dissected from the pericardium and the aorta posteriorly (FIG 11). The esophagus is then encircled with
a 1-in Penrose drain.
The esophagus is mobilized from the esophageal hiatus to the azygous vein (FIG 12). The ultrasonic
dissector or LigaSure device can be used to divide small vessels and lymphatics. The thoracic duct
should be suture ligated if the structure is injured during the esophageal dissection. The thoracic duct
enters the right thorax through the aortic hiatus and is usually located between the azygous vein and the
aorta. The thoracic duct crosses over to the left side at T4-T5 and passes behind the aortic arch. The
thoracic duct passes posteriorly to the left carotid sheath and drains into the junction of the left jugular
and subclavian vein.
The azygous vein is routinely dissected and divided with an Endo GIA linear stapler. The
esophagogastric anastomosis is usually performed at the level of the azygous vein. In cases where the
esophageal tumor is located in midesopahgus, the esophageal dissection may have to be carried more
proximally toward the thoracic inlet.
FIG 11 • Dissection (left) and mobilization (right) of the esophagus.
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FIG 12 • The mobilization of the intrathoracic esophagus using an ultrasonic dissector. The azygous vein is
routinely divided. The esophagogastric anastomosis is usually performed at the level of the azygous vein.
ESOPHAGOGASTRIC ANASTOMOSIS
The gastric conduit is pulled into the right chest and the sutures attaching to the esophagogastrectomy
specimen are divided (FIG 13). The esophagus is divided 2 cm above the azygous vein with an Endo GIA
linear stapler (FIG 14). The proximal esophageal margin and distal gastric margin are evaluated with
frozen section.
The 2-0 Prolene purse-string suture is placed through the mucosa and muscular layers of the
esophagus. A 25-mm or 28-mm anvil is placed in the esophageal lumen and the purse-string suture is
tied around the shaft of the anvil. A second purse-string suture is placed as well.
A gastrotomy is performed along the proximal lesser curvature of the gastric conduit. An end-to-end
anastomosis (EEA) circular stapler is inserted through the gastrotomy and the pin is deployed proximally
along the great curvature. The anvil and EEA stapler are connected and the stapler is deployed (FIGS 15
and 16).
The esophagogastric anastomosis should be inspected and checked for completeness (FIG 17). The
“doughnuts” should be complete to ensure esophageal and gastric mucosal apposition. A nasogastric
tube is then passed under direct vision.
The gastrotomy site is resected with one to two applications of the Endo GIA stapler (FIG 18). The staple
line is oversewn with interrupted 3-0 silk sutures.
The anastomosis is reinforced with 3-0 silk sutures placed between the muscular layer of the esophagus
and the serosa of the gastric conduit.
A pleural flap is harvested and used to wrap the esophagogastric anastomosis. Omentum or intercostal
muscle flaps could be used as alternatives for coverage of the esophagogastric anastomosis.
FIG 13 • Conduit through hiatus.
FIG 14 • Proximal esophagus.
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FIG 15 • The formation of the esophagogastric anastomosis using a circular EEA stapler.
FIG 16 • EEA in conduit (left) with anvil in esophagus (right).

FIG 17 • Anastomosis.
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FIG 18 • The completion of the esophagogastric anastomosis with resection of the gastrotomy site (left)
with a linear endoscopic stapler (right).
PEARLS AND PITFALLS
Preoperative ▪ Preoperative staging should include a PET/CT scan and EUS. Patients with
evaluation transmural tumors and nodal disease benefit from preoperative chemotherapy
and radiation.
▪ Patients with a history of previous gastric surgery may require the use of a
colonic or jejunal conduit.
▪ Patients should undergo pulmonary function tests and echocardiography to

assess perioperative risk.
Mobilization of ▪ The right gastroepiploic artery and vein must not be injured. The primary blood
the stomach supply to gastric conduit is derived from this vascular arcade.
▪ The gastric conduit should be 4 to 5 cm in diameter.
▪ The gastric conduit tip could be ischemic and should be resected if there is
necrosis detected.
Esophagogastric ▪ The anastomosis should be covered with a vascularized pedicle, such as

anastomosis omentum, pleura, or intercostal muscle. An anastomotic leak within the thorax
could result in life-threatening mediastinitis.
▪ A two-layer anastomosis should be performed regardless of the technique.
Postoperative ▪ Postoperative barium esophagram should be obtained 5 to 7 days after the

care procedure to evaluate the integrity of the esophagogastric anastomosis.
Contained leaks can be managed with bowel rest and antibiotics. Large leaks
typically require operative repair.
POSTOPERATIVE CARE
Patients should be extubated in the operating room if possible. A chest radiograph is obtained in the recovery
room or intensive care unit (ICU). An epidural catheter is used to administer local anesthesia for optimal pain
control and pulmonary toilet.
The nasogastric tube is placed on low continuous suction to avoid gastric stasis and aspiration.
Fluid balance should be closely monitored to avoid volume overload and respiratory complications.
Enteral nutrition can be initiated on postoperative day 3 to minimize perioperative malnutrition.
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A barium swallow study is obtained on postoperative days 5 to 7 to assess the anastomosis for a leak. A liquid
diet can be initiated if the barium study is negative for a leak. The diet is slowly advanced to a soft mechanical
diet.
Patients are typically discharged when they are tolerating a soft diet and are able to ambulate without
difficulty.
OUTCOMES
In modern surgical series for Ivor Lewis Esophagectomy, the perioperative mortality rates range from
1.4% to 4.4%. The anastomotic leak rates range from 0% to 3.5%. The overall morbidity rates range from
26.6% to 45%.
The overall 5-year survival rate for patients undergoing Ivor Lewis esophagectomy ranges from the
25.2% to 33.3%. Patients with positive nodal disease have a worse prognosis compared to patients with
negative nodal disease.
COMPLICATIONS
Pneumonia
Anastomotic leak
Thoracic duct injury and chyle leak
Reflux
Aspiration pneumonitis
Pulmonary embolism
Acute myocardial infarction
SUGGESTED READINGS
1. Cerfolio RJ, Bryant AS, Bass CS, et al. Fast tracking after Ivor Lewis esopahagogastrectomy. Chest.
2004;126:1187-1194.
2. Visbal AL, Allen MS, Miller DL, et al. Ivor Lewis esophagogastrectomy for esophageal cancer. Ann Thorac
Surg. 2001;71:1803-1808.
3. Karl RC, Schreiber R, Boulware D, et al. Factors affecting morbidity, mortality, and survival in patients
undergoing Ivor Lewis esophagogastrectomy. Ann Surg. 2000;231:635-643.
4. Gulch L, Smith RC, Bambach CP, et al. Comparison of outcomes following transhiatal or Ivor Lewis
esophagectomy for esophageal carcinoma. World J Surg. 1999;23:271-275.
5. Griffin SM, Shaw IH, Dresener SM. Early complications after Ivor Lewis subtotal esophagectomy with two-
field lymphadenectomy: risk factors and management. J Am Coll Surg. 2002;194:285-297.
6. Van Hagen P, Hulshof MC, Van Lanshot JB, et al. Preoperative chemoradiotherapy for esophageal or
junctional cancer. N Engl J Med. 2012;366:2074-2084.
7. Hulscher JB, Van Sandick JW, De Boer GEM, et al. Extended transthoracic resection compared with
limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002;347:1662-1669.
Chapter 14
Minimally Invasive Esophagectomy
Benjamin Wei
Robert J. Cerfolio
Mary T. Hawn
DEFINITION
The incidence of esophageal cancer, especially adenocarcinoma, has increased dramatically over the
past decades. This phenomenon is secondary to the increasing incidence of obesity contributing to rising
rates of reflux and Barrett’s esophagus in the United States.

Patients with esophageal malignancy present with progressive dysphagia and weight loss. The incidence is
higher in men and in smokers. Patients often have a long-standing history of gastroesophageal reflux
symptoms. The physical examination is usually unremarkable.

All patients with dysphagia should be evaluated with an upper endoscopy and biopsy of suspicious lesions.
Patients with biopsy-proven carcinoma are staged to determine treatment. The staging process includes
computed tomography (CT) of the chest and abdomen, an integrated positron emission tomography
(PET)/CT, and endoscopic ultrasound. Patients with T3 or N1 disease are treated with neoadjuvant
chemoradiation and restaged prior to resection.
SURGICAL MANAGEMENT
If the patient is unable to maintain adequate nourishment during neoadjuvant therapy or is malnourished and
too weak for resection, we place a jejunostomy tube (J-tube), preferably with a laparoscopic approach. This
allows for staging and the ability to rule out metastatic disease. A percutaneous endoscopic gastrostomy tube
should be avoided in any patient that is being considered for esophageal resection. Additionally, having the J-
tube placed up front minimizes the abdominal portion of the esophageal resection procedure.
Positioning for the Abdominal Portion

The patient is positioned in the supine position with both arms tucked and a Foley catheter in place. We do
not routinely use an arterial line or a central line. A nasogastric tube (NGT) is routinely placed. If one is placed,
care must be taken to pull it far back into the esophagus as well as to remove all esophageal temperature
probes or other devices prior to stapling the stomach. If body habitus or other concerns prevent arm tucking, it
is not a necessity.
TECHNIQUES
PORT PLACEMENT
A Veress needle entry technique is used to place a 5-mm trocar approximately 15 cm inferior to the
xiphoid and 3 cm to the left of the midline. The abdomen is then inspected for evidence of distant disease
and any suspicious areas are biopsied and sent for frozen section. Four additional trocars are placed: (1)
12-mm trocar is placed 7 cm inferior to the right costal margin and 3 cm from the midline, (2) 5-mm trocar
is placed 6 cm superior to the 12-mm trocar and usually to the right of the falciform ligament, (3) 5-mm
trocar just off midline to the right and inferior to the base of the xiphoid to retract the left lateral segment
of the liver. A 5-mm locking grasper positioned underneath the left lateral segment of the liver and the
diaphragm is grasped anterior and to the right of the esophageal hiatus taking care to avoid the phrenic
vein, and (4) 5-mm trocar 2 cm below the left costal margin in the anterior axillary line (FIG 1).
The patient is positioned in moderate reverse Trendelenburg position. The surgeon stands on the
patient’s right side and uses the two right-sided ports. The assistant stands on the patient’s left and uses
the left subcostal port and camera port.
FIG 1 • Abdominal port placement for gastric mobilization.
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CRURAL DISSECTION AND ESOPHAGEAL MOBILIZATION
The gastrohepatic ligament is divided using an ultrasonic dissector. The right crus of the diaphragm can
then be identified at the esophageal hiatus. The phrenoesophageal ligament is divided anteriorly, taking
care to follow the stomach toward the angle of His, lateral and inferior to the left esophageal crus. The
crura are dissected circumferentially and the esophagus is isolated.
Once the retroesophageal window is completed, a Penrose drain is placed around the gastroesophageal
junction. The two tails are sutured together with a single 2-0 Vicryl stitch to use as a handle to assist in
the crural dissection and for intrathoracic pull-up and manipulation during the second portion of the
procedure (FIG 2). Dissection of the lower 5 to 7 cm of the esophagus is then performed while the
assistant places the Penrose on traction. This can mostly be performed with blunt dissection. If the left
pleural space is entered, we place a chest tube at the completion of the abdominal portion of the
operation. Radiation changes can make this part of the dissection more difficult.
FIG 2 • Placement of a Penrose around the gastroesophageal junction. It is important to suture the Penrose
so that it can be used to help deliver the conduit into the chest.
GREATER CURVATURE DISSECTION

On the distal aspect of the greater curvature of the stomach approximately 5 cm proximal to the pylorus,
the greater curvature is grasped and elevated anteriorly by the surgeon’s left hand and the assistant
places the transverse colon on downward traction. The surgeon divides the gastrocolic ligament well
inferior to the projected course of the right gastroepiploic vessels. Because the right gastroepiploic
vessels will serve as the primary blood supply for the gastric conduit, great care is taken to avoid injuring
these vessels during greater curvature dissection (FIG 3).
The lesser sac is entered at least 1 to 2 cm inferior to the right gastroepiploic vessels projected course.
Once the lesser sac is entered, the posterior stomach wall is grasped and elevated anteriorly and to the
patient’s right side with the surgeon’s left hand to open the dissection tension plane. This maneuver
positions the gastroepiploic vessels anteriorly and helps protect them from injury due to inadvertent
grasping (FIG 4).
Dissection is then carried proximally, taking care to stay superior to the transverse colon as it courses
toward the splenic flexure. This is accomplished by lifting the posterior stomach wall anteriorly and
toward the patient’s right side with the surgeon’s left hand while the assistant retracts the greater
omentum inferiorly and to the patient’s left. The proximal aspect of the greater curvature is mobilized by
dividing all short gastric vessels until the left crus of the diaphragm is reached. If there is excess omentum
impeding the view, we will place a “fat stay” using a 2-0 Vicryl suture on an MH needle. The suture is
placed through the fat, the needle is removed, and the assistant grasps both ends of the suture and
extracts them through the left-sided trocar. The trocar is then removed and reinserted so that the suture
comes through the track but not the trocar. Tension is placed on the suture until the fat is retracted; then,
the suture is secured with a hemostat at the level of the skin.
We leave some omentum along the superior aspect of the greater curvature of the stomach to be used to
buttress the intrathoracic anastomosis.
FIG 3 • Identification of the right gastroepiploic vessels adjacent to the greater curvature and entering the
lesser sac.
FIG 4 • Grasp the posterior wall of the stomach inferiorly through the lesser sac, rolling the gastroepiploic
vessels onto the anterior stomach wall. This assists in protecting the right gastroepiploic artery as the
dissection is carried proximally along the greater curvature of the stomach.
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LESSER SAC AND LEFT GASTRIC PEDICLE DISSECTION
The posterior attachments to the stomach are divided, exposing the origin of the left gastric vessels along
the lesser curvature. In exposing the left gastric artery, the adjacent fat and lymph nodes should be
elevated anteriorly to allow for resection with the specimen.
The left gastric vessels are then identified on the medial aspect of the lesser curvature. Once these
vessels are skeletonized, a white vascular (2.5 mm) staple load is fired across the left gastric artery at its
origin from the celiac axis (FIG 5).
FIG 5 • Exposure of the left gastric pedicle along the lesser curve.
THE PYLORUS
The gastrocolic ligament is divided beyond the pylorus with care of staying away from the origin of the
right gastroepiploic vessels.
A Kocher maneuver is performed to further mobilize the pylorus. One good assessment of mobility of the
stomach is whether the pylorus can be placed adjacent to the right crus.
We do not perform a pyloromyotomy or pyloroplasty and instead inject botulinum toxin into the anterior
wall of the pylorus.
Botulinum toxin (100 units) is diluted into 5 mL of saline and drawn into a syringe. A 20-gauge spinal
needle is inserted into the anterior aspect of the pylorus (FIG 6). The total volume of botulinum toxin is
divided into at least three to four separate injection sites along the anterior pylorus.
FIG 6 • Percutaneous injection of 100 units of botulinum toxin into the anterior wall of the pylorus.
CREATION OF THE GASTRIC CONDUIT

The lesser curvature is cleared of omentum at approximately the level of the incisura to allow for an
avascular landing zone for the first staple load on the stomach (FIG 7).
The conduit is created with sequential applications of a 60-mm stapler using green (4.8 mm) loads aiming
toward the angle of His. The goal is to create a conduit that is 6 to 8 cm in width. Once divided, staple-
line integrity and hemostasis are verified.
The conduit is then sutured to the proximal stomach remnant using two interrupted 2-0 Vicryl stitches of
alternate color to facilitate orientation following the thoracic pull-up (FIG 8). The tails are left at least 5 cm
long to assist in intrathoracic location/manipulation and the first stitch is always placed at the superior
apex of the conduit to diminish pull-up tension.
The surgeon then places the Penrose drain and proximal stomach into the posterior mediastinum. We do
not routinely enlarge the hiatus unless there appears to be constriction of the conduit.
A laparoscopic J-tube is placed if not already present per standard laparoscopic technique to optimize
postoperative nutrition.
FIG 7 • Lesser curvature dissection in preparation for creation of the gastric conduit.
FIG 8 • Suturing gastric conduit to the proximal stomach to allow for the conduit to be delivered into the
posterior mediastinum during the thoracic portion of the operation.
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POSITIONING AND PORT PLACEMENT FOR THE ROBOTIC THORACIC PORTION
After the abdomen portion is completed, the single lumen endotracheal tube is exchanged for a double
lumen tube.
The patient is placed in a left lateral decubitus position and then rolled even more anteriorly. This allows
all of the benefits of prone positioning without the anesthesia delays. The patient’s body needs to be
turned so that the robot can approach the patient from over his or her back and right shoulder.
The first port placed is the camera port, which is 9 cm from the right axillary port. We use a 5-mm port
here initially, with a 5-mm thoracoscope to assist in placing the other ports. Carbon dioxide (CO2) is
insufflated into the chest at a pressure of 12 cm H2O.
Port placement is shown in FIG 9. It is important to note that the three anterior ports comprise robotic arm
1; the camera port and robotic arm 2 are in a line that runs slightly posterior, headed toward the patient’s
right hip. If the line is in the anterior axillary line, you will be too close to the diaphragm for robotic arm 2.
After the camera port is placed, the robotic arm 3 is placed as posterior and inferior as possible and a
seeker needle is inserted first to ensure its safe trocar placement. Robotic arms 1 and 2 are the 8-mm
ports through which most of the dissection takes place; robotic arm 3 is a 5-mm port and used primarily
for retraction of structures during the dissection.
The access port for the assistant is positioned last. This port should be triangulated behind robotic arm 2
and the camera port so that the robotic arms will not interfere with the assistant. Care should be taken to
avoid the internal mammary artery and the diaphragm when this access port is placed. The insufflation
tubing is switched to the access port so that it does not interfere with the movement of the robotic arms.
FIG 10 demonstrates the anatomic structures of the right hemithorax as seen from the camera port during
the robotic portion of the Ivor-Lewis esophagectomy.
FIG 9 • Port placement for robotic thoracic phase of esophagectomy. C, camera port; 1, robotic arm 1; 2,
robotic arm 2; 3, robotic arm 3; A, assistant port.
FIG 10 • Structures of right hemithorax as seen from camera port during robotic Ivor-Lewis esophagectomy.
ESOPHAGEAL DISSECTION AND NODE RETRIEVAL

Robotic arm 3 holds the lung anteriorly. Robotic arm 2 has a Cadiere forceps and lifts the mediastinal
pleura. Robotic arm 1 has a thoracic dissector that incises the mediastinal pleura along the lung (FIG 11).
The inferior pulmonary ligament is generally divided and lymph node within the ligament resected.
The mediastinal pleura along the right mainstem bronchus is opened and divided all the way up to the
azygous vein and all the way down to the diaphragm. The subcarinal lymph nodes are located posterior
and inferior to the right mainstem bronchus and resected. Care should be taken to achieve proper
hemostasis of this area, as the subcarinal nodes tend to be well vascularized.
FIG 11 • Incision of mediastinal pleura overlying esophagus. E, esophagus; 1, robotic arm 1; 2, robotic
arm 2.
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FIG 12 • The esophagus (E) is dissected off the aorta (A). We perform an en bloc dissection from the
pericardium to the aorta. Robotic arm 3 is used to grasp the Penrose drain that was placed around the
esophagus in the abdomen. It is pulled anteriorly to assist with the esophageal dissection off of the
pericardium and aorta.
The posterior pleura along the hemiazygous vein going up to the azygous vein is opened. The bipolar
thoracic dissector can be used to take the small arteries off the aorta that run to the esophagus. Clips are
not necessary for these arteries (FIG 12).
The lymph node dissection is carried out well above the azygous vein and to the posterior
paraesophageal tissue (FIG 13).
The azygous vein is dissected off the trachea. It is very important to staple the azygous vein posteriorly
(FIG 14). This avoids a long azygous stump from getting in the way of performing an anastomosis.
FIG 13 • Dissection of paraesophageal tissue above the azygous vein (A), vagus nerve (V), and
esophagus (E).
FIG 14 • The azygous vein is stapled as posteriorly as possible.
The esophagus should be completely mobilized from the thoracic inlet to the diaphragmatic hiatus.
Performing this part of the operation robotically allows for a thorough harvest of the periesophageal
tissue, including lymph nodes. The paraesophageal lymph nodes are dissected carefully off the left and
right mainstem bronchi and aorta. Use of the bipolar device and careful dissection during this phase
helps avoid thermal injury to the airway, which may present as an esophagobronchial fistula and can be
catastrophic for the patient. The subcarinal nodes should be included in the specimen. After completion
of the dissection, the pericardium should be visible to the level of the inferior pulmonary veins bilaterally
(FIG 15).
FIG 15 • The entire left mainstem bronchus (L) is identified. We use the bipolar thoracic dissector to
minimize thermal injury to the airway. C, subcarinal space; R, right mainstem bronchus.
DIVISION OF THE PROXIMAL ESOPHAGUS AND MOBILIZATION OF GASTRIC CONDUIT

The Penrose drain encircling the conduit that was placed during the laparoscopic stage of the procedure
is located in the inferior mediastinum and will be used to bring the conduit into the chest.
The thoracic dissector in robotic arm 1 (right arm) is exchanged for the bipolar scissors. With traction
applied to pull it distally, the proximal esophagus is divided just above the azygous vein to ensure the
best possible margin away from cancer and/or Barrett’s esophagus; it is beveled so that the posterior
aspect of the esophagus is longer. Cautery is applied to cut and coagulate simultaneously (FIG 16).
The scissors in robotic arm 1 are switched back to the Cadiere forceps, and the assistant helps pull the
resected esophagus and gastric conduit gently into the chest with
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an atraumatic clamp (rather than using the robotic arm, which because of its strength can damage the
conduit) (FIG 17). Prior to dividing the sutures attaching the esophagus to the conduit, silk sutures are
placed anteriorly and posteriorly, tacking the conduit to the pleura. This helps reduce the amount of
tension on the anastomosis and maintain orientation of the conduit. Care should be taken to avoid
twisting the conduit; the staples from conduit creation (i.e., the former lesser curve) should be oriented
toward the lung. The esophageal specimen is then detached from the conduit (FIG 18).
FIG 16 • The esophagus is mobilized and ready to be cut. The esophagus is pulled downward and it is cut
at the level of the carina just about above the azygous vein. Frozen section analysis is performed to ensure
the proximal margin that is free of Barrett’s metaplasia and cancer. Robotic hot shears are used to cut and
coagulate the esophagus as it is cut.
FIG 17 • The assistant uses a blunt Scanlon clamp, which is less traumatic than the robotic instruments.
The clamp is placed through the nonrobotic access port and grasps the gastric conduit and carefully
transports it into the right hemithorax.
FIG 18 • The sutures attaching the conduit to the specimen are cut so that the specimen can be placed in a
pouch and removed.
CREATION OF THE ESOPHAGOGASTROSTOMY

A double-layered esophagogastrostomy is created. In general, we have found that the best instruments to
use for robotic suturing are a long atraumatic forceps in robotic arm 2 and a suture-cut needle driver in
robotic arm 1.
First, interrupted 3-0 silk sutures are placed along the “back wall” of the anastomosis for the
seromuscular layer (FIGS 19 and 20). Then, a transverse gastrotomy approximately 2 to 3 cm in diameter
on the posterior surface of the stomach approximately 5 mm away from the row of silk sutures is created
with electrocautery (FIG 21).
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The gastrotomy should be located as far away from the staple line as possible, toward the greater curve
of the stomach. Interrupted 3-0 Vicryl suture is used to create the full-thickness layer of the anastomosis
around the circumference of the cut end of esophagus/gastrotomy. Typically, a suture is placed at each
“corner” of the anastomosis and sutured in a running fashion to create the back wall (FIG 22).
FIG 19 • A two-layered completely hand-sewn chest anastomosis is performed. The first suture of the
back row is placed furthest away from the surgeon. It is a 3-0 silk suture on an RB-1 needle and it is
placed as shown to start on the esophagus. This sets up the anastomosis. The conduit is held by the
assistant to keep it in place.
FIG 20 • The spot where the first suture is placed on the conduit side should be located near the greater
curve as far away from the staple line. The conduit is held in place by the bedside assistant to take all
tension off of the first suture.
FIG 21 • Once the posterior row of interrupted sutures are finished, the gastrotomy is performed. The
location is carefully chosen approximately 5 mm from the interrupted back row of silk sutures and as far
away from the staple line as possible. Note that the gastrostomy is performed on the posterior aspect of
the stomach.
FIG 22 • A. The posterior inner layer of interrupted 3-0 Vicryl sutures is placed. B. The NGT is then slid
through the anastomosis prior to placing the anterior inner layer of sutures. All the holes on the NGT are
positioned into the gastric conduit to prevent evacuating the CO2 insufflation and so no sutures go
through the NGT inadvertently. An outer layer of interrupted silk sutures is placed after the inner layer is
completed.
A running 3-0 Vicryl full-thickness suture is then placed in the “front wall,” starting at the corner farthest
away from the surgeon, to complete the anastomosis. The NGT is fed under direct vision into the conduit
prior to completion of this layer. All the holes of the NGT are positioned in the gastric conduit to prevent
evacuating the CO2 insufflation. An additional row of interrupted 3-0 silk sutures is then placed to
complete the doublelayered anastomosis anteriorly.
A tongue of omentum coming off the gastroepiploic artery is brought up from beneath the gastric conduit
and tacked over the anterior side of the anastomosis with silk sutures (FIG 23). If possible, the omentum
can be positioned between the anastomosis and the airway (left mainstem bronchus/trachea) to prevent
fistula formation. The conduit is sutured to the right hemidiaphragm near the hiatus to prevent herniation
of abdominal contents into the chest (FIG 24).
FIG 23 • The omentum is then tacked down to buttress the anterior aspect of the anastomosis. We also
leave a large pad of omentum between the conduit and underlying right and left mainstem bronchus to help
prevent fistula formation.
FIG 24 • A tacking 3-0 silk suture between the gastric conduit and the right hemidiaphragm is placed to help
prevent herniation of abdominal contents into the chest.
REMOVAL OF THE SPECIMEN/CONCLUSION OF SURGERY

The specimen is removed with a large bag via the assistant port, and frozen section examination is
performed to confirm that the proximal and distal margins are clear of tumor and/or Barrett’s mucosa. A
chest tube is placed directly posteriorly and toward the apex through the incision for robotic arm 2. The
ports are removed with the CO2 insufflation turned off to ensure the absence of bleeding. The robot is
undocked and moved away from the patient. The lung is reexpanded and the incisions are closed. We
frequently remove the NGT prior to extubation.
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PEARLS AND PITFALLS
Nutritional evaluation ▪ Assess nutritional status preoperatively and have a low

threshold for pretreatment J-tube placement to improve
nutritional status prior to esophagectomy.
Aberrant arterial anatomy ▪ Clip accessory or replaced left hepatic artery in the
gastrohepatic ligament and assess liver viability prior to
transection.
Excessive intraabdominal fat ▪ Carefully locate the right gastroepiploic vessels prior to
dividing the gastrocolic ligament.
▪ Liberal use of fat stays to retract omentum to expose the

short gastric vessels.
Avoid use of monopolar cautery ▪ Balance risks of airway injury with benefit of taking all
around the airway peribronchial nodes.
▪ Devascularization injury to the airway can result in delayed

esophagobronchial fistula and associated mortality.
Bedside fiberoptic endoscopic ▪ Aspiration is common following esophagectomy. Perform

examination of swallowing (FEES) FEES prior to contrast study evaluating the anastomosis.
prior to initiating oral intake
▪ Some advocate for delayed oral intake for 4-6 weeks

following esophagectomy.
Delayed gastric emptying ▪ Emptying of the gastric conduit is poor even with the use
of concomitant emptying procedures.
▪ Patients must be counseled to keep their head of bed

elevated and not eat close to bedtime.
POSTOPERATIVE CARE
The postoperative care of patients who undergo esophagectomy is based on a team approach. Most literature
shows improved outcomes in high-volume centers. This is secondary to a more experienced team not only in
the operating room (OR) but also on the floor. Low-molecular-weight heparin is administered prior to surgery
and on every postoperative day (POD). Our postoperative care algorithm is as follows for each POD:
POD 1
The patient receives about 100 to 125 mL per hour of lactated Ringer’s solution.
The J-tube is placed to gravity.
Patient begins ambulating three to four times a day.
POD 2
Trophic tube feeds are started though the J-tube at 10 mL per hour.
The intravenous fluid given is decreased based on urinary output, and changed to 5% dextrose in half
normal saline.
Ambulate four to six times a day.
POD 3
The chest tube is usually removed.

The patient continues to ambulate four times a day.
J-tube feedings are advanced as tolerated.
POD 4
The patient receives a bedside fiberoptic endoscopic examination of swallowing (FEES).
If the vocal cords are normal on FEES, the patient is sent to radiology for an upper gastrointestinal (UGI)
swallow. This test evaluates two important components:
The anastomosis
The time for emptying of the gastric conduit
POD 5
If the swallow is negative, the patient is advanced to 30 mL per hour of thickened liquids by mouth.
POD 6 or POD 7
The patient is usually discharged home.
OUTCOMES
We presented the world’s largest series of consecutive robotic Ivor-Lewis esophagectomy procedures in
January 2013; we have now completed over 70 robotic esophageal resections. From our experience, we
have learned that the keys to preventing complications in this operation are contingent on the following:
Performing a mucosa-to-mucosa anastomosis without tension
A well-perfused conduit
Adequate functional status of the patient at the time of surgery
COMPLICATIONS
Despite adherence to these technical concepts during surgery, postoperative complications can
commonly occur. The most frequent complications include the following:
Anastomotic leak: When it is subtle, it can be managed conservatively by keeping the patient NPO and
observation for a week. If it is large, an esophageal stent should be placed endoscopically for 8 to 12
weeks. Video-assisted thoracic surgery (VATS) decortication and drainage of effusion should be
performed if there is any evidence of new or infected pleural material.
Pulmonary complications are common after any thoracic surgery and include atelectasis and
pneumonia, including aspiration pneumonia in particular.
Chylothorax: This is a complication that can require reoperation. We generally choose to manage this
with percutaneous embolization of the thoracic duct for high-output fistulas. If the output is greater than
400 mL per day, it should be immediately treated.
Atrial fibrillation: The incidence of atrial fibrillation after an esophagectomy is reported to be about 20%
and correlates to the extent of the mediastinal node dissection performed during the operation. As
such, patients should be on telemetry in the postoperative period.
Chapter 15
Treatment of Esophageal Perforation: Cervical, Thoracic, and
Abdominal
Nathalie Boutet
Moishe Liberman
DEFINITION
Esophageal perforation is defined as a tear in both the mucosa and muscularis propria layers of the
esophagus.
The presentation of esophageal perforations is variable and thus the differential diagnosis can be quite
extensive. In cases without obvious etiology, cardiac and pulmonary pathologies will often have been
ruled out before the diagnosis of esophageal perforation is made. Myocardial infarction, aortic dissection,
pneumonia, pneumothorax, gastroesophageal reflux, and esophageal spasm are among the pathologies
that can present with symptoms similar to esophageal perforation.

History may include recent events of forceful vomiting, blunt abdominal trauma, ingestion of caustic
substances or foreign bodies, or recent upper gastrointestinal (GI) endoscopy.
Patients may report a history of dysphagia of rapid onset accompanied by neck, chest, or abdominal pain.
Dysphonia and a febrile state may also be reported.
A thorough review of esophageal function should be obtained as symptoms of achalasia or dysphagia may
impact on the choice of treatment.
Evaluation of comorbid conditions such as heart disease and pulmonary function should be performed. A
history of prior surgical and radiation therapy should be sought.
FIG 1 • Chest x-ray showing subcutaneous emphysema and pneumoperitoneum.
Physical exam may reveal the presence of subcutaneous emphysema in the neck or chest. Reduced air entry
may signal the presence of an associated pleural effusion or pneumothorax.

Evaluation of other diagnoses found in the differential will often lead to basic imaging studies being performed
in these patients, such as a chest x-ray. One can expect to find air in the subcutaneous tissues of the neck,
chest wall and mediastinum (FIG 1), and in the prevertebral space on the lateral views. Associated plain film
findings may include pleural effusion, pneumothorax, hydropneumothorax, pneumoperitoneum, or
pneumoretroperitoneum.
Cervical and thoracic computed tomography (CT) scans with oral contrast can be performed to diagnose
esophageal perforations. An extraluminal leak of contrast medium can be seen in the prevertebral or pleural
spaces (FIG 2). CT scan also allows for the evaluation of other potential causes of clinical presentation. CT
scan is the investigation of choice when diagnosis is uncertain. Pneumomediastinum, pneumoperitoneum, and
air in the subcutaneous tissues of the neck will often be seen in cases of esophageal perforation (FIG 3A,B).
CT also allows for the evaluation of the neck, mediastinum, abdominal cavity, and pleural spaces, which can
aid in operative incision planning and/or drainage planning in nonoperative cases.1
FIG 2 • CT scan with extraluminal leak of water-soluble oral contrast in the mediastinum. Subcutaneous
emphysema is also present.
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FIG 3 • A. CT scan showing subcutaneous emphysema in the neck following cervical esophageal perforation.
B. CT scan showing pneumomediastinum.
Gastrografin studies can also be performed and should be immediately followed by a barium swallow in the
event of negative findings, as barium studies are more sensitive than Gastrografin. Water-soluble contrast
should be avoided when tracheoesophageal fistula is considered in the differential. With CT scan and
endoscopy, oral esophagograms are not usually necessary in the modern day diagnosis of esophageal
perforation.
Diagnosis can also be made using endoscopy (FIG 4). Endoscopy should always be performed under general
anesthesia in the operating room at the time of esophageal repair, exclusion, stenting, clipping, or decision
regarding conservative management. It should always be performed by an experienced upper GI endoscopist
and is very important in not only assessing the site of the perforation but also in evaluating for distal
obstruction, quality of the esophagus, size of the hole, associated upper GI pathology, and mucosal
quality/necrosis. It is primordial that insufflation be kept to a minimum in order to avoid increasing the extent of
the perforation.
FIG 4 • Esophagogastroscopy showing an esophageal perforation in the bottom right corner. The esophageal
lumen is seen in the upper left corner. Note the clear margins of the perforation and the absence of mucosal
necrosis.
SURGICAL MANAGEMENT
Appropriate resuscitation is mandatory prior to surgical treatment. Diagnosis should be confirmed either by CT
scan, water-soluble contrast/barium swallow, or endoscopy. This is critical as approaches to cervical, thoracic,
and abdominal esophageal perforations are drastically different. Broadspectrum intravenous antibiotics should
have been started as soon as the diagnosis is made.
We recommend on-table endoscopy under general anesthesia in all cases in order to precisely delineate the
location, size, and extent of the hole and assess the quality of the esophagus (including evaluation of possible
downstream obstruction). Additionally, endoscopy can be used as a treatment option (stenting, clipping) or as
an adjunctive procedure during repair (perforation cannulation, percutaneous endoscopic gastrostomy,
percutaneous endoscopic jejunostomy). In cases requiring thoracotomy, laparotomy, or cervical exploration, a
flexible soft-tipped guidewire is typically placed through the perforation using endoscopy in order to make it
simple and expedient to find the site of perforation during surgical exploration and minimize dissection (FIGS 5
and 6).
FIG 5 • Esophagogastroscopy showing insertion of a guidewire into the esophageal lumen with a large
perforation seen on the right.
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FIG 6 • Dissected esophagus with guidewire through site of esophageal perforation.
Positioning
Cervical perforation
The patient is placed in dorsal position with a bolster under the scapulae to obtain a slight hyperextension
of the neck. The endotracheal tube is secured to the right corner of the mouth and the head is slightly
turned to the right side (FIG 7).
Upper two-thirds thoracic perforation
The patient is placed in left lateral decubitus with a double lumen endotracheal tube in place. The flexion
point of the operating table should be located at the level of the 5th thoracic vertebra. An axillary roll is
placed under the thoracic cage, two fingerbreadths below the left axilla to protect the brachial plexus. The
table is flexed in order to open the intercostal spaces on the right side. The right arm is positioned
anterosuperiorly to the head. Once positioning is adequate, the position of the double lumen endotracheal
tube is confirmed with bronchoscopy and the right lung is isolated from ventilation.
FIG 7 • Slight hyperextension of the neck allows easy access for neck dissection. Incision along the medial
border of the sternocleidomastoid muscle.
Lower one-third thoracic perforation

The patient is placed in right lateral decubitus with a double lumen endotracheal tube in place. All specifics
of positioning are the same as for the left lateral decubitus position previously described.
Abdominal perforation
The patient is placed in dorsal position with both arms abducted.
TECHNIQUES
CERVICAL PERFORATION REPAIR AND DRAINAGE
Skin Incision
The medial border of the left sternocleidomastoid muscle is identified. An incision is performed along the
border of the muscle (FIG 7). The platysma is incised in the orientation of the skin incision.
Dissection
The sternocleidomastoid muscle is dissected and retracted laterally, exposing the vessels of the neck.
The carotid sheath is left intact and retracted laterally. If necessary, the middle thyroid vein is ligated and
the larynx and trachea are retracted to the right. Care is taken to not damage the left recurrent laryngeal
nerve, which lies in the tracheoesophageal groove. The prevertebral plane is entered, moving the
esophagus anteriorly (FIG 8A,B). The entire space is dissected as far caudally as the carina.
Repair
In most instances, the site of the perforation is not identified nor should any extensive amount of time be
spent searching for it. If the perforation is visualized and easily accessible, it can be repaired. The first
step of the repair is the lengthening of the opening in the muscularis propria as this is often smaller than
the orifice in the
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mucosa (FIG 9). Once the entire length of the perforation is exposed, the repair is performed with single
interrupted absorbable sutures on the mucosal plane and nonabsorbable sutures on the muscular plane
(FIG 10). In most cases, the inflammation at the site of perforation will prevent easy identification of both
mucosal and muscular planes. In such instances, it is appropriate to proceed with a single layer repair
using single interrupted absorbable sutures. A rubber bougie should be placed in the esophagus orally to
assure that the repair does not result in esophageal obliteration or significant stenosis.
FIG 8 • A. Transverse section showing the prevertebral space. Dissection is carried medially to the carotid
sheath. The recurrent laryngeal nerve is protected within the tracheoesophageal groove. B. Lateral view of
the dissected prevertebral space with trachea, esophagus, and recurrent laryngeal nerve retracted
anteriorly.
FIG 9 • Esophageal perforation at the tips of the forceps. The esophageal lumen is seen with normal
mucosa.
Sternocleidomastoid Flap
Leaks from primary repairs of esophageal perforations are common and it is preferable to protect the
repair with a vascularized flap. For perforations of the cervical esophagus, the sternal head of the
sternocleidomastoid muscle is detached using electrocautery and rotated to
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cover the site of the perforation. The muscle is fixed with multiple interrupted sutures around the repair.
The muscle should be tightly opposed to the repair site and cover it entirely (FIG 11). In the case of
concomitant tracheal injury, the flap should be placed in between the repaired esophagus and the
trachea to avoid the formation of a tracheoesophageal fistula.
FIG 10 • Repair of esophageal perforation in two planes of single interrupted sutures (mucosa and
muscularis propria).
Drainage
Regardless of whether the site of perforation was identified and/or repaired, the prevertebral space is
irrigated abundantly and drains are left in place. Drains are brought out through separate skin stab
wounds.
Closure
The platysma is reapproximated in the superior portion of the incision with absorbable sutures. The skin
incision is closed with staples.
FIG 11 • Sternocleidomastoid flap. The sternal head is dissected and rotated to cover the entire repair site.
The flap is fixed to the repair with single interrupted sutures.
THORACIC PERFORATION REPAIR AND DRAINAGE

Skin Incision
With the patient in lateral decubitus, left for perforations of the upper two-thirds and right for the lower
third of the esophagus, the tip of the scapula is identified and an incision following the orientation of the
underlying ribs is placed two fingerbreadths caudally (FIG 12).
Dissection
The incision is carried through to the latissimus dorsi. The muscle is incised exposing the serratus
anterior. The serratus anterior is preserved and retracted anteriorly. With single lung ventilation, the 5th
intercostal space is entered by cutting the intercostal muscles immediately above the 6th rib. The 6th rib
is sectioned anteriorly and posteriorly. A 1 to 2 cm portion of the 6th rib can be removed. In very high
perforations, a 4th intercostal space may be chosen to aid in repair, and in very low perforations, a lower
incision (6th, 7th, or 8th interspace) may be chosen.
FIG 12 • Patient positioned in left lateral decubitus. The scapula is drawn along with the incision site two
fingerbreadths below the tip of the scapula following the orientation of the underlying ribs.
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Intercostal Flap Preparation
The periosteum of the 5th rib is opened longitudinally in the center of the bone and retracted inferiorly.
The neurovascular bundle is dissected off of the inferior border of the 5th rib using a periosteal elevator.
The intercostal muscles and the neurovascular bundle are transected anteriorly and the resulting flap is
moved posteriorly to avoid injury with retractors used to open the intercostal space (FIG 13).
Repair
The site of perforation should be identified (FIG 14). The esophagus should be mobilized
circumferentially above and below the perforation and Penrose drains should be placed around the
esophagus to aid in retraction and repair (FIG 15A,B). The repair should proceed in one or two layers of
interrupted nonbraided absorbable suture (3-0 polydioxanone [PDS]) over a bougie (FIG 16).
Intercostal Muscle Flap
The previously prepared intercostal flap is approximated to the site of repair and fixed with interrupted
horizontal mattress, 3-0 silk sutures (FIG 17).
Drainage
The thoracic cavity is irrigated abundantly and two thoracic drains are inserted and positioned close to
the site of perforation. Drains are fixed at the skin.
Closure
The ribs are reapproximated with figure-of-eight sutures of heavy Vicryl. The lung is reexpanded before
tying the sutures and appropriate drain position is confirmed. The serratus anterior is resewn to its fat
and the latissimus dorsi muscle is repaired with running sutures of 0 Vicryl. The subcutaneous fat is
reapproximated with a running suture of 2-0 Vicryl before closing the skin with staples.
FIG 13 • Dissection of intercostal flap. The intercostal muscles are dissected from the superior rib by
removing the periosteum and following the lower border of the superior rib. Care is taken to preserve the
neurovascular bundle with the flap as this is essential to flap viability. The dissection plane is depicted in
the inset.
FIG 14 • Metallic probe inside thoracic esophageal perforation.
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FIG 15 • A. Thoracic esophageal perforation with bougie inside the esophageal lumen. B. Large thoracic
esophageal perforation with nasogastric tube inside lumen.
FIG 16 • Single layer repair of thoracic esophageal perforation over bougie with single interrupted sutures.
FIG 17 • Intercostal muscle flap fixed to site of thoracic esophageal perforation repair. The flap is fixed with
single interrupted sutures and covers the repair entirely.
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ABDOMINAL PERFORATION REPAIR AND DRAINAGE
Skin incision
A midline laparotomy is performed from the xiphoid process to the umbilicus.
Dissection
The gastrosplenic ligament is dissected off of the greater curvature of the stomach using an energy
vascular sealing device. The short gastric vessels are sealed and divided and the angle of His is
dissected. The left and right crus are identified and the esophagus is dissected free. A Penrose drain is
placed around the gastroesophageal junction for exposure.
Repair
The site of perforation needs to be identified and the steps for repair are the same as for cervical and
thoracic perforations. A Nissen fundoplication is then performed to cover the esophageal repair (see
Chapter 5). A fundoplication should not be performed in patients with history of achalasia. In such cases,
a patch of omentum can be fixed on the repair with absorbable sutures.
Drainage
The abdominal cavity is irrigated abundantly and JacksonPratt drains are placed around the area of
repair.
Closure
The rectus abdominis aponeurosis is closed with a running suture of PDS 1. The skin is then closed with
staples.
ESOPHAGECTOMY AND DIVERSION
In cases of severe sepsis, hemodynamic instability, a necrotic esophagus, and/or a very late
presentation, esophagectomy and diversion is a lifesaving procedure. Resection and diversion is always
a last option.
Skin Incision and Dissection
Esophagectomy can either be performed using a transthoracic approach (right thoracotomy; see
“Thoracic Perforation Repair and Drainage”) or using a transhiatal approach through a midline
laparotomy.
Resection
The gastroesophageal junction is stapled off and a draining gastrostomy and feeding jejunostomy are
performed. The entire esophagus is brought out through a left cervical incision (FIG 18A) and amputated
just proximal to the perforation. As much proximal esophagus as possible should be left in place in order
to aid in future restoration of GI continuity.
FIG 18 • A. Thoracoabdominal esophagus dissected and brought out through a left cervical incision. B. End
result of cervical esophagostomy with enterostomal appliance removed. Note that the conserved esophagus
extends below the clavicle, showing preservation of a maximum length of tissue above the site of
perforation.
Stoma Formation
The esophagus is then tunnelled under the skin of the left chest and brought out to the skin as an end
esophagostomy. The stoma is sewn to the skin using 3-0 Vicryl or 3-0 PDS interrupted sutures and an
enterostomal appliance is applied to the skin (FIG 18B). Three to 6 months after diversion, the GI
continuity is restored using either a gastric pull-up or a colon bypass. Primary esophagectomy and
anastomosis is rarely done in case of perforation.
Closure
Closure is performed as previously described in the thoracic and abdominal perforation repair and
drainage sections.
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ENDOSCOPIC APPROACHES
Endoscopic Repair/Clipping
In select cases of very early perforation in a clean esophagus and a very stable patient, an endoscopic
closure of the mucosal defect can be attempted. This is typically performed in cases of endoscopic
perforation where the perforation is immediately recognized and sent directly to a highly specialized
center.
The patient is placed under general anesthesia in the operating room and flexible endoscopy is
performed. The mucosal defect should be inspected for any signs of ischemia, necrosis, or infection (see
FIG 4).
Distal obstruction should be ruled out using endoscopy prior to attempting endoscopic repair.
If the patient is stable, the mucosal defect is small and the hole appears closable, a series of through-the-
scope endoscopic clips may be applied from distal to proximal in order to attempt complete closure (FIG
19A-C).
FIG 19 • A. Esophagogastroscopy showing esophageal perforation above the esophageal lumen. B. Single
clip applied to the distal end of the perforation. Note the persistence of proximal perforation. C. Complete
closure of perforation with application of two clips.
Endoscopic Stenting
Temporary endoluminal esophageal stenting is becoming more popular for the acute treatment of
esophageal perforation.2 The decision to use a stent in the esophagus for the treatment of esophageal
perforation is based on the clinical status of the patient, on preoperative imaging and on the location, and
the size and site of the perforation on intraoperative endoscopy.
As experience with stenting in esophageal perforation is increasing, the indications are expanding and a
stent can often be used in a very septic patient. If spillage can be controlled using a stent and
percutaneous (chest tubes, pigtail drains) and/or thoracoscopic/laparoscopic adjunctive procedures are
performed to allow for abscess drainage, one can often temporize a very sick patient quickly and save
the patient from the long-term morbidity of an esophageal resection and diversion procedure.
If a stenting approach is chosen, a percutaneous gastrojejunostomy is first placed to allow for gastric
drainage and
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postpyloric feeding. A guidewire is then passed into the stomach and the stent is placed under
endoscopic or fluoroscopic vision (FIG 20A). Fully covered metallic stents (FIG 20B) or silicone-polyester
(plastic) stents (FIG 20C) should be used in cases of benign esophageal perforation so that they can be
easily removed without causing esophageal damage. Stents are typically removed 4 to 8 weeks following
perforation. In case of benign esophageal perforation, esophageal stent migration is typical due to the
lack of stenosis or tumor. It is therefore important to use the largest diameter stent possible (typically 23
mm), a very long stent (to help with esophageal wall apposition and prevent migration), and to proximally
cover the whole by at least 6 to 7 cm if possible.
FIG 20 • A. Guidewire in the esophageal lumen. B. Metallic stent. C. Plastic stent.
CONSERVATIVE APPROACH
In cases of esophageal perforation in patients who are hemodynamically stable, the perforation is
discovered early (<24 hours) and there is objective evidence of a contained leak with a contrast study
demonstrating contrast extravasation without pooling in the mediastinum and draining back into the
esophagus, a conservative approach can be chosen.3
These patients should be kept strict NPO with a nasogastric tube in place (inserted endoscopically).
They should be placed on intravenous antibiotics, intravenous fluids, and intravenous proton pump
inhibitors. They should be closely monitored for fever, tachycardia, and leukocytosis.
If signs of sepsis develop, they should be taken to the operating room for endoscopic stenting or
esophageal repair/diversion. In cases of successful conservative treatment of esophageal perforation, a
Gastrografin swallow should be performed at 7 to 10 days following perforation to assess healing of the
perforation.
FIG 21 • Endoscopic view of a PEG-J.
Nutrition can be provided using either nasogastric/nasojejunal feeding or total parenteral nutrition.
Gastrostomy/Jejunostomy
Classically, esophageal repair in the neck, chest, or abdomen was performed in addition to a laparotomy
or laparoscopy in order to perform a gastrostomy (for gastric drainage) and a feeding jejunostomy (for
feeding). In cases where there is no peritoneal soilage, this can be accomplished in less than 5 minutes
prior to esophageal repair using a Percutaneous Endoscopic Gastrostomy with Jejunal feeding limb
(PEG-J) (FIG 21). A PEG-J performed prior to repair or diversion on the operating table at the time of
endoscopy saves the patient a laparotomy and greatly expedites the operation.
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PEARLS AND PITFALLS
History ▪ Symptoms of achalasia preclude the use of a Nissen fundoplication in abdominal

perforations.
▪ Obstructive symptoms should be addressed intraoperatively to avoid postoperative
downstream pressure buildup on the esophageal repair.
Presentation ▪ A high index of suspicion is required to diagnose esophageal perforations.

▪ Diagnostic delays over 24 hours are associated with increased mortality.
Preoperative ▪ Always perform on-table endoscopy under general anesthesia before making
evaluation definitive decisions regarding surgical, endoscopic, or conservative treatment.
Endoscopic ▪ Esophageal stenting can be applied in selected stable patients. It can also be used
treatment as a bail out in patients who are extremely ill, in combination with percutaneous or
video-assisted thoracic surgery (VATS) drainage, to temporize a septic patient.
Repair ▪ Suturing of the esophageal defect is mandatory in perforations of the abdominal and
lower two-thirds of the thoracic esophagus, whereas it is optional in more proximal
(cervical) perforations.
▪ Using flaps greatly reduces the risks of ongoing leaks postoperatively.
Drainage ▪ Adequate drainage of the surgical site prevents formation of abscesses and, in the
case of postrepair leak, allows for controlled leakage.
Underlying ▪ Primary repair of a perforated esophageal cancer is inappropriate.

esophageal
cancer
Postoperative ▪ Percutaneous Endoscopic Gastrostomy with Jejunal feeding limb (PEG-J) can make
nutrition the operative management of intrathoracic and cervical esophageal perforation
quicker, simpler, and less morbid.
Last resort ▪ Esophagectomy and diversion should be a last resort as the operation is extremely
morbid and many patients never go on to definitive reconstruction for restoration of GI
continuity.
POSTOPERATIVE CARE
Close monitoring of patients with esophageal perforation is mandatory and treating physicians should have a
high index of suspicion for leaks. Patients should be kept NPO for 7 days postoperatively with a nasogastric
tube or gastrostomy in place. Ins and outs should be monitored and the appearance of the liquid drained
noted. Patients should be kept on intravenous antibiotics and intravenous proton pump inhibitors until oral
contrast study 7 to 10 days postrepair.
On postoperative days 7 to 10, a water-soluble contrast study should be performed. The absence of leak
should be confirmed with a barium swallow before the nasogastric tube is removed and a liquid diet is begun.
Diet is then progressed as tolerated and drains are removed.
OUTCOMES
Outcome is dependent on multiple factors including the patient's hemodynamic status on presentation,
the patient's age, the site of perforation, delay to diagnosis more than 24 hours, and the presence of
underlying esophageal neoplasia.
Mortality varies from 2% to 27% and morbidity from 53% to 81%.4
COMPLICATIONS
Ongoing leak
Tracheoesophageal or esophageocutaneus fistula
Empyema
Intraabdominal, mediastinal, thoracic, or cervical abscess
Sepsis, septic shock
REFERENCES
1. Lang MH, Bruns DH, Schmitz B, et al. Esophageal perforation: principles of diagnosis and surgical
management. Surg Today. 2006;36:332-340.
2. Soreide JA, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24
hours. Scand J Trauma Resusc Emerg Med. 2011;19:66.
3. Bazerbashi S, Villaquiran J, Bennett M, et al. Stented esophageal transfixion injury. Ann Thorac Surg.
2008;86:1367-1369.
4. Eroglu A, Turkyilmaz A, Aydin Y, et al. Current management of esophageal perforation: 20 years
experience. Dis Esophagus. 2009;22:374-380.
Chapter 16
Vagotomy: Truncal and Highly Selective
Mary T. Hawn
George A. Sarosi Jr.
Ashley Augspurger Davis
DEFINITION
Truncal vagotomy is defined as the division of the anterior and posterior vagus nerves, which innervate
the stomach and remainder of the gastrointestinal (GI) tract, at the level of the distal esophagus.
Vagotomy eliminates cholinergic stimulation to gastric parietal cells and decreases parietal cell response
to gastrin and histamine, thereby reducing gastric acid secretion. By transecting at the entrance point into
the abdomen, all innervation to the liver, gallbladder, pancreas, and small intestine is also divided.
Truncal vagotomy requires a drainage procedure due to the disruption of antral and pyloric muscular
innervation.
For many years, vagotomy was one of the cornerstones of surgical treatment of ulcers. However, with
further understanding of the role of Helicobacter pylori in ulcer pathogenesis and advancement in
pharmacologic management including proton pump inhibitors (PPIs) and histamine blockers, the role of
surgery has changed. Of the classic indications for ulcer, surgery, bleeding, perforation, obstruction,
and intractability, vagotomy is only commonly used in those patients who require surgical control of
ulcer bleeding.
Level one evidence suggests that it is not necessary in the treatment of duodenal perforation in
patients who are H. pylori positive,1 and the number of patients requiring operation for gastric outlet
obstruction and intractability has declined dramatically with the advent of improved pharmacologic and
endoscopic therapy of peptic ulcer disease (PUD). The incidence of definitive acid reduction surgery
decreased by more than 50% from 1993 to 2006.2
Highly selective vagotomy (HSV) is defined as the division of the gastric branches of the nerves of
Latarjet. The nerves of Latarjet, celiac division of posterior vagus, and hepatic division of anterior vagus
are preserved. Therefore, cholinergic stimulation is selectively eliminated to reduce acid secretion by
parietal cells in the body and fundus, and the innervation of the antrum and pylorus, biliary tract, and
small and large intestines are untouched. A drainage procedure is not required with HSV. This is also
known as “parietal cell vagotomy” or “proximal gastric vagotomy.”
The operation was developed to avoid the need for a gastric drainage procedure, which is required
with truncal vagotomy, as up to one-third of patients will develop delayed gastric emptying following
this procedure. Despite the elegance of parietal cell vagotomy, it is a technically demanding operation
with a higher ulcer recurrence rate and much longer learning curve than truncal vagotomy. In an era
when few vagotomies are performed, it has largely fallen out of favor.3
Of historical note, a selective vagotomy sections the anterior vagus just distal to the point where the
branch to the gallbladder and liver and the posterior vagus just distal to the branch to the pancreas and
small intestines. Although in theory this might reduce the side effects of vagotomy, it is unclear in practice
that this had any effect on outcomes.
In a patient with acute severe upper GI bleeding, the differential diagnosis includes a bleeding peptic
ulcer, bleeding esophageal or gastric varices secondary to portal hypertension, esophageal mucosal
diseases such as severe esophagitis and Mallory-Weiss tears, gastric arteriovenous malformations and
Dieulafoy's lesion, and rarely, ulcerated tumors or hemobilia.
In a patient with acute abdominal pain and free air, the differential diagnosis should include a perforated
peptic ulcer, perforated diverticulitis, perforated appendicitis, and small bowel perforation.
In the patient with gastric outlet obstruction, the differential diagnosis includes PUD, gastric cancer,
duodenal web, functional delay in gastric emptying, and chronic ulcer disease related to nonsteroidal
antiinflammatory drug (NSAID) or aspirin use.

The majority of operations for PUD performed now are urgent or emergent operations for complicated ulcer
disease.
A thorough history and physical should be obtained with key focus on the duration of symptoms, previous
ulcer therapy, NSAID or aspirin use, and smoking history. Consider investigation into hypersecretory and
malignant etiologies in patients with refractory ulcer disease.
Patients should be specifically questioned regarding H. pylori status and prior H. pylori treatment including a
history of eradication. In patients unable to stop antiinflammatory drug use or those with H. pylori-negative
ulcer disease, it may be reasonable to consider performing an acid-reducing procedure at the time of ulcer
repair.
Bleeding can occur in 15% to 20% of patients with PUD and is the most common ulcer-related complication.4
The majority will resolve with conservative or endoscopic treatment. In patients undergoing operation for a
bleeding duodenal ulcer, the best available evidence suggests that vagotomy should be combined with
oversewing of a duodenal ulcer.5 As such, the patient's H. pylori status, history of prior NSAID use, or prior
ulcer disease will not affect the use of vagotomy in the management of their bleeding duodenal ulcer
Perforations occur in up to 10% of ulcer complications.4 Patients that will most likely to benefit from acid-
reducing surgical intervention during repair of a perforation include those that have contraindications to PPI,
perforation on PPI, or prior eradication of H. pylori .
Obstruction is the least common complication of ulcer disease at 5% to 8% and occurs as a result of scarring
of the pylorus.4 Endoscopy often delineates location and degree of the obstruction and also allows for
therapeutic balloon dilation of the pylorus. Surgery is reserved for failure of less invasive treatments.
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Intractable disease encompasses failure of medical management to heal the ulcer, relapse of disease while on
current therapy, or multiple courses of medical therapy. Medical management includes acid suppression, H.
pylori eradication, and NSAID cessation. Symptoms should be substantiated with endoscopic visualization of a
persistent or recurring ulcer.

In a patient with sudden onset acute abdominal pain and physical exam findings of peritonitis, an upright chest
radiograph confirming the finding of free intraperitoneal air is a sufficient workup prior to proceeding to the
operating room (OR) for a presumed perforated ulcer.
In patients with a history and physical consistent with a perforated ulcer, but without free air on radiograph, a
computed tomography (CT) scan or upper GI contrast study using water-soluble contrast can help to make the
diagnosis.
Testing for H. pylori is used to confirm presence of or gauge the eradication of disease. Antibody testing
assesses overall exposure but is not specific for active disease. Urease breath test and stool antigen test can
be used to confirm eradication. Full treatment of H. pylori should be attempted before definitive acid reduction
surgery is considered.
Stool antigen testing for H. pylori should be performed prior to operation for PUD, as knowledge of H. pylori
status may help determine the need for vagotomy. As mentioned earlier, it may not be necessary to perform
vagotomy for H. pylori positive disease, but may be considered in treatment of H. pylori-negative ulcer
disease.
Serum gastrin levels should be tested to rule out hypergastrinemic syndromes.
Endoscopy is part of standard investigation of ulcer disease when symptoms persist despite medical therapy.
Endoscopy is also used to assess ulcer healing and perform biopsies to evaluate malignancy, gastritis, and H.
pylori infection.
In patients with a bleeding peptic ulcer, the surgeon should be present at the time of upper endoscopy to gain
an accurate anatomic understanding of the location of the ulcer. Patients with gastric ulcers not caused by
acid, such as ulcers along the lesser curvature proximal to the incisura or near the gastroesophageal (GE)
junction, will not require a vagotomy. Patients with duodenal or prepyloric ulcer should undergo vagotomy at
the time of their operation for bleeding control.
SURGICAL MANAGEMENT
Patients undergoing emergency surgery for peptic ulcer bleeding will have a stomach full of blood and are at
significant risk of aspiration. A nasogastric tube should be placed prior to induction for all vagotomy
procedures, and rapid sequence induction should be used if possible.
When performing an emergency operation for bleeding, the surgeon should ensure that blood is cross-
matched and available.
For laparoscopic procedures, having the ability to perform intraoperative esophagogastroduodenoscopy
(EGD) can facilitate the identification of the ulcer in difficult cases.
With truncal vagotomy, the gastric antrum and pylorus are denervated and concomitant drainage procedure
must be performed.
Options include pyloroplasty, gastrojejunostomy, or gastric resection with reconstruction (see Chapter 17).
HSV preserves antral muscular function and the pylorus mechanism. It is not necessary to perform a drainage
procedure.
Transthoracic vagotomy requires double lumen intubation tube and separate lung ventilation; for sufficient
exposure to distal esophagus, the left lung must be collapsed.
Perioperative antibiotics should be administered; cefazolin is standard, clindamycin plus a fluoroquinolone or
aminoglycoside for penicillin allergy.
Positioning—Open
Open approach: Patient is supine with the arms tucked or extended.
Space is left on the patient's left side to attach a Bookwalter or Omni retractor to the bed rail.
Reverse Trendelenburg position of the table will help with exposure of the hiatus.
Positioning—Laparoscopic
Laparoscopic approach: Patient is supine with right arm tucked. Surgeon stands on patient's right and
assistant stands on patient's left.
Reverse Trendelenburg position of the table will help with exposure of the hiatus.
Positioning—Transthoracic
Patient is placed in right lateral decubitus position.
TECHNIQUES
TRUNCAL VAGOTOMY—OPEN
Skin Incision and Retractor Positioning
Use a standard upper midline incision, from just below xiphoid process to level of the umbilicus.
A body wall retractor blade is placed on eitherside of the upper half of the incision to facilitate exposure.
Depending on the size of the left lateral segment of the liver, it may be necessary to divide the avascular
portion of the left triangular ligament to allow the left lateral segment to be retracted in order to facilitate
visualization of the abdominal esophagus (FIG 1).
Exposure of the Esophagus
The pars flaccida and the phrenoesophageal ligament are divided to expose the right crus and anterior
esophageal wall. Take caution to recognize and preserve an accessory left hepatic artery when dividing
the pars flaccida. The position of the esophagus can be verified by palpation of the nasogastric tube
within the lumen of the esophagus.
Identify the right crus of the diaphragm; gently dissect to expose the anterior surface of the esophagus.
This peritoneal incision should be carried across the
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anterior surface of the esophagus and onto the left crus of the diaphragm to expose the anterior surface
of the esophagus (FIG 2A). By applying downward and rightward traction on the stomach, the surgeon
can place the esophagus on tension to enhance exposure (FIG 2B).
FIG 1 • A Bookwalter-style self-retaining retractor provides excellent exposure of the stomach and
duodenum for drainage procedures. Placement of four abdominal wall blades, two on either side of the
upper and lower aspect of the wound will provide the optimum exposure. A Harrington or malleable
retractor on the left lobe of the liver can facilitate exposure.
Continue to develop a plane between right crus and the esophagus; extend posteriorly to create a
retroesophageal window.
The esophagus is then dissected circumferentially and this, again, can be facilitated by palpating the
nasogastric tube in the lumen of the esophagus.
A Penrose drain is placed around the GE junction to assist with downward traction on the GE junction.
Identification and Division of the Anterior (Left) Vagus Nerve
The vagus nerves rotate counterclockwise at the level of the esophageal hiatus with the right vagus
nerve coursing more posterior and the left vagus nerve anterior with respect to the esophagus.
The left (anterior) vagus nerve is typically anterior and just right of midline at the 1 o'clock to 2 o'clock
position. It is often almost within the longitudinal muscle layer (FIG 3)
Downward traction of the GE junction via the Penrose drain can help tense the nerve like a guitar
string to help with palpation.
Dissect the nerve off the anterior surface of esophagus using a right angle with sharp dissection,
minimal cautery.
Any additional anterior vagus nerve should be dissected free of esophagus if present. In about 10% of
cases, two or rarely more anterior vagal branches may be found.6
A medium clip is then placed on the nerve(s) at the level of the diaphragm and a second clip is placed on
the nerve 3 to 4 cm distal to the first. The segment of nerve(s) between the clips is excised and sent for
pathology to verify nervous tissue was excised (FIG 4).
Identification and Division of the Posterior (Right) Vagus Nerve
The right (posterior) vagus is found at the 7 o'clock position and is often up to a centimeter away from the
esophageal wall between the esophagus and the right crus (FIG 5).
In about 15% of cases, it may be located to the left of midline.6

To identify the posterior vagus trunk(s), the surgeon should again apply downward traction on the
Penrose while sweeping the index finger of the right hand posterior to the esophagus from the left crus to
the right.
The surgeon's finger should be right on the esophageal wall and any tense bands identified should be
hooked with a right angle and dissected free from the esophageal wall (FIG 6).
A clip should be placed at the level of the diaphragm and a second clip is placed on the nerve 3 to 4 cm
distal. The segment of nerve(s) between the clips is excised and sent for pathology to verify nervous
tissue.
Continue with gastric drainage procedure as indicated: pyloroplasty, gastrojejunostomy, or gastric
resection with reconstruction (see Chapter 17).
Assessment of Hemostasis and Closure
After verifying that no additional vagal trunks can be identified, the surgeon should inspect the
diaphragmatic hiatus. During blunt mobilization of the GE junction, a hiatal hernia is sometimes created.
If the surgeon can insert more than the one finger adjacent to the esophagus through the hiatus, the
right and left crura should be reapproximated with one or two 0 braided polyester or silk sutures to
prevent the development of a postoperative hiatal hernia.
At the completion of the repair, a single finger should be able to be inserted alongside the esophagus
to avoid postoperative dysphagia.
After hemostasis is verified, the midline is closed in usual standard fashion.
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FIG 2 • A. Photo (left) and illustrations of the peritoneum of the pars flaccida is incised to expose the right
crus of the diaphragm and the esophagus. This peritoneal incision should be carried across the anterior
surface of the esophagus and onto the left crus of the diaphragm to expose the anterior surface of the
esophagus. B. Beginning on the left of the esophagus, blunt dissection with a finger or a Kittner dissector
will allow the surgeon to separate the esophagus from the left crus. With gentle blunt dissection, it is
possible to encircle the esophagus with the right index finger.
FIG 3 • As seen in this intraoperative photo, the anterior vagus trunk is a large band intimately associated
with the muscular wall of the esophagus and often located on the right anterior surface of the esophagus.
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FIG 4 • The anterior vagus trunk is carefully dissected from the anterior surface of the esophagus, and a
medium clip is then placed on the nerve(s) at the level of the diaphragm and a second clip is placed on the
nerve 3 to 4 cm distal to the first. The segment of nerve(s) between the clips is excised and sent for
pathology to verify nervous tissue was excised.
FIG 5 • As shown in this intraoperative photo, the posterior vagal trunk is less intimately associated with the
esophageal musculature.
FIG 6 • To identify the posterior vagus trunk(s), the surgeon should again apply downward traction on the
Penrose while sweeping the index finger posterior to the esophagus from the left crus to the right. The
surgeon's finger should be right on the esophageal wall and any tense bands identified should be hooked,
dissected free from the esophageal wall, and divided between clips.
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LAPAROSCOPIC TRUNCAL VAGOTOMY
Port Placement and Liver Retraction
Port placement (FIG 7)
5-mm periumbilical camera port 2 cm to the left of midline
5-mm subxyphoid trocar for liver retraction
5-mm right midclavicular line, two fingerbreadths below costal margin: left hand working port
5-mm trocar between the right midclavicular line and camera trocar
5-mm left anterior axillary line, below costal margin: stomach retraction
A Nathanson liver retractor is placed to elevate the left lobe of the liver.
The patient is positioned supine with the right arm tucked.
The surgeons stands to the patient's right and the assistant to the patient's left.
The peritoneum of the pars flaccida and the phrenoesophageal ligament is incised with a Harmonic
scalpel or bipolar cautery device to expose the right crus of the diaphragm onto the anterior surface of
the esophagus and across to the left crus to expose the entire surface of the esophagus.
The position of the esophagus can be verified by palpation of the nasogastric tube within the lumen of
the esophagus or by performing an intraoperative EGD.
The peritoneum overlying the medial edge of the right crus of the diaphragm is identified and incised, and
then, blunt dissection is used to elevate the esophagus off of the right and left crus to make a
retroesophageal window.
FIG 7 • Shows the standard port placement used for a laparoscopic vagotomy.
A grasper is then passed though the window and a Penrose drain is used to encircle the esophagus.
With the magnification inherent in laparoscopy, the anterior vagus can often be visualized directly on the
anterior surface of the esophagus (FIG 3).
If the nerve cannot be easily visualized, downward traction on the GE junction obtained by having the
assistant pull down on the Penrose will make the nerve tense like a guitar string and will allow for
either visual or tactile identification of the anterior vagus.
Using a Maryland dissector, the surgeon should carefully dissect the anterior vagus away from the
esophageal muscle and elevate the nerve.
Using sharp dissection with the Harmonic scalpel or bipolar cautery device, the surgeon should free up
the vagus to the diaphragmatic hiatus.
An endoclip should be placed across the nerve at the hiatus and a second clip placed 3 to 4 cm inferior to
the first. The portion of the nerve between the clips is then excised and sent to pathology.
A search for additional anterior trunks should be conducted as discussed previously.
The posterior vagus is less closely associated with the esophageal wall.
To identify the posterior vagus trunk(s), the assistant should apply caudal and leftward traction on the
Penrose drain with a grasper inserted through the left upper quadrant port.
The posterior vagus should become visible at this point as a tight band traversing between the
posterior wall of the esophagus and the right crus of the diaphragm (FIG 5).
Many times, the posterior vagal trunk will be encircled within the Penrose drain, and the Penrose will
need to be repositioned to allow the dissection of the nerve trunk away from the esophagus.
Using sharp dissection with the Harmonic scalpel or bipolar cautery device, the surgeon should free up
the vagus to the level of the diaphragmatic hiatus
An endoclip should be placed atthe level of the diaphragm and a second clip is placed on the nerve 3 to 4
cm distal. The segment of nerve(s) between the clips is excised and sent for pathology to verify nervous
tissue was excised.
Again, verify no additional vagal trunks
Inspect the diaphragmatic hiatus as described earlier and reapproximate if necessary.
Remove laparoscopic ports under direct vision to ensure hemostasis.
Close skin in the usual standard fashion, with fascial closure for port sites greater than 5 mm.
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TRANSTHORACIC VAGOTOMY
Port Placement
10-mm camera port in 7th or 8th intercostal space, posterior axillary line
10-mm instrument trocar along anterior axillary line at 6th and 10th intercostal space, forming a semicircle
with the camera port
5 mm can be placed in 10th or 11th intercostal space along posterior axillary line if needed (FIG 8).
The left lung will need to be collapsed to visualize the distal esophagus.
Transect the pulmonary ligament with scissors or electrocautery and retract the collapsed lung superiorly
(FIG 9).
Incise the mediastinal pleura to expose the esophagus.
With the magnification in laparoscopy, the anterior vagus can often be visualized directly on the anterior
surface of the esophagus.
Using a Maryland dissector, the surgeon should carefully dissect the anterior vagus away from the
esophageal muscle and elevate the nerve, placing tension by pulling toward the surgeon.
FIG 8 • Positioning and port placement for the transthoracic vagotomy. Patient is in the right lateral
decubitus. Note hand ports are as far away as possible from each other but forming semicircle with video
port.
FIG 9 • To expose the distal esophagus, transect the pulmonary ligament and retract the collapsed left
lung superiorly.
Using sharp dissection with the Harmonic scalpel or bipolar cautery device, the surgeon should free up 3
to 4 cm of the vagus nerve (FIG 10).
The posterior vagus is less closely associated with the esophageal wall.
FIG 10 • Anterior vagus is identified on top of the esophagus. It is carefully dissected by spreading
parallel to esophagus and then placed on tension by pulling toward the surgeon. A segment is then
clipped for removal and sent to pathology.
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Place gentle upward traction on the esophagus. Using a Maryland dissector, continue to spread parallel
to the nerve and esophagus in the retroesophageal plane.
Pull vagus again toward the surgeon to tense nerve like a guitar string in order to transect the nerve.
Using sharp dissection with the Harmonic scalpel or bipolar cautery device, the surgeon should free up 3
to 4 cm of the vagus nerve (FIG 11).
FIG 11 • Gentle traction placed on esophagus to pull anterior in the chest. The posterior vagus nerve is
dissected from the tissue below the esophagus. This is again pulled toward surgeon to aid in excision.

After hemostasis is ensured, a red rubber should then be inserted through on the camera ports and fed
proximally over the lung tissue to act as a chest tube.
The camera port is then withdrawn and lung reinflated under direct visualization.
Closure of laparoscopic port sites in usual standard fashion.
HIGHLY SELECTIVE VAGOTOMY
Exposure of Esophagus
The phrenoesophageal ligament overlying the esophagus is incised and the esophagus is encircled with
a Penrose drain.
Exposure of Vagus Nerves, Nerve of Latarjet
The anterior and posterior vagus nerves are identified and each encircled with a vessel loop. Dissection
is carried far enough into the posterior mediastinum to identify main vagal trunks.
Examine the lesser curvature of the stomach to identify the nerve of Latarjet (FIG 12).
Dissect 6 to 7 cm proximal to the pylorus along the lesser curvature of the stomach at the incisura
angularis. It is key to leave the terminal branches of the nerve, referred to as “crow's foot,” to maintain
innervation to the antrum and pylorus (FIG 13).
FIG 12 • Identify the lesser curve of the stomach; see the anterior vagus nerve coursing in on the lesser
omentum.
Divide the lesser omentum from the lesser curve from the incisura angularis and continue to divide the
vagal branches to 6 cm proximal to the GE junction. Stay inside the main vagal braches.
Clamp and divide neurovascular branches along the lesser curve as close to the stomach as possible
to avoid injury to the nerve of Latarjet (FIG 14).
There is an anterior and posterior bundle and they should be divided separately.
Invert the lesser curvature of the stomach with interrupted Lembert sutures.
Hemostasis and Closure
Midline is closed in usual standard fashion.
Laparoscopic ports close in usual standard fashion, with fascial closure for port sites greater than 5 mm.
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FIG 13 • A,B. Dissection occurs along the lesser curvature of the stomach from proximal to the GE junction
to the incisura angularis, 6 to 7 cm proximal to the pylorus. Leave the terminal branches of the nerve,
referred to as “crow's foot,” to maintain innervation to the antrum and pylorus.
FIG 14 • Clamp and divide neurovascular branches along the lesser curve as close to the stomach as
possible to avoid injury to the nerve of Latarjet. Marked by the X. There is an anterior and posterior bundle
and they should be divided separately.
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PEARLS AND PITFALLS
Indications ▪ In patients with evidence of active H.

pylori infection, treatment of the ulcer
complication and antihelicobacter
therapy may be sufficient.
▪ When the operative indication is GI
bleeding, the surgeon should verify if
the bleeding source is in a location
associated with a high acid state such
as the duodenum or prepyloric
stomach.
Exposure ▪ Take caution when encircling the

esophagus and dissecting the vagus
off of the esophagus to prevent injury.
▪ Avoid the use of cautery when
dissecting the vagal fibers away from
the esophageal surface.
Vagotomy ▪ Ten percent of patients will have

more than one anterior or posterior
vagal trunks; care must be taken to
look for additional fibers after division
of the first trunk.
▪ Always send a section of the excised
vagal trunk to pathology to verify that
nervous tissue was excised.
▪ Most ulcer reoccurrences result from
incomplete vagotomy.
▪ Care to resect above the criminal
nerve of Grassi (FIG 15)
▪ Injury to thoracic duct in
transthoracic approach
FIG 15 • Criminal nerve of Grassi—

Vagus nerve must be dissected
proximal to criminal nerve of Grassi
which, if undivided, can keep high
acid levels postvagotomy.
Drainage procedure ▪ A drainage procedure, a
pyloroplasty, gastrojejunostomy, or
antrectomy should always be
combined with a truncal vagotomy as
up to one-third of patients will develop
gastric stasis after vagotomy alone.
Paraesophageal herniation ▪ Inspect the esophageal hiatus at the

conclusion of the procedure to verify
that an iatrogenic paraesophageal
hernia has not been created.
POSTOPERATIVE CARE
Nasogastric suction may be used in the early postoperative period. In patient who has undergone gastric
drainage procedure or perforation repair, postoperative ileus may last as long as 7 to 10 days.
Consistent with other foregut surgery, diet advancement is as tolerated.
Intolerance to diet should prompt investigation for delayed gastric emptying.
In patients operated on for perforated ulcers, broad-spectrum antibiotic therapy including antifungal agents
should be administered postoperatively.
Patients who are found to be H. pylori positive should receive 10 to 14 days of antibiotic therapy directed at H.
pylori eradication. Eradication should be confirmed by repeat testing.
Patients operated on for bleeding should be carefully monitored for rebleeding for up to 96 hours.
Patients chronically using NSAIDS or aspirin products should be counseled to avoid further use of these
medications. Patients who are medically unable to discontinue these drugs should be started on a PPI.
Transthoracic patients should be monitored with daily chest radiographs until the chest tube is removed
appropriately.
OUTCOMES
Vagotomy
Truncal vagotomy has demonstrated 80% reduction in basal acid secretion.7

Truncal vagotomy has the lowest reoccurrence rates (1% to 10%) but have the highest morbidity (20%
to 25%) and mortality (0.5% to 2%).8,9 Ulcer recurrence rates also vary based on drainage procedure,
with best results from total vagotomy with antrectomy.
Common postoperative morbidity includes diarrhea (10% to 25%), dumping syndrome (10% to 20%),
and bile reflux gastritis (2%).8,9
Vagal-mediated receptive relaxation of the stomach is abolished; there may be more rapid emptying of
liquids and solids.
HSV
Lower mortality and morbidity including diarrhea and dumping syndrome (1% to 5%).3
Higher ulcer recurrence rates, greater than 10% at 5 years.3
Vagal-mediated receptive relaxation of the stomach is abolished, and therefore, there is more rapid
emptying of liquids. However, with preservation of antrum innervation, emptying of solids is unaffected.
COMPLICATIONS
Esophageal perforation
Bleeding
Incomplete vagotomy—failure to identify accessory vagus nerves. Vagus must be taken proximal to the
criminal nerve of Grassi, the first gastric branch of the posterior vagus.
Dumping syndrome
Pleural effusion
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REFERENCES
1. Ng EK, Lam YH, Sung JJ, et al. Eradication of Helicobacter pylori prevents recurrence of ulcer after
simple closure of duodenal ulcer perforation: randomized controlled trial. Ann Surg. 2000;231(2): 153-158.
2. Wang YR, Richter JE, Dempsey DT. Trends and outcomes of hospitalizations for peptic ulcer disease in
the United States, 1993 to 2006. Ann Surg. 2010;251(1):51.
3. Lagoo J, Pappas TN, Perez A. A relic or still relevant: the narrowing role for vagotomy in the treatment of
peptic ulcer disease. Am J Surg. 2014;207(1):120-126.
4. Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Phys. 2007;76:1005-1012.
5. Schroder VT, Pappas TN, Vaslef SN, et al. Vagotomy/drainage is superior to local oversew in patients who
require emergency surgery for bleeding peptic ulcers [published online ahead of print December 23, 2013].
Ann Surg.
6. Skandalakis JE, Rowe JS Jr, Gray SW, et al. Identification of vagal structures at the esophageal hiatus.
Surgery. 1974;75(2):233-237.
7. Ashley SW, Evoy D, Daly JM. Stomach. In: Schwartz SI, ed. Principles of Surgery. 7th ed. New York, NY:
McGraw-Hill; 1999:1181.
8. Yeo CJ, McFadden DW, Pemberton JH, et al. Shackelford's Surgery of the Alimentary Tract. 7th ed.
Philadelphia, PA: Elsevier Health Sciences; 2012:720-730.
9. Lee CJ, Simeone DM. Gastric ulcer. In: General Surgery: Principles and International Practice. 2nd ed.
London, United Kingdom: Springer; 2009:539-548.
Chapter 17
Drainage Procedures: Pyloromyotomy, Pyloroplasty,
Gastrojejunostomy
George A. Sarosi Jr.
DEFINITION
Drainage procedures, or more properly gastric drainage procedures, are a variety of surgical approaches
used to either render incompetent or bypass the pylorus. Drainage procedures are often performed in
conjunction with procedures that interrupt vagal innervation of the pylorus, and the purpose is to facilitate
gastric drainage. Originally performed in conjunction with a truncal vagotomy for the treatment of peptic
ulcer disease, drainage procedures are also performed to facilitate gastric emptying when the stomach is
used as an esophageal replacement and occasionally to address poor gastric emptying in patients who
have undergone fundoplication or paraesophageal hernia repair. Gastrojejunostomy is also frequently
used to treat duodenal or gastric outlet obstruction.
In patients who have undergone prior gastroesophageal (GE) junction surgery, the differential diagnosis
for abdominal bloating includes visceral hypersensitivity (irritable bowel syndrome [IBS]), gastroparesis,
postsurgical delayed gastric emptying secondary to vagal injury, paraesophageal herniation of the
fundoplication or portions of the stomach, and overeating or excess consumption of inappropriate foods
such as carbonated beverages.
In patients who have undergone esophageal replacement with a gastric conduit, the differential diagnosis
of dysphagia, early satiety, or regurgitation of undigested foods includes anastomotic structure, an
inadequate-sized hiatal opening, torsion of the conduit, paraesophageal hernia, and competent pylorus.

Depending on the indication for a drainage procedure, certain historical elements and physical findings should
be sought.
For patients with peptic ulcer disease, the duration of symptoms and any prior treatment of peptic ulcer
disease should be sought. In addition, knowledge of the patients’ Helicobacter pylori status and prior H.
pylori treatment is important. Finally, a history of use of nonsteroidal antiinflammatory drugs (NSAIDs) or
aspirin products should be sought.
In patients with a prior history of peptic ulcer disease who are undergoing surgical treatment of a bleeding
ulcer, a history of prior ulcer disease should alert the surgeon to the possibility of encountering a scarred
and possibly fibrotic duodenum.
Patients known to be H. pylori positive who have not had treatment for their H. pylori may not require an
acid-reducing procedure at the time of surgical bleeding control. Simple ligation of the bleeding site may
be sufficient.
Patients with a significant history of NSAID or aspirin product use are at a significant risk of recurrent
ulcers and must be counseled to avoid all these products in the future.
For patients undergoing drainage procedures after esophageal replacement with a gastric conduit, patients
should be questioned carefully about their symptoms. Patients with poor gastric drainage will describe early
satiety, bloating, regurgitation, or emesis of undigested food. Patients with anastomotic strictures typically
will describe dysphagia.
For patients undergoing or who have undergone a fundoplication, a history of postprandial abdominal pain,
bloating, or early satiety should be sought, as this can be a symptom of poor gastric emptying, which can be
confirmed with a gastric emptying study.

In patients undergoing emergency operations for upper gastrointestinal hemorrhage, all patients should
undergo esophagogastroduodenoscopy (EGD) prior to operation with an attempt at endoscopic hemostasis.
The operating surgeon should make every effort to be present during the endoscopy, as accurate anatomic
information regarding the location of the ulcer will facilitate the operation.
In patients suspected of having poor emptying of their gastric conduit after esophageal replacement, gastric
emptying studies are of limited use due to the altered anatomy and the lack of reference values for emptying.
The author has used EGD and botulinum toxin injection as a diagnostic test for patients with poor emptying of
the conduit.1 Those who have an improvement in symptoms have been offered surgical drainage procedures.
In patients with prior fundoplication or paraesophageal hernia repair suspected of having delayed gastric
emptying, nuclear medicine gastric emptying studies are helpful in identifying patients who could benefit from a
drainage procedure. Hamrick et al.,2 in a large series of revisional paraesophageal hernia patients, used a
T1/2 emptying time of 90 minutes as an indication for the addition of a gastric drainage procedure with good
results. Alternatively, EGD and botulinum toxin injection of the pylorus can also be used as a diagnostic study.
SURGICAL MANAGEMENT
Patients undergoing drainage procedures will have poor gastric emptying and will be at risk for aspiration
during induction of anesthesia. For elective procedures, patients should be placed on a clear liquid diet 24
hours prior to surgery and made NPO the night before the procedure. Patients undergoing emergency surgery
for peptic ulcer bleeding will have
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a stomach full of blood and are at significant risk of aspiration. Whenever feasible, rapid sequence induction
should be used. Antibiotic prophylaxis with 1 to 2 g of cefazolin is the standard approach; clindamycin plus a
fluoroquinolone or aminoglycoside is the appropriate choice for those patients with allergies to cefazolin.
When performing an emergency operation for bleeding, the surgeon should ensure that blood is crossmatched
and available. For laparoscopic procedures, having the ability to perform intraoperative EGD can facilitate the
identification of the pylorus and bleeding source in difficult cases.
Positioning
For open drainage procedures, the patient is positioned in the supine position with both arms extended. Space
is left on the patient's left side to attach a Buchwalter or Omni retractor to the bed rail. During the surgical
procedure, the patient will often be placed in reverse Trendelenburg to facilitate exposure of the upper
abdominal organs. In a laparoscopic approach, the same position is used, but a footboard and safety strap
should also be added to prevent the patient from sliding when steep reverse Trendelenburg position is used.
TECHNIQUES
OPEN PYLOROPLASTY
An upper midline incision is used for all open drainage procedures. This should begin at the level of the
umbilicus and extend to just below the xiphoid process. Body wall retractor blades are placed on either
side of the upper half of the incision to facilitate exposure. If necessary, a malleable or Harrington
retractor blade can be placed on the left lobe of the liver to expose the pylorus (FIG 1).
Kocher Maneuver
A Kocher maneuver is performed to facilitate exposure of the duodenum and pylorus and to eliminate
tension on the suture line. A forceps is used to grasp the peritoneum lateral to the duodenum, which is
then incised with scissors or the electrosurgical device. The surgeon then can insert an index finger
behind the duodenum and head of the pancreas and sweep the finger to the right, elevating the lateral
duodenal ligament and avascular retroperitoneal tissues, which can then be divided with the
electrosurgical device (FIG 2). The plane of dissection should remain close to the duodenal wall to avoid
injury to the gonadal vein on the anterior surface of the inferior vena cava. The duodenum and head of
the pancreas should be mobilized from the junction of the duodenal bulb and second portion of the
duodenum to just before the lateral aspect of the superior mesenteric vein. If the procedure is being
performed for a bleeding duodenal ulcer, the Kocher maneuver step can be deferred until after control of
the bleeding vessel has been achieved.
FIG 1 • A Bookwalter style self-retaining retractor provides excellent exposure of the stomach and
duodenum for drainage procedures. Placement of four abdominal wall blades, two on either side of the
upper and lower aspect of the wound, will provide the optimum exposure. A Harrington or malleable
retractor on the left lobe of the liver can facilitate exposure.
Pyloric Incision
The pylorus is identified either visually or by palpation of the muscular ring with a finger inserted from the
gastric side. Beginning roughly 2 cm proximal to the pylorus on the gastric antrum, incise the gastric wall,
enter the lumen, and extend the incision distally parallel to the long axis of the bowel across the pylorus
onto the duodenum to distance of roughly 5 cm using the electrosurgical device (FIG 3). This incision will
provide reasonable exposure of the duodenal bulb. If the operation is being performed for ulcer bleeding,
the incision can be extended further along the duodenum to expose the bleeding site. The pyloroplasty
incision can be facilitated by placing a seromuscular stay stitch on the superior and inferior edge of the
pylorus.
Bleeding Control
If the operation is being performed for a bleeding duodenal ulcer, the ulcer is identified on the posterior
aspect of the duodenal bulb. Temporary hemostasis is achieved by digital pressure, and then definitive
hemostasis is achieved by placing three 2-0 silk suture ligatures. The first suture is placed at the cranial
margin of the ulcer, encircling the proximal gastroduodenal artery (GDA). The second suture is placed at
the caudal edge of the duodenal ulcer encircling the distal GDA. The final suture is a U suture placed
underneath the ulcer crater to control the posterior entry of the transverse pancreatic artery into the back
wall of the GDA (FIG 4).
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FIG 2 • Application of leftward traction on the stomach and duodenum will allow the surgeon to score the
peritoneum lateral to the duodenum with the electrosurgical device as shown in the inset. The surgeon's
index finger can then bluntly elevate the avascular tissues between the duodenum, pancreas, and vena
cava, making division of these tissues with the electrosurgical device easy.
FIG 3 • Placing silk stay sutures superior and inferior to the proposed pyloroplasty incision will make the
entry into the duodenum easier. (From Nussbaum MS. Master Techniques in Surgery: Gastric Surgery.
Philadelphia, PA: Lippincott Williams & Wilkins; 2013.)
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FIG 4 • When operating to ulcer bleeding, placing the pyloroplasty incision directly over the ulcer crater will
optimize exposure. Control of bleeding from the GDA is achieved with three sutures. A simple or figure-of-
eight suture is placed at the cranial and caudal edge of the ulcer to ligate the trunk of the GDA. A third
horizontal U stitch is placed under the ulcer crater to control the transverse pancreatic branches. GDA,
gastroduodenal artery. (From Nussbaum MS. Master Techniques in Surgery: Gastric Surgery. Philadelphia,
PA: Lippincott Williams & Wilkins; 2013.)
Closure of Pyloroplasty—Heineke-Mikulicz
The most common closure of the pyloroplasty is the Heineke-Mikulicz approach, closing the longitudinal
pyloroplasty with a single layer of sutures in a transverse fashion. This closure is appropriate when the
duodenum is not distorted or scarred and the pyloroplasty incision is shorter than 6 to 7 cm. The closure
is performed by applying superior and inferior traction on the stay sutures, converting the longitudinal
gastroduodenal incision into a transverse incision. The incision is then closed with interrupted 3-0 silk
sutures or 3-0 polyglycolic acid sutures with either a full-thickness simple stitch or a Gambee stitch. The
closure is best performed by starting at the top corner of the incision and alternating from the top to the
bottom proceeding toward the middle. The sutures may be tied as they are placed until the last three
sutures, which should be left untied until all of the sutures are placed to ensure that the mucosal layer is
included in all of the bites (FIG 5). A vascularized pedicle of omentum is then placed over the closure and
the stay sutures tied over the omental pedicle to hold it in place in the fashion of a Graham patch.
Closure of Pyloroplasty—Finney
If the duodenum is significantly inflamed or scarred from chronic peptic ulceration or if a longer
duodenotomy is required to obtain hemostasis on a bleeding source beyond the duodenal bulb, a Finney
closure of the pylorus is appropriate to prevent tension on the closure and gastric outlet obstruction. The
Finney closure is in essence a side-to-side gastroduodenostomy with the pylorus at the cranial apex of
the anastomosis. The duodenum will need to be completely mobilized to allow
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this closure to be tension free. Remove the inferior stay suture and apply cranial tension on the superior
stay suture to convert the longitudinal incision into an inverted U shape. The Finney closure is a standard
two-layered anastomosis. A back row of interrupted 3-0 silk seromuscular (Lembert) sutures is placed
between the inferior edge of the duodenum and the gastric wall (FIG 6A). These sutures should be
placed 5 to 10 mm from the cut edge of the mucosa. It is often necessary to extend the incision on the
gastric side of the pylorus to ensure that the lengths of the two arms of the incision are equal. When
extending the pyloroplasty in this fashion, it is advisable to cheat toward the greater curvature of the
stomach. Next, begin the inner layer of the closure using a 3-0 polyglycolic acid running suture beginning
at the divided pylorus muscle, suturing the inferior edge of the duodenum to the inferior edge of the
stomach (FIG 6B). Run this suture around the inferior edge of the closure onto the anterior edge of the
gastroduodenal anastomosis. Next, begin a second running 3-0 polyglycolic acid at the superior edge of
the cut pylorus, suturing the superior edge of the duodenum to the stomach and running toward the other
suture (FIG 7A). Many surgeons prefer to use a Connell suture on the anterior wall to achieve better
mucosal inversion. Tie the two sutures and then complete the pyloroplasty closure with an anterior layer
of interrupted 3-0 silk seromuscular sutures (FIG 7B).
FIG 5 • With traction applied to the stay sutures, the longitudinal pyloroplasty is closed transversely using
interrupted sutures alternating from either end of the closure. The inset shows the completed closure.
FIG 6 • A. With superior traction on the superior stay suture, the back row of the Finney pyloroplasty is
created by approximating the duodenum to the greater curvature of the stomach with seromuscular sutures.
B. The back portion of the inner row is begun using a running suture approximating the duodenal mucosa to
the gastric mucosa beginning at the inferior edge of the transected pylorus. This suture is then run up to the
anterior surface of the pyloroplasty.
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FIG 7 • In panel (A), after the inner mucosal suture is run to the middle of the anterior surface of the closure,
a second inner running suture is begun at the superior cut edge of the pylorus, approximating the duodenal
and gastric mucosa. This suture is run to the posterior suture and they are tied together, completing the
inner row of sutures. In panel (B), the pyloroplasty is completed with a second layer of seromuscular
sutures. (From Nussbaum MS. Master Techniques in Surgery: Gastric Surgery. Philadelphia, PA: Lippincott
Williams & Wilkins; 2013.)
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OPEN PYLOROMYOTOMY
Incision and Identification of the Pylorus
An upper midline incision and fixed retractor is used as described previously for pyloroplasty (FIG 1). The
pylorus is identified either visually or by palpation of the muscular ring with a finger inserted from the
gastric side.
Serosal Incision and Division of Muscular Fibers
A 3-cm long longitudinal serosal incision is made across the pylorus, beginning 1 to 2 cm proximal to the
pylorus on the gastric side and extending 1 cm distal to the pylorus. This serosal incision can be
performed either with a knife or an electrosurgical device (FIG 8A). If the electrosurgical device is used,
care should be exercised to avoid deep penetration into the muscularis and thermal injury to the mucosa.
Beginning on the gastric side of the incision, use a fine tipped hemostat to dissect the muscular fibers off
of the submucosa and divide the circular muscular fibers with a knife (FIG 8B). Muscular bleeders can
usually be controlled with pressure, and there is a very limited role for cautery at this point of the
operation. Great care should be taken to avoid mucosal injury especially on the duodenal side, as the
submucosa is thinner and more fragile. When properly performed, the mucosa and submucosa will bulge
out of the incision (FIG 8C).
FIG 8 • In panel (A), the surgeon scores the serosa with a scalpel blade exposing the muscular layer. In
panel (B), a hemostat is used to spread the longitudinal muscle fibers and dissect the circular fibers away
from the mucosa for division with a scalpel. When the myotomy is completed, the mucosa will bulge as
shown in panel (C). (continued)
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FIG 8 • (continued) An omental patch is then sewn to the serosal edges of the myotomy to cover the
mucosa in as shown in panel (D).
Omental Patch
A vascularized pedicle of omentum is placed over the pyloromyotomy and sutured with three 3-0 silk
sutures. The first is placed through the superior edge of the divided pyloric ring and the superior edge of
the omental pedicle to prevent the two cut edges of the pylorus from coming into contact. The next two
are placed between each lateral edge of the serosal incision and the lateral edges of the omental patch
to ensure that the patch covers the entire pyloromyotomy (FIG 8D).
OPEN GASTROJEJUNOSTOMY
An upper midline incision is used for all open drainage procedures. This should begin at the level of the
umbilicus and extend to just below the xiphoid process. Body wall retractor blades are placed on either
side of the upper half of the incision to facilitate exposure (FIG 1). If necessary, a malleable or Harrington
retractor blade can be placed on the left lobe of the liver to expose the stomach and pyloric region.
Preparation of the Stomach and Identification of Proximal Jejunum
There is insufficient evidence to recommend a posterior gastrojejunostomy over an anterior
gastrojejunostomy, and an antecolic, anterior gastric wall gastrojejunostomy is the easiest to create.
Identify the pylorus, and then identify a point, 5 cm proximal to the pylorus, as the gastric site of the
anastomosis. Next, identify the ligament of Treitz, and select a section of the jejunum 15 to 30 cm distal to
the ligament of Treitz, which will easily reach the distal stomach without tension.
Construction of the Anastomosis
A standard double-layered side-to-side anastomosis is constructed by aligning the small bowel with the
stomach in an isoperistaltic fashion, with the distal portion of the small bowel located closest to the
pylorus. The back row of the anastomosis is first created by suturing the jejunum to the greater curvature
of the stomach using seromuscular 3-0 silk interrupted sutures. The tails of the sutures at either corner
are left long to allow them to be used as stay sutures (FIG 9A). Using the electrosurgical device, a full-
thickness jejunotomy is made in the small bowel, and a gastrotomy is made in the stomach roughly 5 mm
from the outer layer of the anastomosis (FIG 9B). Beginning in the middle of the posterior portion of the
anastomosis, the inner layer of the anastomosis is constructed by running two 3-0 polyglycolic acid
sutures from the middle of the back row in opposite directions (FIG 10A). Many surgeons prefer to use
Connell sutures on the anterior row to achieve better eversion, but this step is not necessary (FIG 10B).
The anastomosis is completed with an outer anterior layer of seromuscular 3-0 silk interrupted sutures.
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FIG 9 • An antecolic, isoperistaltic gastrojejunostomy is begun by placing a back row of seromuscular

sutures between the greater curvature of the stomach and the antimesenteric edge of the jejunum over a
distance of 8 cm and shown in panel (A). The stomach and the jejunum are then opened with the
electrosurgical device in panel (B).
FIG 10 • A double-armed suture is placed in the center of the back row of the anastomosis and run to the
corners of each side as shown in panel (A). This same suture is then run to the middle of the anterior row
as shown in panel (B). The anterior row can either be Connell sutures or simple sutures based on surgeon
preference.
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LAPAROSCOPIC PYLOROPLASTY
Port Placement and Liver Retraction
We use a standard four-trocar approach for gastric procedures, with a 5-mm port in the left upper
quadrant, a second 5-mm trocar just to the left of the umbilicus, a 12-mm trocar at the level of the
umbilicus in the midclavicular line, and a 5-mm trocar in the right upper quadrant. A Nathanson liver
retractor is placed to elevate the left lobe of the liver (FIG 11).
Identification of the Pylorus and Pyloric Incision
The pylorus is identified either visually or by performing an EGD with CO2 insufflation. Placing a 3-0 silk
seromuscular stay suture at the superior and inferior edge of the duodenum at the level of the pylorus will
facilitate the rest of the operation. Beginning roughly 2 cm proximal to the pylorus on the gastric antrum,
incise the gastric wall, enter the lumen, and extend the incision distally parallel to the long axis of the
bowel across the pylorus onto the duodenum to a total distance of roughly 5 cm using the electrosurgical
device or an ultrasonic dissector (FIG 12).
Closure of the Pyloroplasty
The assistant grasps the superior stay suture and applies cranial and leftward traction to convert the
longitudinal incision into a transversely oriented closure. The surgeon then begins at the superior aspect
of the duodenum and begins the closure. The easiest method is a running closure with 3-0 or 2-0 silk or
polyglycolic suture. The surgeon should run this suture toward the inferior aspect of the duodenum
stopping about two-thirds of the way down. A laparoscopic clip is placed on the suture to maintain tension
while the surgeon focuses on the lower aspect of the closure. A second suture is then run
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from the inferior edge of the pyloroplasty to the middle and tied to the upper suture after first removing the
clip from the suture. The assistant can facilitate the suturing angles by retracting the inferior stay suture
caudal and rightward. An alternative approach is to perform an interrupted closure. This allows for more
precise suture placement but requires more intracorporeal knot tying (FIG 13). With an interrupted
closure, alternating sutures from the either end and tying after placing each suture allows for precise
suture placement. The last suture will be placed blindly, but if the assistant applies cranial traction on the
tail of the suture just superior to the last one, it reduces the likelihood of back-walling the duodenum.
Methylene blue can be placed into the distal stomach via the EGD scope to ensure the pyloroplasty
closure is water tight.
FIG 11 • Shown is the standard port placement used for all laparoscopic drainage procedures. The surgeon
stands on the patient's right. The first port placed is the left upper quadrant 5-mm port, which will be the
assistant's instrument. The left periumbilical port is for the camera, and right 12-mm port is for the surgeon's
dominant hand instrument. The lateral right port is for the surgeon's nondominant hand. A Nathanson liver
retractor is placed in the subxiphoid position to retract the left lobe of the liver. (From Nussbaum MS. Master
Techniques in Surgery: Gastric Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.)
FIG 12 • Two stay sutures are placed above and below the proposed pyloroplasty incision. The surgeon
retracts the superior suture with their nondominant hand, and the assistant retracts the inferior suture from
the far left port. A hooked cautery is then used to incise the pylorus beginning from the gastric side.
FIG 13 • Although the assistant provides cranial traction on the superior stay suture to convert the
longitudinal pyloroplasty incision into a transversely oriented incision, the surgeon closes the pyloroplasty
with either interrupted or running sutures.
Omental Patch
The author then covers the completed pyloroplasty suture line with a vascularized pedicle of omentum,
which is secured in place by tying the superior and inferior stay sutures over the pedicle in the fashion of
a Graham patch. This is easier to perform and less likely to narrow the pyloric outlet than a second layer
of seromuscular sutures.
LAPAROSCOPIC GASTROJEJUNOSTOMY
Port Placement
We use a standard four-trocar approach for most gastric procedures, with a 5-mm port in the left upper
quadrant, a second 5-mm trocar just to the left of the umbilicus, a 12-mm trocar at the level of the
umbilicus in the midclavicular line, and a 12-mm trocar in the right upper quadrant. A Nathanson liver
retractor is sometimes placed to elevate the left lobe of the liver and facilitate exposure of the anterior
and inferior gastric wall (FIG 11).
Preparation of the Stomach and Identification of Proximal Jejunum
First, identify the pylorus by either palpation with a grasper or by performing an intraoperative EGD.
Identify a point 5 cm proximal to the pylorus, and then select a section of the jejunum 15 to 30 cm distal to
the ligament of Treitz, which will easily reach the distal stomach without tension in an antecolic fashion.
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Construction of the Anastomosis
A stapled side-to-side gastrojejunostomy is then constructed in an isoperistaltic fashion by aligning the
distal portion of the small bowel with the pyloric side of the stomach. Placement of two interrupted 2-0 silk
seromuscular sutures between the greater curvature of the stomach and the small bowel 6 cm apart
serves to align the bowel for the stapled anastomosis. Using the electrosurgical device, an enterotomy is
made in the stomach and small bowel (FIG 14). A 60-mm Endo GIA stapler is inserted via the most lateral
right side port and fired to construct the anastomosis (FIG 15A). A blue or green load of the stapler
device should be used depending on the thickness of the stomach. The common enterotomy is then
closed using two 3-0 polyglycolic acid sutures in either a running fashion or an interrupted fashion as
described for pyloroplasty (FIG 15B). A second layer of seromuscular 3-0 silk Lembert sutures is placed
to complete the closure of the common enterotomy.
FIG 14 • Two sutures are used to approximate the selected segment of jejunum to the greater curvature of
the stomach in an antecolic, isoperistaltic fashion. With the assistant providing cranial traction from the left
on the proximal suture and the surgeon providing caudal and rightward traction, the hooked cautery is used
to make a full thickness open in the stomach and jejunum for insertion of a linear endocutting stapler.
FIG 15 • In panel (A), a blue or green load 60-mm endostapler is fired to construct the anastomosis. In panel
(B), the common enterotomy defect is then closed in two layers with sutures. The assistant can facilitate the
suturing with cranial traction on the distal stay suture.
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PEARLS AND PITFALLS

Indications ▪ When performing a drainage procedure for delayed gastric emptying with a
fundoplication, documentation of poor emptying with a gastric emptying study is
strongly recommended prior to surgery.
▪ When operating for GI bleeding, being present at the initial endoscopy to see
the precise bleeding location will help avoid having to make an excessively large
pyloroplasty incision.
Pyloroplasty ▪ Incisions longer than 7 or 8 cm are difficult to close in a Heineke-Mikulicz

incision fashion without narrowing the pyloric lumen and may require a Finney closure.
Kocher manuever ▪ Is not always necessary with a short pyloroplasty and a Heineke-Mikulicz
closure but is always required with a Finney closure
Pyloromyotomy ▪ Is very hard to perform without mucosal perforation in the setting of any
duodenal inflammation. If a significant mucosa perforation occurs during
pyloromyotomy, the safest approach is to convert to pyloroplasty.
Gastrojejunostomy ▪ Predisposes to marginal ulceration if a vagotomy is not performed. Patients

undergoing gastrojejunostomy drainage without vagotomy will require lifetime
proton pump inhibitor therapy.
▪ In the setting of a prior gastric outlet obstruction, a prolonged period of delayed
gastric emptying may be encountered despite an adequate anastomotic lumen.
POSTOPERATIVE CARE
Most patients will require nasogastric decompression for 24 to 48 hours after a drainage procedure.
OUTCOMES
When performed in conjunction with fundoplication in patients with delayed gastric emptying, 80% of
patients report an improvement in bloating symptoms.3
The incidence of diarrhea reported when pyloroplasty is performed in conjunction with fundoplication in
the setting of delayed gastric emptying is reported to be as high as 25%.4
The incidence of clinically significant dumping syndrome after drainage procedures is less than 10%.5
COMPLICATIONS
Leak from suture or staple line
Surgical site infection
Dumping syndrome
Diarrhea
Duodenogastric reflux is quite rare after pyloroplasty.
Bile reflux gastritis following gastrojejunostomy
REFERENCES
1. Reddymasu SC, Singh S, Sankula R, et al. Endoscopic pyloric injection of botulinum toxin-A for the
treatment of postvagotomy gastroparesis. Am J Med Sci. 2009;337:161-164.
2. Hamrick MC, Davis SS, Chiruvella A, et al. Incidence of delayed gastric emptying associated with
revisional laparoscopic paraesophageal hernia repair. J Gastrointest Surg. 2013;17:213-217.
3. Masqusi S, Velanovich V. Pyloroplasty with fundoplication in the treatment of combined gastroesophageal

reflux disease and bloating. World J Surg. 2007;31:332-336.
4. Khajanchee YS, Dunst CM, Swanstrom LL. Outcomes of Nissen fundoplication in patients with
gastroesophageal reflux disease and delayed gastric emptying. Arch Surg. 2009;144:823-828.
5. Tack J, Arts J, Caenepeel P, et al. Pathophysiology, diagnosis and management of postoperative dumping
syndrome. Nat Rev Gastroenterol Hepatol. 2009;6:583-590.
Chapter 18
Antrectomy
J. Spencer Liles
John D. Christein
DEFINITION
By strict definition, antrectomy refers to removal of the gastrin-secreting portion of the stomach and when
combined with a vagotomy results in an 85% reduction in gastric acid secretion.1,2 In the 1960s and 1970s,
antrectomy with or without vagotomy was routinely performed for treatment of benign gastric and duodenal ulcers
but, due to pharmacologic developments in reducing acid secretion and elucidation of the role of Helicobacter
pylori in ulcer development, is now rarely performed for ulcer disease.3,4
Today, the term antrectomy is loosely applied to any distal gastric resection and is indicated in recurrent or
persistent gastric ulcers to rule out malignancy, complicated peptic ulcer disease (i.e., obstruction, hemorrhage,
perforation), and for resection of certain neoplasms of the antrum and pyloric channel (Table 1).3
When an antrectomy is performed for complicated peptic ulcer disease, a vagotomy may be included to reduce
the chance of anastomotic ulcer formation in patients who are not candidates for H. pylori treatment and lifelong
proton pump inhibitor therapy due to unreliability, noncompliance, or medication side effects.5,6
Antrectomy is named by the type of gastrointestinal (GI) anastomosis performed.
Billroth I procedure—antrectomy and gastroduodenostomy
Billroth II procedure—antrectomy and gastrojejunostomy
A modification of the Billroth II procedure that involves a gastrojejunostomy via a Roux limb and is known as
a Roux-en-Y gastrojejunostomy
Complicated peptic ulcer disease and distal gastric neoplasms, both benign and malignant, account for the vast
majority of the antral resections performed today. These diagnoses will be discussed separately.
Peptic ulcer disease refers to irritation of GI mucosa from gastric acid due to either increased acid presence or
weakness in the mucosal protection and typically presents with epigastric pain.2,4 Peptic ulcers can occur
anywhere in the GI tract, but duodenal and gastric ulcers are most common. Duodenal ulcers typically arise
within 2 cm of the pylorus, are highly associated with H. pylori infection (>90%), and frequently resolve with
appropriate H. pylori therapy. Gastric ulcers are less likely to be associated with H. pylori infection and are
classified into five types based on their location and association with acid secretion (Table 2).7
The differential diagnosis of epigastric pain similar to that found in complicated peptic ulcer disease is chronic
cholecystitis, acute pancreatitis, chronic pancreatitis, functional indigestion or dyspepsia, gastritis, and reflux
esophagitis. Complicated peptic ulcer disease can also present with upper GI hemorrhage, and a differential
should include esophagitis (reflux and infectious); gastroesophageal varices, arteriovenous malformations;
Mallory-Weiss tear; stress gastritis; and neoplasm of the esophagus, stomach, duodenum, pancreas, and
biliary tree.
Lastly, pyloric obstruction due to chronic inflammation and scarring will cause nausea, emesis, and early
satiety. The differential for these symptoms includes gastric motility disorders (i.e., gastroparesis),
gastroenteritis, small bowel obstruction, electrolyte abnormalities, and extrinsic compression from pancreatic
pseudocysts or neoplasms.
Distal gastric neoplasms—Gastric neoplasms include benign polyps, adenocarcinoma, neuroendocrine tumors,
lymphoma, B-cell mucosa-associated lymphoid tissue (MALT) lymphomas, GI stromal tumors, leiomyomas, and
leiomyosarcomas. Any gastric neoplastic process can cause upper GI bleeding, epigastric pain, and luminal
obstruction, and a differential similar to peptic ulcer disease should be considered.
Table 1: Indications for Antrectomy
• Intractability—persistent or recurrent gastric ulcers in order to rule out malignancy

• Perforation—distal gastric or duodenal ulcer
• Bleeding—type I, II, or III gastric ulcer
• Obstruction—any gastric outlet or duodenal obstruction due to chronic ulcer scarring
Neoplasm
• Benign—single giant gastric polyp or multiple gastric polyps not amenable to endoscopic resection,
leiomyoma, lipoma
• Malignant—leiomyosarcoma, gastrointestinal stromal tumor, early-stage adenocarcinoma, neuroendocrine
tumor
• Gastroparesis—role is debated in chronic gastroparesis only after extensive workup

All patients should undergo a thorough history and physical exam with questions focusing on the nature of the
symptoms, specifically determining the relationship between symptoms and eating, deciphering whether symptoms are
acute or chronic, and determining the severity of the symptoms. A vast majority of patients will have abdominal pain.
Pain related to peptic ulcer disease that results from the corrosive effect of gastric acid on vulnerable GI mucosa and
typically occurs in the epigastrium is described as gnawing or burning and follows a daily cycle. This pain typically
arises shortly after eating breakfast and persists until lunch at which time the oral intake alleviates the pain. Relief is
transient and pain recurs in the early afternoon and again persists until dinner. Meals, specifically ones consisting of
milk and dairy products, and antacids provide temporary relief from ulcer pain. Acute, severe epigastric pain can
signify ulcer perforation, whereas back pain suggests ulcer penetration into the pancreas.8
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Table 2: Peptic Ulcer Disease
Location Common Acid Other

Complications Secretion
Esophageal Gastroesophageal Hemorrhage High

junction and distal
esophagus
Gastric
I Gastric body on Perforation Normal or • Older

lesser curvature low patients
near the angularis • Associated
incisura with
Helicobacter
pylori
II Two ulcers; Hemorrhage, High • Younger

gastric body and obstruction, or patients
duodenal ulcer perforation • Association
with active
or quiescent
duodenal
ulcers
III Prepyloric Hemorrhage, High • Younger

perforation patients
• Similar to
type II
gastric
ulcers and
duodenal
ulcers
IV High on lesser Hemorrhage Low • Likely a

curvature variant of
type I gastric
ulcers
• Difficult to
treat
surgically
V Anywhere Perforation Normal • Related to

NSAID use
Duodenal 95% occur within Hemorrhage, Normal or

2 cm of pylorus obstruction, or high
perforation
NSAID, nonsteroidal antiinflammatory drug.
Nausea and vomiting can be seen with ulcer disease even in the absence of pyloric obstruction. Nausea that is
chronic in nature and associated with early satiety and weight loss suggests inflammation and scarring of the pyloric
channel due to chronic ulceration.
It is not uncommon for complicated peptic ulcers to present with upper GI bleeding, perforation, or obstruction in a
patient with no history of peptic ulcer disease.
Bleeding—hematemesis, melena, recent diagnosis of anemia

Perforation—acute onset upper abdominal pain and peritonitis
Obstruction—nausea, emesis, food regurgitation, early satiety, weight loss
Acute or chronic upper GI bleeding can signify complicated ulcer disease and may present as melena, weakness,
fatigue, general malaise, or a recent diagnosis of anemia.
Risk factors for developing ulcer disease include a history of H. pylori infection; smoking; Zollinger-Ellison syndrome;
and use of nonsteroidal antiinflammatory drugs (NSAIDs), steroids, and other immunosuppressive medications.1,8
Therefore, an accurate medication list should be obtained and reviewed with the patient. History of previous ulcer
disease should be elicited, and the success and timing of previous treatment modalities should be documented.
Presence of H. pylori infection, completion of antibiotic therapy, and documentation of eradication is crucial (Table 3).
Ulcers that persist despite appropriate
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treatment of H. pylori, cessation of NSAID use, or are found in H. pylori -negative patients should raise suspicion for
underlying malignancy.
A gastric lesion can also present with epigastric pain and obstruction. This pain is typically vaguer in nature and lacks
a gnawing or burning component. Furthermore, these patients may describe a sensation of persistent fullness and
early satiety despite hunger.
A subjective assessment of nutrition and functional status is necessary to evaluate the patient's ability to tolerate a
major surgical procedure.
Table 3: Helicobacter pylori Testing
Sensitivity Specificity Other
Noninvasive
Urease >95% >90% Determines active infection but must stop PPI 2 wk prior;
breath test takes 30-60 min and is used to confirm eradication
Fecal >90% >95% Determines active infection but is positive for up to 12 wk

antigen after eradication
detection
Serology 85% 79% Cannot be used to confirm eradication because antibodies

persist
Invasive
(endoscopic)
Biopsy >90% >95% Decreased sensitivity with ongoing PPI, H2 antagonist,

urease test antibiotic, and bismuth compound use or with recent GI
bleeding
Histology >90% >95% Multiple available stains and widely used; increased
sensitivity with increased biopsies
Culture 80% 100% Difficult and expensive; reserved for persistent infections
and antibiotic sensitivity testing
PPI, proton pump inhibitor; GI, gastrointestinal.

Diagnostic evaluation of suspected peptic ulceration and upper GI lesions can include endoscopy, contrast
radiography, and computed tomography (CT) (FIG 1).
Endoscopy is felt to be superior because it allows for tissue sampling. Sampling of gastric mucosa can be used to
confirm the presence of H. pylori. On endoscopy, ulcers are sharply demarcated; often have exposed underlying
submucosa; and frequently occur in the first portion of the duodenum, the prepyloric area, and the pyloric channel. All
gastric ulcers should be biopsied at least six times at the ulcer edge and brush biopsied to evaluate for underlying
malignancy. Even if negative for malignancy, repeat endoscopy after medical treatment is indicated to evaluate for
therapeutic response, and in instances of persistent or intractable disease, ulcer resection is indicated.8
Other relevant imaging modalities include contrast radiography and CT. Double-contrast radiography of the upper GI
tract detects roughly 90% of gastric and duodenal ulcers but does not allow for tissue sampling. In the acute setting,
CT is helpful in identifying gastric or duodenal ulcer perforation. Additionally, CT can identify wall thickening in chronic
ulcer inflammation or neoplastic situations but again lacks the ability to provide tissue sampling.
Zollinger-Ellison syndrome is a rare condition of increased serum gastrin levels secondary to a gastrinoma with
resulting severe ulcer disease. In nonsmoking patients who are negative for H. pylori, serum fasting gastrin levels
should be obtained to evaluate for Zollinger-Ellison syndrome. Normal basal gastrin levels average to 50 to 100 pg/mL,
and levels over 200 pg/mL can almost always be considered high. Diagnosis of Zollinger-Ellison syndrome can alter
your treatment approach.9
FIG 1 • Radiology. A. CT scan of pyloric obstruction from chronic pyloric inflammation. B. Endoscopic image of near-
complete pyloric obstruction from chronic pyloric inflammation (left); endoscopic image of a large gastric ulcer with a
central necrotic region (right). C. Contrast radiography demonstrating pyloric obstruction from chronic pyloric
inflammation.
SURGICAL MANAGEMENT
The indications for antrectomy are listed in Table 1. As explained earlier, an antrectomy is rarely performed for its
original purpose of removing the antrum and reducing acid secretion.
Antrectomy is not the primary treatment option for bleeding or perforated peptic ulcers. A vast majority of bleeding
ulcers is controlled endoscopically and, in the 5% to 10% that require operative intervention, a formal antrectomy is
rarely needed. Roughly 90% of perforated ulcers can be safely controlled with primary closure and omental patching.
Thus, antrectomy for bleeding or perforated ulcers is reserved for cases when less invasive treatment options are
ineffective.
All patients should undergo preoperative endoscopy to identify the extent of disease and preoperative nutritional
assessment. All patients should receive preoperative antibiotics in a timely fashion to reduce the risks of perioperative
infectious complications from gram-positive cocci and enteric gram-negative bacilli pathogens.
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Several factors must be considered when deciding between performing a Billroth I and Billroth II procedure. The
advantage to a Billroth I procedure is that the anatomic arrangement of the GI tract is preserved, which maintains the
innate regulatory pathways of bicarbonate and pancreatic enzymes and significantly decreases the rate of
postprandial dumping. Unfortunately, the lack of a pylorus results in bile reflux gastritis in a majority of patients. A
Billroth I procedure cannot always be performed due to inflammation and scarring from prepyloric, pyloric, or duodenal
ulcers. In these instances, the Billroth II procedure allows for a tension-free anastomosis of noninflamed tissue but
introduces the problems of potential afferent loop syndrome and bile reflux gastritis, whereas a Roux-en-Y
gastrojejunostomy diminishes the occurrence of bile reflux at the cost of a second anastomosis. Lastly, in cases of
invasive neoplasms or concerning gastric masses, a Billroth II procedure with or without reconstruction with a Roux-en-
Y gastrojejunostomy is preferred as it allows for dissection of much wider margins and is less likely to obstruct in the
unfortunate setting of recurrent disease.10,11
Positioning
The patient should be positioned supine with arms out. A urinary catheter and a nasogastric tube should be placed to
decompress the stomach. Positioning should allow for attachment of a self-retaining retractor system to the operating
room table.
TECHNIQUES
EXPOSURE
A midline supraumbilical incision is made and carried to the level of the xiphoid. The falciform ligament is divided
and a self-retaining retractor system is placed to widely expose the upper abdomen (FIG 2).
FIG 2 • A. A midline upper abdominal incision is used. B. Division of the falciform ligament and placement of self-
retaining retractor allows adequate exposure of the upper abdomen.
GASTRIC MOBILIZATION
Mobilization of the distal stomach is best achieved by starting on the greater curvature. The gastrocolic ligament
is identified and incised to enter the lesser sac (FIG 3). Downward traction on the transverse colon and upward
traction on the stomach will help expose this plane (FIG 4). Identification of the right and left gastroepiploic
vessels along the greater curvature is essential. In benign disease, the plane of dissection can be very close to
the stomach inside the gastroepiploic vessels. A large part of this plane is avascular and can be divided with
electrocautery, whereas encountered vessels should be divided between clamps and ligated with 3-0 silk
ligatures. Once the lesser sac is identified, electrosurgical devices can be used to further mobilize the greater
curvature (FIG 5). Proximally, dissection is carried to the midpoint of the greater curvature preserving the left
gastroepiploic artery. Distally, the plane is developed beyond the pylorus to the duodenum and, once identified,
the right gastroepiploic artery should be clamped, ligated with 2-0 silk ligatures, and divided. Here, one should be
aware of the underlying pancreatic tissue and dissection should be meticulous.
Dissection along the greater curvature allows entrance to the lesser sac, and the stomach can be lifted superiorly
exposing its posterior surface and the congenital
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attachments to the underlying pancreatic capsule (FIG 6). These attachments should be sharply divided. As this
plane is developed in a superior direction, great care should be taken to not injure the left gastric artery at its
origin from the celiac axis. Inflammation and scarring can be encountered in the setting of posterior gastric wall
ulcers.
Attention is then turned to division of the gastrohepatic ligament along the lesser curvature. Retracting the
stomach inferiorly and to the patient's left facilitates exposure of the lesser curvature. This dissection can start in
the
transparent pars flaccida and is carried proximally to the incisura and distally to the right gastric artery, which
should be clamped, ligated with 2-0 silk ligatures, and divided (FIG 7). Again, electrocautery or electrosurgical
devices can be used along the lesser curvature. One must be aware of an aberrant or replaced left hepatic artery
originating from the left gastric artery and traversing the gastrohepatic ligament. If encountered, attempts should
be made to preserve this vessel. After clamping but before division of the right gastric artery, blood flow to the
liver should be confirmed by palpation of the hepatoduodenal ligament.
FIG 3 • Dissection of the greater curvature. A. Division of the greater omentum along the greater curvature will allow
access to the lesser sac. The gastroepiploic vessels should be identified and care should be taken to not damage
the transverse colon and its mesentery. B. Cross-sectional view of the upper abdomen demonstrating the plane of
dissection that allows entrance to the lesser sac and mobilization of the greater curvature.
FIG 4 • Traction on the stomach and the colon will aid dissection through the gastrocolic ligament allowing entrance
to the lesser sac. As seen here, the lesser sac will be a true space that lies deep to the greater omentum.
FIG 5 • Once the lesser sac is identified, the greater curvature can be dissected both proximally and distally taking
care to identify the gastroepiploic vessels.
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FIG 6 • Dissection of the greater curvature allows for superior retraction of the stomach exposing its posterior
surface and the underlying pancreas. Here, the lesser curvature and the left gastric artery are seen from the
posterior aspect of the stomach.
FIG 7 • Dissection of the lesser curvature.
DIVISION OF THE STOMACH

A stapling device is used to divide the stomach along a plane from just proximal to the incisura angularis on the
lesser curvature to a point on the greater curvature twothirds of the way from the gastroesophageal junction to
the pylorus. Some recommend placing Babcock forceps distal to the staple line to prevent sliding or rotation of
the gastric mucosa as the stapler is closed. This will help ensure a clean, even cut across the anterior and
posterior layers of gastric mucosa (FIG 8).
Division of the duodenum varies based on the type of reconstruction planned. The duodenum is divided between
Potts clamps for a Billroth I procedure in order to facilitate the gastroduodenal anastomosis. If possible, a stapling
device should be used to divide the duodenum in a Billroth II procedure.
FIG 8 • Division of the stomach.
RECONSTRUCTION: GASTRODUODENOSTOMY (BILLROTH I)

If a Billroth I anastomosis is planned, a Kocher maneuver is needed to mobilize the duodenum.
The duodenum is transected distal to the diseased area but proximal to the ampulla between Potts clamps, and
the specimen is handed off the sterile field (FIG 9). It is essential that all gastric antrum be resected to prevent
persistent ulcer disease from retained gastric antrum. If there is question, a frozen section can be sent to confirm
duodenal tissue at the resection line.
At this point, one can gauge the mobility of the stomach, and if limited, the attachments of the fundus to the base
of the diaphragm can be divided along with the gastrosplenic ligament taking care to preserve the left
gastroepiploic vessels. This further mobilization should allow for a tension-free gastroduodenal anastomosis. If
there
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is concern about the ability to perform a tension-free anastomosis due to difficulty mobilizing the duodenum or the
stomach, then a Billroth II procedure should be performed.
For a Billroth I procedure, the duodenal stump is cleared of adjacent adipose tissue for roughly 1.5-cm distance in
preparation for an end-to-end anastomosis. This anastomosis is constructed in standard two-layer fashion. Silk 3-
0 seromuscular “stay” sutures are placed at the ends of the anastomosis to approximate the duodenum to the
inferior aspect of the gastric staple line and the posterior layer is completed with interrupted 3-0 silk seromuscular
sutures. Next, the inferior portion of the gastric staple line is removed using electrocautery for a length that
correlates with the width of the duodenal stump. Two running 3-0 polydioxanone (PDS) sutures are used for the
inner layer and an anterior layer of interrupted 3-0 silk seromuscular sutures completes the anastomosis. The
remaining gastric staple line can be oversewed with interrupted 3-0 silk sutures (FIG 10).
FIG 9 • Division of proximal duodenum.
FIG 10 • A-C. Billroth I.
RECONSTRUCTION: GASTROJEJUNOSTOMY (BILLROTH II)

In performing a gastrojejunostomy, the gastric staple line is oversewed with interrupted 3-0 silk sutures.
Next, the duodenum is divided distal to any disease with a stapling device. If it is not possible to fit a stapler into
this plane, the duodenum can be divided with electrocautery and closed with a running 3-0 PDS. To buttress this
closure, 3-0 silk full-thickness sutures can be placed and left untied. Omentum can be mobilized and loosely
secured in place over the closure with the silk suture ends.
We preferentially perform an isoperistaltic, retrocolic gastrojejunostomy, although an antecolic anastomosis is
widely accepted. In the setting of malignancy, an antecolic approach may be favored as concern exists that
progression of disease and future diffuse mesenteric lymphadenopathy may obstruct a retrocolic anastomosis.
The anastomosis should be performed as close to the ligament of Treitz as possible (usually 10 to 15 cm),
allowing for a tension-free anastomosis to minimize the risk of developing afferent limb syndrome.
Although we prefer a stapled anastomosis, both stapled and hand-sewn techniques are widely accepted with
similar rate of postoperative complications. A 45-mm stapled
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gastrojejunal anastomosis is formed by creating a posterior wall gastrotomy and an antimesenteric enterotomy.
Care is taken to ensure that the anastomosis is away from the prior gastric staple line on the posterior wall of the
stomach. The common enterotomy is then closed with a 3-0 PDS full-thickness layer and an overlying layer of
interrupted 3-0 silk sutures (FIG 11). Interrupted 3-0 silk sutures are then used to close the colonic mesentery
defect to prevent bowel herniation (FIG 12).
FIG 11 • A,B. Billroth II.
FIG 12 • Retrocolic gastrojejunostomy.
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PEARLS AND PITFALLS
Indication ▪ Today, there is no role for antrectomy in treatment of noncomplicated peptic ulcer disease.
▪ A vast majority of peptic ulcers complicated by hemorrhage or perforation can be controlled

with less invasive procedures.
Operative ▪ Preoperative endoscopy is essential to evaluate for the scope of disease and to allow
planning biopsy of persistent gastric ulcers to rule out malignancy.
▪ In the setting of malignancy, preoperative staging is warranted and a more extensive,
oncologic resection may be indicated.
Laparotomy ▪ Prior to extensive dissection, the extent of disease should be gauged to determine the
operative plan and feasibility of a Billroth I anastomosis.
Gastric ▪ With mobilization of the greater curvature, the middle colic vein is at risk of injury. Caudal
mobilization traction on the transverse colon during dissection can help prevent an inadvertent injury.
Duodenal ▪ Great care should be taken to not fracture or injure the head of the pancreas, which can be
transection closely adherent due to chronic inflammation.
▪ If the common bile duct is difficult to identify, a cholecystectomy can be performed and a
catheter can be placed in the cystic duct. Palpation of the catheter can aid in safely
identifying the portal structures during dissection of the duodenum.
Reconstruction ▪ Billroth I and II procedures are performed with acceptable postoperative morbidity.
▪ A Billroth II anastomosis should be performed if there is concern about mobility of the
duodenum or the stomach.
▪ A short afferent limb (10 to 15 cm from the ligament of Treitz) can help minimize the
likelihood of significant postoperative complications.
POSTOPERATIVE CARE
Unless concerning comorbidities exist, patients can be monitored on the hospital floor/ward. A nasogastric tube is
positioned intraoperatively in the proximal stomach and typically can be removed on postoperative day (POD) 1. There
is no role for postoperative antibiotic prophylaxis. Unless contraindicated, all patients receive chemical prophylaxis for
deep vein thrombosis and are encouraged to ambulate on POD 1 and begin pulmonary toilet with incentive spirometry.
There is no convincing evidence for routinely placing abdominal drains after Billroth I and Billroth II procedures. If there
is concern for the GI anastomosis or adequate closure of the duodenal stump, a closed suction abdominal drain can
be placed. Oral intake is reintroduced on POD 3 and advanced as tolerated.
OUTCOMES
Serious morbidity from postgastrectomy syndromes develops in 3% to 5% of patients.
Thirty-day mortality for uncomplicated gastric ulcer disease is 1% to 2% and increases in emergency settings.11
COMPLICATIONS
After an antrectomy, short-term complications include delayed gastric emptying, anastomotic leak, bleeding, and
pancreatitis. Long-term complications include the postgastrectomy syndromes (described below) and anastomotic
stricture. Additionally, chronic anemia, neuropathy, and osteopenia can result from iron, copper, and calcium
malabsorption due to bypassing of the proximal small bowel in a Billroth II procedure.12
Postgastrectomy syndromes
Afferent loop syndrome
Postprandial right upper abdominal colicky pain that accumulates in bilious emesis that alleviates the pain
Results from chronic dilation, obstruction, or stasis of the duodenum (afferent limb) after a Billroth II
procedure
Rarely occurs but can be corrected by revision of the Billroth II, conversion to a Roux-en-Y reconstruction, or
performing an afferent to efferent bypass (Braun enteroenterostomy)
Reflux gastritis—Patients report epigastric burning pain resulting from reflux of bile into the stomach. As
expected, bile reflux is more common after Billroth I and Billroth II procedures than Roux-en-Y reconstruction
and if severe can be treated by conversion to a Roux-en-Y reconstruction.
Dumping—Early dumping presents as crampy abdominal pain and diarrhea shortly after eating due to the large
hyperosmolar load of simple sugars which quickly enter the small bowel in the absence of a pylorus. Late
dumping occurs roughly 2 hours postprandial with the symptoms of hypoglycemia likely due to insulin response
to the large sugar bolus. Dumping occurs in 5% of postgastrectomy and is controlled with diet modifications,
and rarely, octreotide is given with success in severe and refractory cases. Retained gastric antrum—
Incomplete antrectomy with retained G cells within the duodenal stump can result in recurrent ulceration from
continued intense gastrin secretion. Exposure of the jejunum to high levels of acid results in an anastomotic or
marginal ulcer. A sodium 99m technetium scan identifies antral tissue and reexcision is needed for complete
symptom relief.
REFERENCES
1. Glasgow RE, Rollins MD. Stomach and duodenum. In: Norton JA, Barie PS, Bollinger RR, et al, eds. Surgery:
Basic Science and Clinical Evidence. 2nd ed. New York, NY: Springer; 2008:841-874.
2. Gray RJ, Kelly KA. Peptic ulcer. In: Kelly KA, Sarr M, Hinder R, eds. Mayo Clinic Gastrointestinal Surgery.
Philadelphia, PA: Saunders; 2003:103-124.
3. Zittel TT, Jehle EC, Becker H. Surgical management of peptic ulcer disease today—indication, technique, and
outcome. Langenbecks Arch Surg. 2000;385:84-96.
4. Bardhan KD, Royston C. Time, change, and peptic ulcer disease in Rotherdam, UK. Dig Liver Dis.
2008;40(7):540-546.
5. Lundell L. Acid secretion and gastric surgery. Dig Dis. 2011;29(5): 487-490.
6. Lipof T, Shapiro D, Kozol RA. Surgical perspectives in peptic ulcer disease and gastritis. World J Gastroenterol.
2006;12(20):3248-3252.
7. Doherty GM, Way LW. Stomach and duodenum. In: Doherty GM, ed. Current Diagnosis & Treatment: Surgery.
13th ed. New York, NY: McGraw-Hill; 2010.
8. Mulholland MW. Gastroduodenal ulceration. In: Mulholland MW, Lillemoe KD, Doherty GM, et al, eds. Greenfield's
Surgery: Scientific Principles and Practice. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
9. Hou W, Schubert ML. Treatment of gastric carcinoids. Curr Treat Options Gastroenterol. 2007;10(2):123-133.
10. Chassin JL, Henselman C. Gastrectomy (antrectomy) for peptic ulcer. In: Chassin JL, Henselman C, eds.
Chassin's Operative Strategy in General Surgery: An Expositive Atlas. New York, NY: Springer-Verlag; 1994.
11. Siewert JR, Bumm R. Distal gastrectomy with Billroth I, Billroth II, or Roux-Y reconstruction. In: Fischer JE, Bland
KI, eds. Mastery of Surgery. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:849-859.
12. Bolton JS, Conway WC II. Postgastrectomy syndromes. Surg Clin N Am. 2011;91:1105-1122.
Chapter 19
Subtotal Gastrectomy for Cancer
Vikas Dudeja
Patrick G. Jackson
Waddah B. Al-Refaie
DEFINITION
Subtotal gastrectomy is removal of 70% to 80% of distal stomach. This is performed when the necessary
5- to 6-cm proximal margin can be obtained while maintaining a gastric remnant of reasonable size.

Presentation
In United States, gastric cancer is often diagnosed at an advanced stage and nearly 65% of patients harbor
nodepositive disease.1,2 The most common symptoms are weight loss, anorexia, and early satiety. Some of
these symptoms overlap with those of benign peptic ulcer disease. Patients with distal gastric cancer may
present with symptoms of gastric outlet obstruction, including postprandial vomiting and weight loss. Patients
may also present with progressive abdominal distension secondary to malignant ascites.
Special attention should be paid to weight loss. Although this may reflect metastatic disease or gastric outlet
obstruction, in patients with resectable disease, it signifies a need for preoperative nutritional optimization.
Specifically, patients with more than 10% weight loss are at increased risk of perioperative complications.
Attention to pretherapy performance status is critical, as this correlates well with ability to tolerate various
oncologic therapies including major surgical resection and systemic therapy.
Patients presenting with gastric outlet obstruction may have dehydration and electrolyte imbalances.
Placement of a nasogastric (NG) tube, volume replacement (initially with normal saline), and correction of
electrolyte imbalance is paramount.
Physical Findings
Most patients with early stage disease will have a normal physical examination. However, signs of
malnutrition, cachexia, and jaundice should be sought. Patients with advanced stage disease may present
with supraclavicular lymphadenopathy, pleural effusion, abdominal mass, hepatomegaly, malignant ascites, or
drop metastases in the cul-de-sac known as “Blumer's shelf.” Presence of any of these physical findings
suggest unresectability.

Laboratory Tests
A baseline hemoglobin will assess whether iron deficiency anemia is present. Patient's renal function and
hydration status should be assessed by measuring serum blood urea nitrogen (BUN) and creatinine in
preparation for cross-sectional imaging. Evaluation and correction of abnormalities in electrolytes are
important in patients with gastric outlet obstruction. Serum albumin and prealbumin are essential tools for
assessing nutritional status.
Diagnostic Studies and Staging Evaluation

The evaluation of any upper gastrointestinal (GI) symptomatology begins with an upper GI endoscopy,
especially if gastric cancer is suspected. Endoscopy provides histopathologic diagnosis as well as guidance
toward the location and extent of the gastric tumor (FIG 1A,B). For example, the endoscopist needs to
comment on the location of the tumor as well as the relationship to the first portion of the duodenum.
Additionally, it is important to exclude the presence of linitis plastica by insufflating the stomach and evaluating
its distensibility, as patients with linitis plastica carry a higher risk of metastatic disease and a median survival
of approximately only 14 to 16 months.
Endoscopic ultrasound performed at the time of or subsequent to diagnostic endoscopy provides the most
accurate estimation of the tumor depth (T stage) and needle biopsy of surrounding lymph nodes can be
performed.3
Pretherapy cross-sectional imaging (contrast computed tomography [CT] scan or magnetic resonance imaging
[MRI] of abdomen and pelvis) is important to exclude distant metastatic disease to the liver or omentum (FIG
2A). In patients with proximal gastric cancer, the addition of chest crosssectional imaging is helpful to exclude
the presence of metastases to the lung. The presence of bulky adenopathy adds prognostic value but should
not preclude resection unless it is outside the area of resection, such as the periportal area or mesenteric
vessels. Fewer than 15% of patients present with locally advanced disease extending to the pancreas. In
these patients, we perform staging laparoscopy to exclude M1 disease and then recommend neoadjuvant
chemotherapy.
FIG 1 • Esophagogastroduodenoscopy helps with histologic diagnosis as well as provides information about
extent of tumor. A. Biopsy-proven poorly differentiated adenocarcinoma with signet cell features in the
antral/prepyloric region of stomach. B. Fungating adenocarcinoma of the distal third of the stomach in a 75-
year-old male who presented with iron deficiency anemia.
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FIG 2 • Cross-sectional imaging in the form of CT and CT/PET helps to evaluate for distant metastatic disease
as well as extent of locoregional disease. A. CT scan in a patient with gastric cancer demonstrates thickening
of the gastric antrum with nodularity in the gastrocolic ligament suggestive of direct spread to the transverse
colon. B. PET/CT corroborated with CT scan to suggest involvement of gastrocolic ligament. No metastatic
disease was observed.
Positron emission tomography (PET)/CT scan has evolved as a noninvasive radiographic staging modality to
exclude the presence of metastatic disease (FIG 2B).
Staging laparoscopy: Due to the natural history of gastric cancer, up to a third of patients who have
localized disease on staging evaluation have unsuspected hepatic and/or peritoneal disease.4 Thus, all
patients should undergo staging laparoscopy to detect “subradiologic” disease. Staging laparoscopy is
typically performed in a reverse TNM fashion. The operating surgeon should inspect the intraabdominal cavity
for presence of peritoneal, omental, or hepatic metastases. The addition of peritoneal washing for cytology is
an area of debate.5,6 It may have a place in patients at risk of undeclared metastatic disease or suboptimal
performance status, as patients with positive peritoneal cytology have unfavorable overall prognosis.6 In the
absence of concerning radiographic features, staging laparoscopy is typically performed at the time of the
intended resection.
SURGICAL MANAGEMENT
Margin-negative resection along with an adequate lymphadenectomy are the most critical components of the
surgical resection.
Addressing preoperative malnutrition: Gastric outlet obstruction caused by tumor as well as anorexia
associated with malignancy contribute to malnutrition. As such, these patients may benefit from a placement of
a preoperative nasojejunal tube and enteral nutrition. In patients presenting with malignant distal gastric
obstruction, an endoscopic transpyloric stent may address the gastric outlet obstruction and thus help in
optimizing the nutrition. Staging laparoscopy and placement of a feeding jejunostomy tube is another option.
Evaluation of the patient's functional status: A careful review and optimization of underlying comorbidities
(e.g., cardiac, pulmonary, diabetes) and performance status should be performed. A subset of high-risk
individuals may benefit from preoperative admission to optimize the nutrition, electrolytes imbalance, and
improve performance status (e.g., physical therapy) in preparation for the oncologic resection.
Preoperative antibiotics: Patients should have preoperative first- or second-generation cephalosporins prior
to incision to reduce the risk of wound infection.
Deep venous thrombosis (DVT) prophylaxis: All patients should have a sequential compression device
applied during the procedure. Use of subcutaneous heparin/low-molecularweight heparin is initiated on
postoperative day 1 and continued throughout the hospitalization unless contraindicated.
Positioning
The patient is placed in supine position with both arms out at 90 degrees. Nipples to upper thigh should be
prepped and draped in the operative field.
TECHNIQUES
STAGING LAPAROSCOPY
Pneumoperitoneum is created by either open technique or Veress needle. A 30-degree scope is inserted
at the umbilicus. One to two additional 5-mm ports on left or right side of the abdomen are needed for
additional visualization, grasping, and biopsy of suspicious tissue. A complete survey of the peritoneal
cavity is performed, including undersurface of the diaphragm, liver surface, spleen, lining of peritoneal
cavity, pelvis, small bowel surface, and omentum, for metastatic disease. If suspicious disease is
observed, it is sent for frozen section. In the setting of biopsy-proven peritoneal disease, gastrectomy
should not be considered and nonsurgical treatments should be initiated. However, selective palliative
surgical procedures may be indicated, for example, in bleeding or obstructing cancers that cannot be
palliated by endoscopic procedures. These decisions need to be individualized based on the
performance status of the patient, extent of metastatic burden, and the projected survival.
If the staging laparoscopy is negative for peritoneal spread of the disease, operative resection is
performed.
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EXPLORATORY LAPAROTOMY
Abdomen is entered through a midline incision extending from the xiphoid process to just below the
umbilicus. A bilateral subcostal incision, approximately 2 cm below the costal margin, also provides good
exposure. During entry into the abdomen, the falciform ligament should be preserved as it can be used to
buttress the duodenal closure.
A careful exploration of the peritoneal cavity is performed to exclude presence of subradiographic
peritoneal or metastatic disease. The liver is carefully examined for any suspicious nodules.
MOBILIZATION OF THE GREATER CURVATURE OF THE STOMACH
In this step, the transverse colon is separated from the greater omentum in an avascular plane (FIG 3).
The stomach and the greater omentum are reflected superiorly, and the transverse colon is reflected
inferiorly. The plane of fusion between the greater omentum and the transverse mesocolon is identified
as a faint white line. This plane is incised with electrocautery to enter the lesser sac. This plane is
advanced proximally and distally along the transverse colon.
The dissection proceeds to the proximal greater curvature of the stomach using either clamps and ties or
an energy device, such as Harmonic™ or LigaSure™, to divide the short gastric vessels. When
performing a subtotal gastrectomy, this dissection should stop at the beginning of the short gastric
vessels as short gastric arteries provide the blood supply to the proximal gastric remnant.
FIG 3 • Separation of the omentum from the transverse colon. Omentum is separated from the transverse
colon along the avascular embryonic planes of fusion thus allowing access to the lesser sac.
DUODENAL MOBILIZATION AND TRANSECTION

The hepatic flexure of the colon is mobilized by dividing the avascular attachment of the right colon to the
retroperitoneum. The separation of the greater omentum from the transverse mesocolon is continued to
the hepatic flexure. This exposes the gastrocolic trunk, which is formed by the confluence of right
gastroepiploic vein with a colonic vein and drains into the superior mesenteric vein (FIG 4). The right
gastroepiploic vein is divided at its junction with the gastrocolic trunk. Alternatively, the gastrocolic trunk
can be divided with a single fire of
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vascular stapler. At this stage, the right gastroepiploic artery is divided at its origin at the infraduodenal
level. The infrapyloric nodes, located adjacent to the origin of gastroduodenal artery, are mobilized with
the specimen (FIG 5).
FIG 4 • Ligation of the right gastroepiploic vein. Right gastroepiploic vein is ligated at its junction with the
colonic veins. Alternatively, the gastrocolic trunk can be divided with a single fire of a vascular stapler
load.
FIG 5 • Dissection of the infrapyloric nodal packet at the level of right gastroepiploic vessels.
The lesser curvature is mobilized by dividing the lesser omentum as close to the liver as possible (FIG 6).
If a replaced or accessory left hepatic artery is identified, it should be temporarily ligated, and the
perfusion of the left lobe of the liver should be assessed prior to transecting the vessel. The dissection is
carried distally to the portal triad. The right gastric artery arising from the common hepatic artery is
divided including the lymphatic tissue with the specimen. The duodenum is circumferentially dissected
about 2 to 3 cm distal to the pylorus, encircled with a Penrose drain and divided with either a stapler or in
between straight bowel clamps (FIG 7). Care is taken not to injure the bile duct, hepatic artery, or portal
vein when encircling the duodenum. The stapled duodenal line is oversewn with 3-0 silk Lembert sutures
and can be buttressed with the falciform ligament (Moossa's patch). However, in the setting of extensive
inflammation around the periduodenal area, consideration should be given to dividing the duodenal
stump in between two straight bowel clamps and suture closure of the duodenal stump.
FIG 6 • Mobilization of the lesser curvature of the stomach. Lesser omentum is divided as close to the
liver as possible. Presence of replaced or accessory left hepatic artery is carefully sought for.
FIG 7 • Division of duodenum. Duodenum is encircled with a Penrose and divided with a blue GIA stapler
load. Care is taken to avoid injury to portal vein, bile duct, and hepatic artery.
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The gastrectomy specimen, now disconnected distally, is lifted upward. The left gastric artery is
identified, suture ligated, and divided at its origin (FIG 8). The lymphareolar tissue with the left gastric
artery is mobilized with the specimen.
FIG 8 • Division of left gastric artery. Stomach is lifted upward, left gastric artery is identified, and suture
ligated. The lymph node packet along the left gastric artery is mobilized along with the specimen.
GASTRIC TRANSECTION
Next, the stomach is divided about 4 to 6 cm proximal to the gastric cancer (FIG 9). Our preference is to
use several green loads of a GI stapler.
We send the resected specimen in separate containers in the following manner: (1) stomach with a
marking stitch on proximal end, (2) greater omentum, (3) infrapyloric nodal packet, and (4) lesser
curvature nodal packet with a long stitch on the left gastric artery. The operating surgeon should
communicate with the pathologist to orient him/her to the specimen and indicate the proximal and distal
margins for frozen section assessment.
FIG 9 • Division of the stomach. Stomach is divided 5 to 6 cm proximal to the most proximal extent of the
tumor along a line extending from 2 cm distal the gastroesophageal (GE) junction to the greater curvature.
EXTENT OF LYMPHADENECTOMY
The extent of lymphadenectomy in patients with operable gastric cancer is an area of controversy.7,8 To
ensure adequate lymphadenectomy, the gastric arteries need to be divided at their origin. We typically
perform a pancreas- and spleen-preserving lymphadenectomy. That is, taking the right gastric artery,
right gastroepiploic artery, and left gastric arteries at their origin along with celiac axis nodal dissection.
We acknowledge that the addition of a celiac axis dissection is an area of controversy.
RECONSTRUCTION
Restoration of GI continuity can be achieved by performing a Billroth II loop gastrojejunostomy or Roux-
en-Y gastrojejunostomy. Our preference is Roux-en-Y gastrojejunostomy.
Roux-en-Y reconstruction: While awaiting frozen section on the gastric margins, we proceed with the
reconstruction. A loop of jejunum distal to the ligament of Treitz that reaches the stomach pouch without
tension is identified. The jejunum is divided at this point
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with a blue gastrointestinal anastomosis (GIA) stapler. The staple line on the end of the Roux limb is
oversewn with 3-0 silk stitches in Lembert fashion. The Roux limb needs to be at least 40 cm (i.e., from
its beginning at the level of stomach to the jejunojejunostomy). A defect is created in the transverse
mesocolon to the left of the middle colic vessels (FIG 10). We then confirm that the Roux limb can easily
reach the stomach without tension when placed in the retrocolic position. Our preference is to first
perform a stapled side-to-side anastomosis between the biliopancreatic limb and the jejunum. Our
rationale behind this order of reconstruction is to allow for an easier reconstruction of this anastomosis
away from the transverse mesocolon defect. Stay sutures are placed between the biliopancreatic limb
and the jejunum. Enterotomies are made in the biliopancreatic limb and the jejunum. One limb of the blue
GIA stapler is introduced into the biliopancreatic limb and the other in the jejunum. The blue load is fired
and the common enterotomy is closed either in a handsewn fashion or with a single fire of GIA or
thoracoabdominal (TA) stapler.
Then, the Roux limb is navigated through the defect in the transverse mesocolon. A two-layered side-to-
side anastomosis is created between the anterior surface of the gastric pouch and the Roux limb. A
posterior layer of interrupted 3-0 silk seromuscular (Lembert) sutures are placed (FIG 11A). Two
opposing enterotomies are made on the stomach and the antimesenteric border of the Roux limb. The
length of the opening in jejunum should be shorter than that made in the stomach as the opening in the
small bowel tends to expand. Next, an inner posterior layer of full-thickness interrupted 3-0 silk (or
absorbable) sutures are placed, followed by an anterior layer of interrupted 3-0 silk (or absorbable) full-
thickness stitches (FIG 11B). Prior to completion of anterior layer, the anesthesiologist advances the NG
tube into the afferent limb of the jejunum. Following completion of the inner layer of the two-layered
anastomosis, an anterior layer of interrupted 3-0 silk seromuscular (Lembert) sutures are placed (FIG
12). Alternatively, the surgeon can perform this anastomosis as a stapled anastomosis. The Roux limb is
sutured to the transverse mesocolon to prevent herniation of small bowel through this defect.
FIG 10 • Creation of defect in transverse mesocolon. A defect is created in the transverse mesocolon to the
left of middle colic veins. The Roux limb is taken to the gastric remnant in a retrocolic fashion.
FIG 11 • Construction of two-layered hand-sewn gastrojejunal anastomosis. A. A series of posterior layer of

interrupted 3-0 silk sutures are placed. B. Anterior inner layer also consists of interrupted 4-0 absorbable
full-thickness stitches. Prior to completion of anterior layer, an NG tube is advanced into the afferent limb of
the jejunum. Following completion of the inner layer of the two-layered anastomosis, an anterior layer of
interrupted 3-0 silk is placed.
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FIG 12 • Final anatomy after completion of gastrojejunal anastomosis.
CLOSURE
At this point, abdomen is irrigated and the fascia closed with a running no. 1 absorbable monofilament
suture. The skin is closed with staples or running subcuticular absorbable suture.
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PEARLS AND PITFALLS
Diagnostic ▪ The endoscopy should be performed or personally discussed with the

studies endoscopist for better operative planning and intraoperative localization of the
tumor.
Staging ▪ Staging laparoscopy is critical to avoid nontherapeutic laparotomy. Up to a third of

laparoscopy the patients with localized disease on imaging will have subradiologic peritoneal
spread.
Preoperative ▪ Preoperative nutrition should be addressed by nasojejunal tube placement and

nutrition enteral nutrition. Addressing gastric outlet obstruction by endoscopic means (e.g.,
stenting) or placement of a jejunostomy tube (J tube) at the time of staging
laparoscopy also helps with nutritional optimization.
Mobilization of ▪ Greater curvature of the stomach should be mobilized, taking care to avoid
greater unnecessary traction on splenic adhesions thus avoiding splenic injury and
curvature of splenectomy. The blood supply to the proximal gastric pouch is from short gastric
the stomach vessels, which should be preserved above the point of transection. If injury to
spleen requires a splenectomy then total gastrectomy should be performed, as the
removal of spleen jeopardizes the vascular supply of the proximal gastric remnant.
Circumferential ▪ Careful dissection around the duodenum in the infrapyloric area is a key step to
dissection of ensure adequate lymphadenectomy and avoid injury to common bile duct and
duodenum portal vein.
Left gastric ▪ Identification and ligation of left gastric vein should be done with care to avoid
pedicle bleeding or venous tear propagating to the portal vein.
dissection
Reconstruction ▪ Before constructing the gastrojejunal anastomosis, the orientation of the Roux
of the limb should be carefully checked to prevent twisting or undue tension on the
gastrointestinal anastomosis.
continuity
Delayed ▪ Up to 15% to 20% of the patients demonstrate delayed gastric emptying after
gastric gastric surgery. Early recognition of symptomatology, by not mistaking vomiting or
emptying early satiety as postoperative ileus, is important. Treatment is supportive with
gastric decompression and trial of prokinetic agents (e.g., metoclopramide or
intravenous [IV] erythromycin).
POSTOPERATIVE CARE
General management: Similar to other intraabdominal operation, patients with subtotal gastrectomy should
undergo a regimen of aggressive pulmonary hygiene, early ambulation, and physical therapy. Careful attention
should be paid to the volume status, electrolytes, and input/output balance.
DVT prophylaxis: We start patients on DVT prophylaxis within 24 hours after completion of the procedure
unless contraindicated.
NG tube: We keep the NG tube until 2 to 3 days postoperatively. If the tube gets dislodged accidently, we do
not replace it. If replacement of an NG tube is necessary, it should be performed under fluoroscopy to avoid
accidental disruption of the anastomosis by a blindly placed NG tube.
Diet: A clear liquid diet is initiated on postoperative day 3 or 4 and advanced as tolerated. We consult a
dietitian to educate patients on issues related to postgastrectomy diet.
OUTCOMES
Prognosis: 5-year survival is 70% for stage IA, 57% for stage IB, 45% for stage IIA, 32% for stage IIB,
20% for stage IIIA, 14% for stage IIIB, 9% for stage IIIC, and 4% for stage IV.9
In a landmark study,10 adjuvant chemoradiation therapy for the treatment of stage IB to IV M0 (AJCC
1988) resectable gastric cancer improved the 3-year overall and relapse-free survival from 41% to 50%
and 31% to 48%, respectively.
Similarly, perioperative chemotherapy without radiation11 for gastric cancer led to an improvement of
overall 5-year survival from 23% to 36%.
COMPLICATIONS
Pulmonary complications
Pulmonary complications are frequent after upper abdominal surgery including atelectasis, aspiration,
pneumonia, DVT, and pulmonary embolism. Good pulmonary toilet, early mobilization, elevation of the
head of the bed, close attention to fluid balance, and early initiation of DVT prophylaxis are paramount
to minimize the occurrences.
Postoperative bleeding
Presentation: Postoperative bleeding can occur intraluminal or intraabdominal. Intraluminal bleeding
presents with fresh blood in NG tube, melena, falling hemoglobin, and if severe, as hemodynamic
instability. Bleeding from the anastomosis line is the major cause of the intraluminal bleeding and
usually occurs around postoperative days 5 to 7.12 Intraabdominal bleeding presents with hypotension,
tachycardia, dropping hemoglobin, and abdominal distension. Intraabdominal bleeding usually
presents in the first 12 to 24 hours following surgery. Unrecognized splenic injuries in the form of
capsular tears and lacerations and/or inadequate control of short gastric vessels are the major causes
of postoperative intraabdominal bleeding.12
Management: Intraluminal bleeding can generally be managed by supportive measures in the form of
correction of coagulopathy and volume resuscitation. Bleeding that causes hemodynamic compromise
or does not respond to supportive measures requires careful endoscopic therapeutic measures.
Reoperation for bleeding not controlled with endoscopy is rare. Intraabdominal bleeding requires
volume resuscitation and correction of coagulopathy. Patients with hemodynamic compromise or who
do not immediately respond to supportive measures (suggesting ongoing bleeding) should return to the
operating room for definitive control of the bleeding source.
Anastomotic leak
Presentation: The overall incidence of anastomotic leak after subtotal gastrectomy is much less as
compared to esophagojejunal anastomosis leak after total gastrectomy and is about less than 2%.
Anastomotic leak presents with intraabdominal sepsis with fever and leukocytosis.
Management: When anastomotic leak or intraabdominal sepsis is suspected, a CT scan of the
abdomen and pelvis with oral and IV contrast is performed. CT scan may suggest the presence of
anastomotic leak and would demonstrate the presence of any drainable abdominal collection. The
anastomotic leak can further be confirmed and characterized with a Gastrografin swallow study. Most
leaks can be managed by making the patient NPO, parenteral nutrition, and drainage of any
intraabdominal collection. Weekly Gastrografin swallow studies can document when the leak is healed.
Rarely is surgical intervention required. Small leaks can be closed primarily and buttressed with an
omental patch. Larger leaks may require a revision of anastomosis with wide drainage and jejunostomy
tube for enteral feeding.
Duodenal stump blowout
Presentation: Duodenal stump blowout can present as either peritonitis and hemodynamic instability
or in a more localized fashion as signs and symptoms of intraabdominal abscess. Overzealous
dissection of duodenum leading to its devascularization, chronic scarring of duodenum complicating its
closure, and obstruction of the biliopancreatic limb are potential etiologies.
Management: A CT scan will demonstrate an abscess in the right upper quadrant and will not contain
oral contrast. A percutaneous drain with a contrast study through the drain will confirm connection with
duodenum. Management is largely through supportive measures
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including NPO, parenteral or enteral nutrition, and replacement of fluid losses. A percutaneous
transhepatic duodenal diversion can assist with closure of the leak by diverting the bile and pancreatic
juices away from the fistula. Operative management might be required if the fistula does not close. If
the duodenal blowout presents as acute abdomen, then exploratory laparotomy, placement of a tube
duodenostomy, and wide drainage of right upper quadrant is performed.
Delayed complications:
Presentation: Disruption of normal mechanisms of gastric emptying and motility with gastric
surgery leads to delayed gastric emptying. Delayed gastric emptying presents as nausea, vomiting,
bloating, hiccoughs, and continued high NG tube output in presence of antegrade bowel function.
The diagnosis is clinical and can be confirmed by slow emptying of stomach on contrast study or
nuclear medicine gastric emptying study.
Management: Treatment is largely supportive and includes gastric decompression with NG and
trial of promotility agents such as metoclopramide (10 mg three times daily) and/or erythromycin (up
to 250 mg four times a day).
Alkaline reflux gastritis
Presentation: Contact of gastric mucosa with biliary contents causes alkaline reflux gastritis and
presents as epigastric pain unrelieved by antacids, nausea, and bilious vomiting. Diagnosis is
clinical and one of exclusion. Anastomotic ulceration, afferent and efferent loop syndrome, and
disease of the gallbladder and pancreas must be ruled out. Endoscopy demonstrates hyperemic
gastric mucosa with biliary staining, which supports the diagnosis. Bile reflux can be further
documented using a HIDA scan.
Management: Alkaline reflux gastritis does not respond well to medical therapy. However, a trial of
medical therapy with cholestyramine, sucralfate, or antacid is still warranted. Surgical treatment
involves diverting duodenal contents away from the stomach by converting loop gastrojejunostomy
to a Roux-en-Y gastrojejunostomy with a 45- to 60-cm Roux limb. A vagotomy should be performed
at the time of reoperation to reduce the risk of marginal ulcer.
Afferent and efferent loop syndrome
Presentation: Afferent or efferent loop syndrome occurs due to obstruction of the afferent or the
efferent loop when a loop gastrojejunostomy has been used to restore GI continuity. This can
present as an acute problem if the obstruction is complete or as a chronic problem due to partial
obstruction. The potential causes are numerous and include internal herniation, volvulus, or kinking
at the anastomosis. Acute afferent limb obstruction is the most common cause of duodenal stump
blowout and is a surgical emergency. Patient presents with severe epigastric and right upper
quadrant pain associated with nausea and vomiting. Physical examination may reveal an
intraabdominal mass, and CT scan of the abdomen reveals the diagnosis. When the afferent limb is
partially blocked, then it presents as chronic afferent loop syndrome where patients complain of
postprandial abdominal pain with nausea and projectile vomiting, which typically does not contain
food and relieves the pain. Diagnosis is clinical and is complemented with endoscopy and upper GI
fluoroscopy studies. Obstruction of the efferent loop is less common and presents as abdominal
pain, nausea, and bilious vomiting with food particles in it. The diagnosis can be confirmed by
Gastrografin study, which shows a holdup in the passage of contrast into the efferent limb. Potential
causes include retroanastomotic hernia, adhesions, and stricture.
Management: Acute afferent loop syndrome is an emergency and requires immediate operative
exploration. If the duodenum and afferent limb are viable, then addressing the etiology may include
shortening the redundant afferent limb, reducing internal herniation, closing the mesenteric defects,
or revision of gastrojejunal anastomosis. However, necrosis of the duodenum in this condition is a
difficult problem and may require a pancreaticoduodenectomy. In case of chronic afferent loop
syndrome, conversion of a loop gastrojejunostomy to Roux-en-Y anastomosis addresses the
problem. Surgery is usually required for efferent loop obstruction and involves correction of the
underlying cause.
Nutritional consequences: Gastrectomy is associated with specific mineral and vitamin
deficiencies12 as described below.
Iron deficiency: Iron deficiency is the most common cause of anemia after gastrectomy. Iron
malabsorption, decreased intake, and increased losses from friable mucosa are reasons for iron
deficiency. Daily supplementation of 150 to 300 mg per day in divided doses should be provided.
Vitamin B12 deficiency: Reduction in production of intrinsic factor and decrease in stomach acidity
thus decreasing absorption of vitamin B12 leads to vitamin B12 deficiency. Daily supplementation of
100 μg of oral vitamin B12 or a monthly 1 mg intramuscular vitamin B12 injection is recommended
following subtotal gastrectomy.
Other mineral and vitamin supplementation: Decreased oral intake and decreased absorption
due to decreased gastric acid secretion can contribute to folate deficiency thus supplementation of
folate is also recommended. Supplementation of vitamin D and calcium is also recommended after
gastric surgery.
REFERENCES
1. Dudeja V, Habermann EB, Abraham A, et al. Is there a role for surgery with adequate nodal evaluation
alone in gastric adenocarcinoma? J Gastrointest Surg. 2012;16(2):238-246; discussion 246-237.
2. Dudeja V, Habermann EB, Zhong W, et al. Guideline recommended gastric cancer care in the elderly:
insights into the applicability of cancer trials to real world. Ann Surg Oncol. 2011;18(1):26-33.
3. Abdalla EK, Pisters PW. Staging and preoperative evaluation of upper gastrointestinal malignancies.
Semin Oncol. 2004;31(4):513-529.
4. Sarela AI, Lefkowitz R, Brennan MF, et al. Selection of patients with gastric adenocarcinoma for
laparoscopic staging. Am J Surg. 2006; 191(1):134-138.
5. Abe S, Yoshimura H, Tabara H, et al. Curative resection of gastric cancer: limitation of peritoneal lavage
cytology in predicting the outcome. J Surg Oncol. 1995;59(4):226-229.
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6. Bentrem D, Wilton A, Mazumdar M, et al. The value of peritoneal cytology as a preoperative predictor in
patients with gastric carcinoma undergoing a curative resection. Ann Surg Oncol. 2005;12(5): 347-353.
7. Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. N Engl J
Med. 1999;340(12):908-914.
8. Cuschieri A, Weeden S, Fielding J, et al. Patient survival after D1 and D2 resections for gastric cancer:
long-term results of the MRC randomized surgical trial. Surgical Co-operative Group. Br J Cancer. 1999;
79(9-10):1522-1530.
9. Edge SB, Byrd DR, Compton CC, et al. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer;
2010.
10. Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery
alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001;345(10):725-
730.
11. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for
resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11-20.
12. Mulholland MW. Complications in General Surgery. Philadelphia, PA: Lippincott Williams & Wilkins;
2006.
Chapter 20
Minimally Invasive Total Gastrectomy
Elliot Newman
Marcovalerio Melis
DEFINITION
Please refer to the Minimally Invasive Distal Gastrectomy chapter for details on definitions and
indications.
Currently, total gastrectomy is indicated for adenocarcinoma of the stomach where the proximal location
precludes a lesser resection with a proximal 5- to 6-cm grossly negative margin.
Randomized trials have shown that total gastrectomy offers no oncologic value over a distal gastrectomy
as long as a negative margin can be obtained.1,2
Occasionally, gastrointestinal stromal tumors located near the gastroesophageal junction may also
require a total gastrectomy to achieve negative resection margins.

Following the diagnosis of gastric adenocarcinoma, accurate clinical staging is necessary.
Endoscopic ultrasound will evaluate depth of tumor invasion and possible lymph node metastases
Computed tomography (CT) scan of the chest abdomen and pelvis will evaluate for metastatic disease.
Positron emission tomography (PET)/CT is recommended if no metastatic disease is detected by the CT.
Diagnostic laparoscopy can be considered for advanced tumors (e.g., T3N1) to rule out subradiographic
peritoneal dissemination.
SURGICAL MANAGEMENT
Same as Minimally Invasive Distal Gastrectomy. Please refer to the appropriate chapter.
Positioning
Same as Minimally Invasive Distal Gastrectomy (FIG 1)
Please refer to the appropriate chapter for further details.
FIG 1 • Positioning of the patient on the operative table.
TECHNIQUES
ACCESS AND PORT PLACEMENT
Same as Minimally Invasive Distal Gastrectomy, except for the camera port, which is placed routinely
two to three fingerbreadths above the umbilicus and to the left of the midline, and a 15-mm trocar used
for the most lateral trocar site on the left (FIG 2).
Please refer to the appropriate chapter for further details.
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FIG 2 • Port placement for laparoscopic distal gastrectomy. Depending on surgeon’s preference for liver
retraction, either a 5-mm trocar is placed at the epigastrium for a Nathanson retractor or a 10-mm trocar is
placed in the lateral right upper quadrant for a fan retractor.
DISSECTION OF THE GREATER CURVE

Retract the transverse colon and the greater omentum caudally.
Access the lesser sac by entering the gastrocolic ligament in an avascular area with ultrasonic shears.
Extend the dissection of the gastrocolic ligament distally toward the pylorus and cephalad toward the
spleen with the ultrasonic shears.
Continue the dissection of the gastrocolic ligament along the upper third of the greater curvature with the
division of the left gastroepiploic vessels and then the gastrosplenic ligament including the short gastric
vessels. This portion of the dissection is greatly facilitated by bringing the stomach down and rolling it up
to expose the back wall of the stomach.
By performing the dissection of the greater curvature lateral to the gastroepiploic arcade, the lymph
nodes along the gastroepiploic vessels (stations 4d and 4sb) are included in the specimen.
In order to expose the lesser cavity in its entirety, divide the avascular posterior gastropancreatic
adhesions that are almost always present between the posterior wall of the stomach and the anterior
surface of the pancreas. Division of those adhesions will also facilitate anterior retraction of the stomach
(FIG 3).
FIG 3 • The stomach is retracted anteriorly to the patient’s right, and adhesions between pancreas and
posterior aspect of the stomach are divided.
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Next, continue the dissection more cranially along the greater gastric curvature, until all of the short
gastric vessels are divided and the fundus is completely mobilized. At this time, the left crus and the
hiatus with the distal esophagus should be visualized (FIG 4). Having the operating surgeon retract the
anterior fundus toward the anterior abdominal wall and to the patient’s right with the assistant retracting
the posterior fundus in the same direction can improve the exposure.
Using the ultrasonic dissector, divide the lateral portion of the phrenoesophageal ligament and expose
the fibers of the left crus.
FIG 4 • The greater curvature is completely dissected off the spleen and the stomach is elevated and
rotated to the right, exposing the diaphragmatic hiatus.
ANTRAL DISSECTION
Firm anterior retraction of the stomach aids in the duodenal dissection. While retracting the antrum
toward the abdominal wall, separate bluntly or with Endoshear the posterior wall of the duodenum off the
anterior surface of the pancreatic head. The gastroduodenal artery marks the limit of this
pancreaticoduodenal dissection (FIG 5).
FIG 5 • The antrum and the first portion of the duodenum are dissected off the pancreas. The
gastroduodenal artery marks the limit of the duodenal dissection. The right gastroepiploic artery is
identified at its takeoff from the gastroduodenal artery.
Identify the origin of the right gastroepiploic artery. This is usually a direct continuation of the
gastroduodenal
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artery caudally emanating from the inferior edge of the pancreas. Use the lower border of the pancreas
as a guide for where to divide the right gastroepiploic artery.
Sweep the lymphatic tissue around the right gastroepiploic vessels (infrapyloric nodes, station 6) toward
the specimen. Now, divide the right gastroepiploic vessels between clips or using a vascular load stapler.
If clips have been used in proximity of the vessels, take great care to ensure they are not included in the
stapler line.
The right gastric artery can be dissected from behind the stomach and duodenum with good visualization.
Dissect the filmy adhesions superior and posterior the first portion of the duodenum until the right gastric
artery is visualized. Sweep the lymphatic tissue around the right gastric artery toward the specimen. This
maneuver clears the suprapyloric lymph nodes (station 5).
You can also retract the duodenum caudally and visualize the right gastric artery anteriorly at its takeoff
from the common hepatic artery. Dissect it free, doubly clip, and divide it.
DIVISION OF THE DUODENUM
Remove nasogastric tubes and/or temperature probes from the patient’s mouth to prevent their inclusion
in the jaws of the stapler.
Make sure adequate length of duodenum is mobilized to easily allow placement of a linear stapler across
the first portion of the duodenum, just distal to the pylorus.
Place an Endo GIA with 3.5-mm cartridge close to the level of the duodenal dissection to avoid the pyloric
ring and minimize duodenal ischemia. We often use a staple line reinforcement of biologic material,
although usefulness of this device for prevention of postoperative leakage has not been proven. Before
firing, make sure that any esophageal tube has been removed and that the portal structures are excluded
from your stapler line.
Make every attempt to divide the duodenum in one firing. Carefully inspect the integrity of duodenal
staple line.
DISSECTION OF THE HEPATODUODENAL LIGAMENT
Incise the peritoneum overlying the common hepatic artery and the bile duct with the hook electrocautery.
Divide the gastrohepatic ligament, remaining along the left lobe of the liver and paying attention to
identify and preserve an accessory or replaced left hepatic artery.
Identify the base of the right crus.
The lymph nodes along the common hepatic (station 8) and proper hepatic (station 12) arteries are
removed en bloc just anterior to the portal vein. Our preference is to use the hook for dissection and the
ultrasonic scalpel for division of larger vessels. Frequently, a vessel loop around the hepatic artery aids
in retraction.
DISSECTION OF THE INTRAABDOMINAL ESOPHAGUS
Have the assistant retract the stomach down and to the patient’s left. This will improve exposure to the
right crus, which had been previously identified.
Free the gastroesophageal junction from the hiatus by dissecting up the right crus with ultrasonic shears.
Take down the phrenoesophageal ligament and proceed through the connective tissue posterior to the
esophagus to extend the dissection toward the left crus.
Divide the right and left vagus nerves when identified.
The gastroesophageal junction is now dissected circumferentially. Guide a 2-cm wide Penrose drain
around the esophagus. Secure the two ends of the Penrose together with an Endo GIA stapler (Covidien,
Norwalk, CT) or an Endo loop, leaving little space between the drain and the esophageal wall.
The assistant may now use the Penrose drain to retract the esophagus caudally and increase exposure
of the hiatal region. Complete the dissection of the lower esophagus using blunt and ultrasonic
dissection.
DIVISION OF THE LEFT GASTRIC ARTERY
Use either the Nathanson liver retractor or a handheld retractor to elevate the stomach and identify the
left gastric artery and the celiac trunk.
The left gastric vessels at this time should be readily identifiable caudad to the Penrose drain, between
the two “windows” created by the hiatal dissection, and by the opening of the gastrohepatic ligament.
Once the celiac anatomy is evident, dissect the left gastric artery and skeletonize its takeoff from the
celiac trunk, therefore mobilizing nodal tissue of station 7 (left gastric artery) and 9 (celiac artery)
anteriorly toward the specimen. Once the left gastric pedicle is skeletonized, divide it at its origin, using a
2.5-mm Endo GIA cartridge flush, with the anterior pancreatic body. Our practice is to take the coronary
vein and the left gastric together in a single fire of the stapler.
Once the left gastric artery is divided, skeletonize the splenic artery thus mobilizing station 11 nodes.
Again, vessel loops may aid in retraction of the larger arteries in concert with gentle downward retraction
of the
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pancreatic body. Care must be taken to identify and preserve the splenic vein.
We do not routinely include the peritoneum covering the anterior surface of the pancreas in our
dissection.
We do not routinely perform a splenectomy or a distal pancreatectomy, because in the western literature,
potential benefits of a complete dissection of the lymph nodes in station 11 is outweighed by a significant
increase in postoperative morbidity (specifically pancreatic leaks) without measurable effect in long-term
survival.
PROXIMAL DIVISION
Division of the left gastric artery will increase exposure to the hiatus.
With the assistant pulling on the Penrose to retract the stomach caudally, complete (if necessary) the
mobilization of the intraabdominal esophagus using ultrasonic shears.
Place two stay sutures on each side of the esophagus, proximally to the planned division. Those sutures
will facilitate retrieval of the esophagus should it retract in the mediastinum after removal of the specimen.
Transect the distal esophagus using a 3.5-mm Endo GIA of appropriate length.
The specimen is placed in a 15-mm endo bag and extracted by enlarging as needed the most lateral
trocar site on the left. If you have to make a large incision to remove the specimen, you may need to use
a ballooned trocar for this site to seal the peritoneal cavity and avoid loss of the pneumoperitoneum.
Obtain hemostasis.
The stump of the excised portion of esophagus may be submitted for frozen section examination to
assure a microscopically negative margin.
RECONSTRUCTION WITH STAPLED ESOPHAGOJEJUNOSTOMY
Our choice for the reconstruction is a Roux-en-Y esophagojejunostomy in an antecolic fashion, using an
endto-end anastomosis (EEA) OrVil™ stapler device with a 25-mm diameter. Alternatively, a 21-mm
diameter EEA stapler can be used for a smaller caliber esophagus.
The OrVil™ is a device prepared with an EEA anvil head fastened in a tilted state to a long polyester
tube.
End-to-side esophagojejunostomy
Exposure of the distal esophagus is facilitated by gentle tension on the stay sutures previously placed.
Insert the OrVil™ device through the patient’s mouth and guide it into the esophagus until the tip
reaches the stapled line at its blinded end.
Create a small esophagotomy in the midportion of the stapled line, and let the tip of the OrVil™ pass
through it.
Use a grasper inserted through a left trocar to pull the tube outside the esophagus, until the anvil is
seen effacing the stapled line at the end of the esophageal stump. You must pay extreme attention
during this maneuver, as it is relatively easy to tear the esophagus. Maneuvers that assist in passing
the OrVil™ include adequate paralysis, jaw thrust, and deflating the balloon in the endotracheal tube.
The anvil head and the tube are kept connected by two pieces of polyester yarns; while securing the
anvil, cut one thread and detach the tube from the anvil.
Identify the ligament of Treitz at the base of the transverse mesocolon. Proper anatomy is confirmed by
visualization of the inferior mesenteric vein.
Divide the jejunum 20 cm away from the ligament of Treitz with a 3.5-mm Endo GIA.
Starting from the mesenteric side, remove most of the stapled line from the distal limb of the divided
jejunum. Make sure not to completely excise the stapled line from the jejunum, but leave it attached to
the antimesenteric side; you can use it as a handle to facilitate maneuvering this loop of bowel over the
stapler.
Remove the trocar from the left lateral incision and use this opening to insert the EEA stapler into the
abdomen. Enlarge this incision as needed to accommodate the EEA. Usually, two fingerbreadths are
sufficient. Your assistant should now use two graspers to grab the mesenteric side and the thin strip of
jejunum with the staples still attached to the antimesenteric side. While your assistant provides
adequate exposure of the jejunal lumen with the two graspers, guide the EEA inside the lumen of the
jejunum.
Select an appropriate site on the antimesenteric side of the jejunum for the esophagojejunostomy.
Make sure it can easily reach the esophageal stump without tension.
Once you are satisfied with the site for the anastomosis, advance the spike of the EEA through the
antimesenteric wall of the jejunum.
Ask your assistance to maintain tension on the jejunum, so that it does not retract off the EEA. Paying
extreme attention to keep the spike of the EEA through the jejunotomy, advance the EEA toward the
esophageal stump (FIG 6).
Firmly hold the anvil with a right-angle grasper, and use the other hand to progressively guide the
spike of the EEA into the anvil until the two parts of the stapler click together.
Now close the EEA while advancing it toward the esophagus in order to avoid excessive tension of the
anvil against the esophageal stapled line.
The anvil and the main unit are now connected. Make sure that nothing is caught between the
esophagus and the jejunum while you fire the EEA stapler. Fire the stapler to complete the
anastomosis.
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FIG 6 • An end-to-side esophagojejunostomy is created with a mechanical stapler. The assistant holds
the jejunum to avoid its displacement off the stapler. The surgeon advances the stapler over the colon
toward the anvil while avoiding excessive tension of the anvil against the esophageal stapled line.
Use a 3.5-mm Endo GIA to close the open end of the jejunum. Our practice is to leave approximately 3
cm of jejunum as blind end.
Side-to-side jejunojejunostomy
The jejunojejunostomy is typically created 40 to 50 cm distal to the esophagojejunostomy.
Use stay sutures to secure in a side-to-side fashion the stapled end of the biliopancreatic limb to the
alimentary limb of the jejunum, just caudal to the transverse colon and avoiding any tension.
Use the ultrasonic shears to make a small enterotomy in the antimesenteric side of each limb.
Insert the jaws of a 3.5-mm Endo GIA in the enterotomies. Make sure that no mesentery or other loops
of bowel are caught in the stapler prior to firing.
Once the stapler is fired, the staple line is inspected for bleeding.
Close the remaining anastomotic defect, which corresponds to the proximal end of the staple rows in
two layers using running nonabsorbable suture.
CLOSING
Complete a final inspection of all staple lines and vascular pedicles for hemostasis and well-formed
staples. Bleeding points and areas of malformed staples should be oversewn with absorbable suture.
Closed suction drainage is optional.
Abdominal fascia is closed for all port sites larger than 5 mm.
POSTOPERATIVE CARE
We usually keep a nasojejunal tube for 24 hours in order to avoid distension of the proximal jejunum, which
may compromise the integrity of the anastomosis. Whether this decreases the leak rate has not been proven.
Immediately after surgery, the patient is instructed to use incentive spirometry, cough, and take deep breaths.
Patients are encouraged to stay out of bed and ambulate within 6 hours from surgery.
Prophylactic antibiotics are not indicated in the postoperative period.
Unless an epidural catheter is used for analgesia, the Foley catheter is removed in postoperative day 1.
If the patient is able to protect his or her airway and the abdomen is not distended, clear liquids are allowed on
postoperative day 1, then diet is advanced to a postgastrectomy diet as tolerated.
OUTCOMES
Minimally invasive total gastrectomy is a safe and effective treatment of gastric cancer.
Available evidence shows no major differences in morbidity, mortality, number of nodes harvested, or
disease-free survival.
The addition of a D2 dissection elevates this operation to much higher difficulty level.
Oncologic principles and safety are paramount and should not be sacrificed for a less invasive approach.
COMPLICATIONS
The postoperative complications observed after minimally invasive total gastrectomy generally are
comparable with those of an open procedure.
Intraoperative
Bleeding
Splenic injury
Iatrogenic enterotomy
Early postoperative
Esophagojejunal leak
Duodenal leak
Bleeding
Late postoperative
Dumping
Afferent limb syndrome
Malnutrition
REFERENCES
1. Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year
survival rates in a multicenter randomized Italian trial. Ann Surg. 1999;230:170-178.
2. Gouzi JL, Huguier M, Fagniez PL, et al. Total versus subtotal gastrectomy for adenocarcinoma of the
gastric antrum: a French prospective controlled study. Ann Surg. 1989;209:162-166.
Chapter 21
Minimally Invasive Distal Gastrectomy
John K. Saunders
Marcovalerio Melis
DEFINITION
The indications for minimally invasive distal gastrectomy (MIDG) do not differ from the indications for
open gastrectomy and include both benign and malignant diseases.
Gastric malignancies (adenocarcinomas, neuroendocrine tumors, gastrointestinal stromal tumors [GIST],
and other submucosal neoplasms) account for the single largest indication for gastric resection and will
be the focus of this chapter.
MIDG performed for malignancies should follow the same standard oncologic principles generally
followed during open resections.
For adenocarcinomas, gastric resection should be extended proximally for 5 to 6 cm from the gross tumor
margins. For tumors of the distal stomach, this is generally achievable with a partial gastrectomy.
Randomized trials have shown that total gastrectomy offers no oncologic value over a distal gastrectomy
as long as a negative margin can be obtained.1,2 Appropriate extent of lymphadenectomy for gastric
adenocarcinoma in the western population is a topic of great debate and beyond the scope of the present
chapter. In our practice, we usually perform a D2 lymph node dissection. A recent meta-analysis has
shown that MIDG for gastric adenocarcinoma is safe and associated with reduced overall morbidity.3
Comparative studies with long-term follow-up are still lacking, but available evidence suggests that
oncologic outcomes are comparable after either MIDG or open distal gastrectomy. Perioperative
chemotherapy is indicated for any gastric adenocarcinoma stage T2N0M0 or greater as recommended by
National Comprehensive Cancer Network (NCCN) guidelines.
For GIST, gastric resection follows different oncologic principles. A lymph node dissection is not required
and surgery is considered curative as long as the resection margins are negative. Therefore, more limited
resections (e.g., wedge resections) are appropriate for GIST. Partial gastrectomies may still be required
for large tumors or when the gastroesophageal junction or the pylorus is involved.
Although decreasing in frequency, complications of peptic ulcer disease (bleeding, gastric outlet
obstruction, failure of medical treatment) are still significant indications for distal gastrectomy. The same
technique described in this chapter may be used for benign pathologies, omitting the lymphadenectomy.

Following the diagnosis of gastric adenocarcinoma, accurate clinical staging is necessary.
Endoscopic ultrasound will evaluate depth of tumor invasion and possible lymph node metastases.
Computed tomography (CT) scan of the chest abdomen and pelvis will assess metastatic disease.
Positron emission tomography (PET)/CT is recommended if no metastatic disease is detected by the CT.
Diagnostic laparoscopy can be considered for advanced tumors (e.g., T3N1) to rule out subradiographic
peritoneal dissemination but not routinely indicated.
SURGICAL MANAGEMENT
The choice of laparoscopic versus open techniques should be at the discretion of the surgeon.
Regardless of the technique, the primary goals of the operation are the same: resection of the cancer with
negative margins and restoration of intestinal continuity.
The patient should be medically optimized for surgery. Special attention needs to be given to malnourished
patients.
Preoperative nutritional panels are mandatory, and occasionally, the placement of a preoperative feeding
jejunostomy is warranted. Consider preoperative tube feedings in patients with significant weight loss or other
evidence of malnutrition, especially if candidates for neoadjuvant treatment.
Consider neoadjuvant treatment for lesions T2 or greater and/or for suspected lymph node involvement.
Insist on smoking cessation to reduce postoperative pulmonary and wound complications.
Consider a preoperative liquid protein diet to improve steatohepatitis in obese patients.
Perioperative antibiotic should be given within 30 minutes prior to the initial skin incision.
Deep vein thrombosis (DVT) prophylaxis with calf length pneumatic compression devices or subcutaneous
heparin (or both) should be instituted prior to induction of anesthesia.
General anesthesia may be supplemented with epidural analgesia.
The bladder is decompressed with a Foley catheter.
An orogastric or a nasogastric tube is inserted.
Positioning
Use an operating room (OR) table that may accommodate very steep reverse Trendelenburg position.
Preferred position is supine split leg with foot plate attachments to prevent patient migration. The foot plates
should be snugly placed with the toes pointing slightly outward (FIG 1).
Pad pressure points along arms and legs and secure the knees in the locked position. Pillow cases or folded
sheets and 2-in silk tape can be used to keep the knees from buckling. Arms are secured either by Kerlix???
gauze wrapped around the armboard or by commercially made arm straps.
Prior to prepping and draping, check the positioning by manipulating the bed in all of the positions that will be
used during the operation.
P.186
FIG 1 • Positioning of the patient on the operative table.
TECHNIQUES
ACCESS AND PORT PLACEMENT
Port placement is dictated by the body habitus of the patient. The umbilical trocar is generally used for
the camera. In obese patients, or with an unusually low umbilicus, the camera port may need to be more
cephalad, often two or three fingerbreadths above the umbilicus and left to the midline.
Place a 10-mm trocar at the umbilicus with usual Hassan technique.
Establish a 15 mmHg pneumoperitoneum and perform a diagnostic laparoscopy to rule out peritoneal or
hepatic metastases. If metastatic lesions are suspected, they should be biopsied and sent for frozen
section prior to committing to gastrectomy. If ascites is present, washings should be performed.
Identify the neoplasm by visualization or by palpation. If unsuccessful, intraoperative endoscopy is
encouraged.
Place the patient in steep reverse Trendelenburg position and insert the trocars under direct visualization
and in a direction that minimize torque. Our typical port setup is shown in FIG 2.
Retract the liver with a subxiphoid Nathanson retractor. However, stiff or floppy livers are best retracted
with a 10-mm handheld fan retractor from the patient’s right side.
FIG 2 • Port placement for laparoscopic distal gastrectomy. Depending on surgeon’s preference for liver
retraction, either a 5-mm trocar is placed at the epigastrium for a Nathanson retractor or a 10-mm trocar is
placed in the lateral right upper quadrant for a fan retractor.
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GASTROCOLIC DISSECTION
Reflect the greater omentum cephalad. Retract the transverse colon caudally.
Mobilize the omentum off of the transverse colon using ultrasonic scissors. In the course of this
mobilization, the lesser sac is entered. It is helpful to widely open the lesser sac in order to aid the
anterior retraction of the distal stomach.
Care must be taken to preserve at least the most proximal short gastric vessels to assure adequate
perfusion to the remnant stomach.
Lysing the gastropancreatic adhesions is helpful in obtaining the proper retraction.
ANTRAL DISSECTION
Once the greater curvature is fully mobilized, complete the gastric dissection by dividing sharply any
gastropancreatic or retrogastric adhesions until the entire posterior wall of the stomach are visualized in
its entirety (FIG 3).
Firm anterior retraction of the stomach aids in the duodenal dissection. By retracting the antrum toward
the abdominal wall, the duodenum may be freed from the anterior surface of the pancreatic head. The
gastroduodenal artery marks the limit of this pancreaticoduodenal dissection.
Identify the origin of the right gastroepiploic artery (which corresponds to lymph node station 6 [FIG 4]).
This is usually a direct continuation of the gastroduodenal artery, caudally emanating from the inferior
edge of the pancreas. Use the lower border of the pancreas as a guide for where to divide the right
gastroepiploic artery.
FIG 3 • Posterior dissection of the antrum. The stomach is retracted anteriorly to the patient’s right, and
adhesions between pancreas and posterior aspect of the stomach are divided. The first portion of the
duodenum has to be completely mobilized in order to allow safe use of the Endo GIA stapler for its
transection.
FIG 4 • The right gastroepiploic artery is divided between clips or using a stapler or energy-sealing
device.
Sweep the lymphatic tissue around the right gastroepiploic vessels toward the specimen. Then divide the
right gastroepiploic vessels between clips or using a vascular load stapler. If clips have been used in
proximity of the vessels, take great care to ensure they are not included in the stapler line.
The right gastric artery can be dissected from behind the stomach and duodenum with good visualization.
Dissect the filmy adhesions superior and posterior to the first portion of the duodenum until the right
gastric artery is visualized. You can also retract the duodenum caudally and visualize the right gastric
anteriorly at its takeoff from the common hepatic artery. Dissect it free, doubly clip, and divide it.
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DIVISION OF THE DUODENUM
Remove nasogastric tubes and/or temperature probes from the patient’s mouth to prevent their inclusion
in the jaws of the stapler.
Make sure adequate length of duodenum is mobilized to easily allow placement of a linear stapler across
the first portion of the duodenum, just distal to the pylorus.
Place an Endo GIA with 3.5-mm cartridge close to the level of the duodenal dissection to avoid the pyloric
ring and minimize duodenal ischemia. We often use a staple line reinforcement of biologic material,
although usefulness of this device for prevention of postoperative leakage has not been proven. Before
firing, make sure again that any esophageal tube has been removed and that portal structures are
excluded from your stapler line.
Make every attempt to divide the duodenum in one firing. Carefully inspect the integrity of the duodenal
staple line.
DISSECTION OF THE HEPATODUODENAL LIGAMENT
Incise the peritoneum overlying the common hepatic artery and the bile duct with the hook electrocautery.
Take care to identify aberrant left hepatic arteries. Divide the entire lesser omentum remaining along the
left lobe of the liver.
The base of the right crus is identified.
Identify the hepatic artery and skeletonize it, mobilizing stations 12, 5, and 8. Our preference is to use the
hook for dissection and the ultrasonic scalpel for division of larger vessels. Frequently, a vessel loop
around the hepatic artery aids in retraction.
DIVISION OF THE LEFT GASTRIC ARTERY
Use either the Nathanson liver retractor or a handheld retractor to elevate the stomach and identify the
left gastric artery and the celiac trunk.
Once the celiac anatomy is evident, dissect the left gastric artery and skeletonize its takeoff from the
celiac trunk by mobilizing station 9 nodal tissue anteriorly. Once the left gastric pedicle is skeletonized,
divide it at its origin using a 2.5-mm Endo GIA cartridge flush with the anterior pancreatic body (FIG 5).
Our practice is to take the coronary vein and the left gastric together in a single fire.
Once the left gastric artery is divided, skeletonize the splenic artery thus mobilizing station 11 nodes.
Again, vessel loops may aid in retraction of the larger arteries in concert with gentle downward retraction
of the pancreatic body. Care must be taken to identify and preserve the splenic vein.
FIG 5 • Elevating the stomach toward the abdominal wall and to the patient’s right helps identification and
isolation of the left gastric artery, which is then divided with a vascular stapler. Hepatic and splenic arteries
should also be identified prior to firing the stapler.
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PROXIMAL DIVISION OF THE STOMACH
Divide the greater omentum and the gastroepiploic arcade (may use a vascular stapler) at the level
chosen on the greater curvature for the proximal resection margin.
Divide the stomach, taking care to achieve a minimum of 5- to 6-cm margin of normal stomach from the
tumor. Our choice is Endo GIA 4.8-mm cartridge with bioabsorbable buttressing.
The specimen is placed in a 15-mm endo bag and extracted via the 15-mm trocar in the right
midclavicular line.
Oversew any bleeding points with absorbable suture.
RECONSTRUCTION WITH STAPLED ANASTOMOSIS
Our choice for the reconstruction is a stapled antecolic isoperistaltic gastrojejunostomy.
Identify the ligament of Treitz at the base of the transverse mesocolon. Proper anatomy is confirmed by
visualization of the inferior mesenteric vein.
Use an umbilical tape cut to 40 cm to identify the jejunal loop to be used for the anastomosis. Make sure
that this loop of jejunum can lie next to the gastric pouch without tension. If tension is encountered, the
approach should be converted to a retrocolic position. If additional length is required, consider a Roux-
en-Y reconstruction and/or mobilization of the intraabdominal esophagus and esophageal hiatus to
decrease the anastomotic tension.
Use stay sutures to secure the jejunum to the lesser curvature of the stomach. The planned line of the
gastrojejunal anastomosis should be 2 to 3 cm from distal resection margin to ensure adequate blood
supply.
Use the ultrasonic shears to make a small enterotomy and a small gastrotomy that can accommodate the
Endo GIA stapler.
At this point, you should have an idea regarding the thickness of the stomach. A thicker stomach requires
a 4.8-mm stapler; otherwise, use a 3.5-mm cartridge (FIG 6).
Once the stapler is fired, the staple line is inspected for bleeding.
Close the remaining anastomotic defect which corresponds to the proximal end of the staple anastomosis
in two layers using running absorbable suture.
Reconstruction With Hand-Sewn Anastomosis
Depending on the skill set of the surgeon, a hand-sewn gastrojejunostomy may be accomplished either
intracorporeally or through a carefully positioned midline or subcostal small incision. For extracorporeal
anastomoses, it is our practice to use a wound protector; this incision can also be used to extract the
operative specimen.
FIG 6 • A mechanical linear stapler is used for the hepaticojejunostomy. The stapler should be introduced
from the afferent limb side. This maneuver minimizes the risk of anastomotic stricture of the efferent limb
when closing the anastomotic defect used for introduction of the stapler.
CLOSING
Complete a final inspection of all staple lines and vascular pedicles for hemostasis and integrity. Bleeding
points and areas of malformed staples should be oversewn with absorbable suture.
Closed suction drainage is optional.
Abdominal fascia is closed for all port sites larger than 5 mm.
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POSTOPERATIVE CARE
We usually keep a nasogastric tube for 24 hours in order to decrease gastric distension, which may
compromise the integrity of the anastomosis. Whether this decreases the leak rate has not been proven.
Immediately after surgery, the patient is instructed to use an incentive spirometer, cough, and take deep
breaths. Also, patients are encouraged to ambulate within 6 hours from surgery.
Prophylactic antibiotics are not indicated in the postoperative period.
Unless an epidural catheter is used for analgesia, the Foley catheter is removed in postoperative day 1.
If the patient is able to protect his or her airway and the abdomen is not distended, clear liquids are allowed on
postoperative day 1, then diet is advanced as tolerated.
OUTCOMES
Available evidence shows no major differences in morbidity, mortality, number of nodes harvested, or
disease-free survival.
MIDG is a safe and effective treatment of gastric cancer.
The addition of a D2 dissection elevates this operation to much higher difficulty level.
Oncologic principles and safety are paramount and should not be sacrificed for a less invasive approach.
COMPLICATIONS
The postoperative complications observed after MIDG generally are comparable with those of an open
procedure.
Intraoperative
Bleeding
Splenic injury
Iatrogenic enterotomy
Early postoperative
Gastrojejunal anastomotic leak
Duodenal leak
Bleeding
Late postoperative
Dumping
Afferent limb syndrome
Marginal ulcer
Bile reflux gastritis
Malnutrition
REFERENCES
1. Bozzetti F, Marubini E, Bonfanti G, et al. Subtotal versus total gastrectomy for gastric cancer: five-year
survival rates in a multicenter randomized Italian trial. Ann Surg. 1999;230:170-178.
2. Gouzi JL, Huguier M, Fagniez PL, et al. Total versus subtotal gastrectomy for adenocarcinoma of the
gastric antrum: a French prospective controlled study. Ann Surg. 1989;209:162-166.
3. Zorcolo L, Rosman AS, Pisano M, et al. A meta-analysis of prospective randomized trials comparing
minimally-invasive and open distal gastrectomy for cancer. J Surg Oncol . 2011;104:544-551.
Chapter 22
Proximal Gastrectomy
Sushanth Reddy
Martin J. Heslin
DEFINITION
Proximal gastrectomy is defined as a procedure to remove the upper third to one-half of the stomach and
the distal portion of the esophagus. This is a procedure to remove cancers or premalignant lesions in the
cardia of the stomach, the gastroesophageal (GE) junction, or the distal esophagus. Proximal
gastrectomy is usually used in conjunction with systemic chemotherapy and external beam radiation for
malignant lesions in this area.

Patients typically present with difficulty swallowing, dysphagia, upper gastrointestinal (GI) bleeding, or reflux
symptoms, especially in the setting of unexplained weight loss. Initial diagnostic evaluation typically includes
an esophagogastroduodenoscopy (EGD) with biopsy showing malignancy.
A thorough history and physical examination should be performed prior to surgery. Particular attention should
be paid to cardiac and pulmonary comorbidities and nutritional status. Risk factors for cancer including acid
reflux disease, history of Barrett’s esophagus, and tobacco use should be identified.
Patients who have disease in the proximal to midesophagus should not undergo proximal gastrectomy.1 These
patients should be considered for either an Ivor-Lewis (Chapter 13) or transhiatal esophagectomy (Chapter
12).
All patients with cancer should undergo staging prior to consideration for surgery.
Patients with high-grade dysplasia or T1 tumors without lymph node metastases should be considered for
surgery first. Patients with advanced tumors (T2 or greater) or those with lymph node involvement should be
considered for upfront (neoadjuvant) chemotherapy and radiation therapy.2,3 Those patients who are
nutritionally depleted should have a feeding jejunostomy tube placed prior to initiating therapy.4
Following completion of chemotherapy and radiation therapy, patients should be restaged. The presence of
distant metastases is a contraindication for surgery.
The period of upfront therapy allows for optimization of cardiac and pulmonary comorbidities prior to surgery.

All patients should undergo staging evaluation prior to surgery. Endoscopic ultrasound (EUS) is used to
identify tumor depth (T stage) and regional lymph node metastases (N stage). Computed tomography (CT)
scan or positron emission tomography (PET) scan is used to identify distant metastases. The liver is the most
common site of distant metastases for adenocarcinoma and squamous cell carcinoma (the two most common
tumor histologies).
Staging should be repeated after the completion of upfront chemotherapy prior to surgery.
The celiac axis anatomy should be carefully studied prior to surgery to look for anomalies. Specific attention
should be paid toward an accessory or replaced left hepatic artery within the gastrohepatic ligament.
SURGICAL MANAGEMENT
Many patients with gastric or esophageal malignancy have comorbid conditions related to age or tobacco use.
These patients should undergo optimization of their comorbidities prior to surgery.
Anesthesia should consider placement of an arterial monitoring catheter and/or a central venous catheter.
During hiatal dissection, the heart may be compressed and invasive monitoring can be useful in guiding
resuscitation in the operating room.
A nasogastric (NG) tube will be placed during the operation. It may not be possible to pass an NG tube prior to
removal of the tumor (if it is obstructing). The surgeon should have good communication with anesthesia in
regard to NG tube position as it will be manipulated through the operation.
Positioning
The patient is positioned with both arms at 90 degrees with the torso. This will facilitate with exposure by
spreading the lower ribs laterally. Alternatively the right arm can be tucked to the patient’s side to aid in
attachment of the self-retaining retractor device to the operating room table. If a feeding jejunostomy tube has
already been placed, the tube should be prepped into the sterile field.
TECHNIQUES
DIAGNOSTIC LAPAROSCOPY
The abdomen is entered through the supraumbilical midline and a laparoscope placed (Chapter 21). The
entire abdomen should be evaluated with specific attention to the liver and the peritoneal surfaces for the
presence of metastatic disease. Any suspicious lesions should be biopsied and sent for frozen section
analysis in the pathology. The presence of metastatic disease is a contraindication for surgical resection.
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MOBILIZATION OF THE STOMACH
A formal laparotomy is performed and a self-retaining retractor is placed. Excision of the xiphoid process
may be used to aid with retraction (this allows for wider retraction of the costal margin).
The lesser sac is entered along the avascular plane that separates the gastrocolic omentum from the
transverse mesocolon. The dissection should proceed away from the greater curve of the stomach to
avoid injury to the right gastroepiploic artery. The right gastroepiploic artery will be the primary blood
supply of the residual stomach (FIG 1). The right gastric artery can be spared to keep the gastric conduit
well vascularized. Mobilization of the stomach is usually sufficient for resection and reconstruction for a
proximal gastrectomy without the need for ligation of the right gastric artery and a Kocher maneuver to
mobilize the duodenum (needed for transhiatal esophagectomy [Chapter 12] or Ivor-Lewis
esophagectomy [Chapter 13]).
The left lateral section of the liver is mobilized to expose the lesser curve of the stomach and the
esophageal hiatus: The left triangular ligament is incised. This is avascular. The falciform ligament may
also be incised to aid with visualization of the left triangular ligament (FIG 2). The ligament need not be
mobilized to its confluence with the falciform to avoid injury to the left hepatic vein. The gastrohepatic
ligament is divided. This structure is typically also avascular, but attention should be paid for any
accessory or replaced left hepatic artery (FIG 3). This will allow exposure of the esophageal crura.
The gastrosplenic ligament is divided between clamps and ties. The vasa brevia are individually
dissected and divided between ties. Alternative strategies for division of this structure would include an
advanced energy device or an articulating 45-mm stapler with vascular loads.
FIG 1 • The greater curve of the stomach is mobilized. Care is taken to stay outside the right
gastroepiploic artery as this is the vascular pedicle of the gastric conduit. This portion of the gastrocolic
omentum is typically avascular, although small blood vessels may be encountered requiring ligation. The
vasa brevia should be ligated as dissection proceeds cephalad.
FIG 2 • The left lobe of the liver is mobilized. The falciform ligament has already been divided and the left
triangular ligament is being incised. Both of these structures are avascular. The falciform ligament should
be divided near the liver. As dissection proceeds cephalad, the falciform will divide into the right and left
triangular ligaments when dissection is closer to the liver. If dissection is closer to the abdominal wall,
division of the falciform will lead into the hepatic venous confluence. Injury to one of these vessels can
lead to catastrophic blood loss.
The distal esophagus is circumferentially freed using a combination of sharp and blunt dissection. A
Penrose drain is placed around the esophagus to aid with retraction (FIG 4). The Penrose drain can be
used to retract the esophagus to expose the diaphragmatic hiatus and aid with lower mediastinal
dissection. The hiatal attachments of the esophagus are taken down with an advanced energy device.
The hiatus should be opened to facilitate dissection of the esophagus. During this dissection, it may be
necessary to put pressure on the heart to free the mediastinal attachments of the esophagus. The
proximal extent of the tumor and the length of the intraabdominal esophagus will dictate the amount of
mediastinal dissection necessary.
With the stomach reflected anteriorly, the left gastric vessels are ligated (FIG 5). Prior to ligation, the left
gastric artery is test clamped to make sure that flow remains in both the common hepatic artery and the
splenic artery. The left gastric artery is ligated at its root off the celiac trunk to facilitate appropriate
lymphadenectomy.
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FIG 3 • The lesser curve of the stomach is mobilized. By mobilizing the left lobe of the liver, the left lateral
section can be retracted to expose the gastrohepatic ligament. This is also typically avascular. Attention
should be given in case there is an accessory or replaced left hepatic artery. This can usually be seen on
preoperative contrast CT scans. By opening the gastrohepatic ligament, the diaphragmatic crura can be
visualized.
FIG 4 • The distal esophagus and GE junction are dissected. Once the stomach’s greater and lesser curve
have been mobilized, this dissection can be performed bluntly. In patients who have undergone
preoperative radiation therapy, scarring in this region can make dissection difficult. A Penrose drain is
placed around the esophagus. This drain allows the esophagus to be manipulated in all directions to aid
with transhiatal dissection. A sufficient length of esophagus should be mobilized into the abdomen so that
the proximal esophageal margin is grossly clear from the tumor. A high-energy device can be used to aid
with distal esophageal mobilization (minimizing blood loss seen with blunt or cautery dissection).
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FIG 5 • The left gastric pedicle is divided. The stomach should be reflected to expose the lesser sac. This
will facilitate exposure of the left gastric artery near its origin at the celiac axis. This structure should be test
clamped prior to ligation (pulses should be assessed in both the common hepatic and splenic arteries).
Ligation of the left gastric artery near its origin will facilitate with lymphadenectomy (for patients with
malignancy).
GASTROESOPHAGEAL RESECTION AND RECONSTRUCTION

Using the NG tube as a guide, place two purse-string sutures in the esophagus proximal to the neoplasm
(FIG 6). These will be an alternating horizontal mattress to ensure complete donuts after stapling. Do not
allow the sutures to go through the NG tube.
Anesthesia should retract the NG tube into the esophagus. Partially divide the esophagus with
electrocautery below the purse-string sutures and above the neoplasm. The posterior wall of the
esophagus and the purse-string sutures are used to keep the proximal esophagus in an intraabdominal
position. The anvil of a circular linear stapling device is placed in the esophagus and the purse-string
sutures are tied. The division of the esophagus is completed. The GE junction can now be delivered
extracorporally. A proximal surgical margin is sent for frozen section analysis. Typically, a 25-mm circular
stapler will be sufficient for reconstruction.
Multiple firings of the gastrointestinal anastomosis (GIA) linear stapler are used to both resect the
proximal stomach while tubularizing the remaining stomach for the reconstruction. The first staple load is
deployed perpendicular to the greater curvature of the stomach. The stapler is fired sequentially toward
the lesser curve, creating a gastric tube (FIG 7). The stomach should not be completely transected.
A gastrotomy is created along the lesser curve to allow placement of the handle of a circular stapling
device. This gastrotomy should be positioned so that it will be resected as part with additional firings of
the GIA linear stapler to completely transect the proximal stomach. The stapler is attached to its anvil in
the proximal esophagus and fired (FIG 8). The anastomotic donuts are examined to ensure that two intact
rings are present. The esophagogastrectomy is completed with additional firings of the GIA stapler to
excise the gastrotomy site, the proximal stomach, the tumor, and the distal esophagus. Tension from the
proximal esophagus will usually retract the anastomosis into the thorax. A closed suction drain should be
placed at the anastomosis. The NG tube should be advanced into the stomach.
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FIG 6 • The resection margins are planned. The proximal resection margin can be grossly approximated
based on the tumor’s location. Two purse-string sutures are placed on the esophagus just above the
planned proximal margin. The NG tube can be used as a guide to ensure the sutures are transmural (as the
needle meets resistance from the NG tube, it should be rotated away from the tube). The suture should not
pass through the NG tube. After the sutures are placed, the NG tube should be retracted into the
esophagus above the sutures. The anterior wall of the esophagus is then transected, and the anvil of a 25-
mm circular stapler is placed into the esophagus. The sutures are tied to keep the anvil in place. The
posterior wall of the esophagus is then divided. The distal esophagus and stomach can now be delivered
extracorporally. An esophageal margin should be sent for frozen section to ensure negative resection
margins (this can be taken from the distal esophagus above the tumor).
FIG 7 • A GIA stapler is then used to begin gastric transection. The first staple load should be horizontally
across the stomach just below the vasa brevia (to a portion of the stomach with vascular supply from the
right gastroepiploic artery). Subsequent staple loads should be fired in a manner to create a gastric tube for
the esophagogastrostomy anastomosis.
P.196
FIG 8 • Prior to completing the gastric resection, a gastrotomy is made in the lesser curve in a portion of the
stomach that will be transected with the GIA stapler. The handle of the circular stapler is inserted to create
an end-to-side esophagogastrostomy. The handle is opened so that it can dock with the anvil in the
proximal esophagus. This stapler is fired to create an end-to-side esophagogastric anastomosis. The
stapler is removed and the anastomotic donuts are retrieved. Both donuts should be intact. After removing
the circular stapler, additional firings of the GIA stapler are used to complete the gastric transection along
the lesser curve. The NG tube is then advanced into the gastric conduit and secured at the nose. A closed
suction drain is left in proximity of the anastomosis.
PYLOROMYECTOMY
The pylorus is identified by palpation and the presence of the vein of Mayo. Stay sutures are placed at
the 12 o’clock and 6 o’clock positions. The pylorus muscle is opened sharply and a piece of the muscle is
removed with a 15 blade knife to the level of the mucosa without entering the GI tract.
The pyloromyectomy is closed transversely with interrupted sutures (FIG 9).
If the mucosa is opened inadvertently, a Heineke-Mikulicztype pyloroplasty is performed instead (Chapter
17). A drain should be left in Morrison’s space (hepatorenal recess).5
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FIG 9 • A pyloromyectomy is performed. First, stay sutures are placed at the 6 o’clock and 12 o’clock
positions (to ligate the vein of Mayo). The serosa and submucosa of the pylorus are incised with a knife.
The mucosa should not be entered. In most patients, the pyloric muscle can be visible after sharp
transection. The pyloromyectomy should be closed transversely with interrupted sutures. If the mucosa is
opened, a Heineke-Mikulicz pyloroplasty should be performed. A closed suction drain should be placed.
FEEDING JEJUNOSTOMY
If a jejunal feeding tube has not already been placed, one should be created at this time (Chapter 25).4
PEARLS AND PITFALLS
Workup ▪ The nutritional status of the patients should be assessed prior to proximal
gastrectomy with strong consideration of a feeding jejunostomy tube prior to
attempting proximal gastrectomy.
▪ Careful preoperative and intraoperative staging should take place to assure that
there is no distant metastatic disease.
▪ Patients with comorbid conditions should undergo optimization of their

cardiopulmonary status prior to proximal gastrectomy.
Mobilization ▪ Care should be taken to avoid injury to the right gastroepiploic artery when
entering the lesser sac through the gastrocolic omentum.
▪ While mobilizing the lesser curve of the stomach, attention should be paid for a
replaced left hepatic artery.
▪ The left gastric artery should be test clamped prior to ligation in case there is a
celiac axis anomaly.
Postoperative ▪ The NG tube should not be manipulated or replaced blindly.
care
▪ Most postoperative leaks can be managed with drainage alone.
▪ Many patients will have symptoms of reflux requiring prolonged use of proton
pump inhibitors.
Nutrition ▪ The feeding jejunostomy tube should be left in place until the patient can
demonstrate adequate oral intake to maintain nourishment—especially if the
patient will undergo adjuvant therapy.
▪ If the patient does not have a feeding jejunostomy placed prior to operation, there
should be one placed in all cases of a proximal gastrectomy because leaks and
delayed gastric emptying are two major complications.
POSTOPERATIVE CARE
Most patients have medical comorbidities related to advanced age and tobacco use. Intensive care unit (ICU)
care with special attention to aspiration precautions should be considered for the immediate postoperative
period.
The NG tube should remain in place until a contrast esophagogastrogram is performed. If the NG tube is
inadvertently removed, it should not be blindly replaced.
On postoperative days 4 to 5, the anastomosis should be studied with a contrast esophagogastrogram. A
watersoluble contrast agent should be used initially followed by barium to evaluate for anastomotic leaks. After
a successful swallow study, the patient may begin oral nutrition.
The operative drain should be removed only after the patient starts an oral diet without clinical evidence of an
anastomotic leak.
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The feeding jejunostomy tube should be left in place to supplement nutrition until the patient reliably
demonstrates adequate oral intake to maintain nourishment.4
OUTCOMES
Reflux esophagitis and anastomotic strictures are present in up to 40% of patients undergoing proximal
gastrectomy.6
The overall survival for patients undergoing proximal gastrectomy is similar to other gastric resections
and is heavily dependent on tumor stage (5-year survivorship: stage I, 75% to 90%; stage II, 49%; stage
III, 13% to 33%; stage IV, 11%).7
COMPLICATIONS
If there is a small leak identified after the swallow study, replacement of an NG tube should almost never
be considered. Keeping the patient NPO with enteral nutrition solves the majority of these leaks.
Additional CT- or ultrasound-guided percutaneous drains should be considered if the surgical drain does
not adequately drain the leak. A contrast esophagogastrogram should be repeated prior to initiating oral
nutrition. An endoscopically placed covered stent may facilitate closure of a leak.
If a large leak is identified on the initial contrast study, consider early reoperative intervention. Options
can include wide drainage or conversion to an Ivor-Lewis or transhiatal esophagectomy. However, the
majority of the time, simply widely draining the region and controlling abdominal sepsis is the primary
focus of early reoperative surgery for leaks.
REFERENCES
1. An JY, Youn HG, Choi MG, et al. The difficult choice between total and proximal gastrectomy in proximal
gastric cancer. Am J Surg. 2008;196(4):587-591.
resectable gastric cancer. N Engl J Med. 2006;355(1):11-20.
3. Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared to surgery
730.
4. Llaguna OH, Kim HJ, Deal AM, et al. Utilization and morbidity associated with placement of a feeding
jejunostomy at the time of gastroesophageal resection. J Gastrointest Surg. 2011;15(10):1663-1669.
5. Nakane Y, Michiura T, Inoue K, et al. Role of pyloroplasty after proximal gastrectomy for cancer.
Hepatogastroenterology. 2004;51(60): 1867-1871.
6. Wen L, Chen XZ, Wu B, et al. Total vs. proximal gastrectomy for proximal gastric cancer: a systematic
review and meta-analysis. Hepatogastroenterology. 2012;59(114):633-640.
7. Kim JH, Park SS, Kim J, et al. Surgical outcomes for gastric cancers in the upper third of the stomach.
World J Surg. 2006;30(10):1870-1876.
Chapter 23
Total Gastrectomy for Cancer
Vikas Dudeja
Eugene A. Choi
Waddah B. Al-Refaie
DEFINITION
Total gastrectomy is removal of the stomach in its entirety including the gastroesophageal (GE) junction.
This is typically performed for patients with proximal gastric cancer, including Siewert type II and III GE
junction cancers,1 in whom a subtotal gastrectomy with 5- to 6-cm proximal margin does not leave a
reasonable gastric remnant. Rarely, diffuse involvement of stomach with malignant processes other than
gastric adenocarcinoma may warrant a total gastrectomy. Even though proximal gastric resection is
widely performed in Asia and select U.S. cancer centers for proximal gastric tumors, this procedure has
not gained wide adoption in western centers.2

Presentation: In the United States, most patients with gastric cancer are diagnosed at advanced stages.
Weight loss, anorexia, dyspepsia, progressive dysphagia, and early satiety are the most common symptoms.
Unfortunately, some of these symptoms (dyspepsia, nausea, anorexia) overlap with those of benign reflux
disease and explain the late presentation of proximal gastric cancers in the United States. Poor oral intake
because of cancer-induced anorexia and dysphagia contributes to patients’ weight loss. As such, patients with
more than 10% weight loss are at increased risk of perioperative complications. Thus, quantification of weight
loss in the preoperative period provides a meaningful estimate of nutritional status and helps in pretherapy
planning in terms of preoperative nutrition. Patients may also present with iron deficiency anemia due to occult
blood loss.
Evaluation of the performance status and frailty is important for the formulation of a treatment plan. Eastern
Cooperative Oncology Group's (ECOG) performance status scale provides a standardized method to assess
and compare performance status of the patient.3 Patients with ECOG performance score of 0 to 1 are
generally able to tolerate major oncologic resections. Those with a score of 2 may require individualized
decision making, factoring comorbidities into the overall treatment plan. Patients with a score of 3 and above
are unable to tolerate any major oncologic resection. Attention to pretherapy performance status and frailty are
critical, as these two important yet underassessed parameters correlate well with the ability to tolerate various
oncologic therapies, including major oncologic resection and systemic therapy.
Physical findings: In early stages, the physical examination is essentially normal. However, surgeons need
to look for signs of malnutrition. Patients with advanced-stage gastric cancer may present with supraclavicular
lymphadenopathy, pleural effusion, abdominal mass, hepatomegaly, malignant ascites, or drop metastases in
the form of “Blumer's shelf” appreciated on rectal examination. Presences of any of these physical findings
suggest unresectability.

Laboratory tests: Baseline hemoglobin, platelet count, and complete metabolic profile should be obtained.
Serum albumin and prealbumin are useful to guide assessment of nutritional status.
Diagnostic studies and staging evaluation: The evaluation of any upper gastrointestinal symptomatology
starts with an esophagogastroduodenoscopy (EGD), especially if gastric cancer is suspected. Endoscopy
provides histopathologic diagnosis as well as gives information on location and extent of gastric tumor, GE
junction involvement, presence of linitis plastica, and status of duodenal bulb (FIG 1A,B). Endoscopic
ultrasound (EUS), performed at the time of or subsequent to diagnostic endoscopy, provides the most
accurate estimation of the tumor depth (T stage) (FIG 1C) and can help in evaluation and needle biopsy of
surrounding lymph nodes.4 Furthermore, EUS provides information on the degree of distal esophageal
involvement.
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Cross-sectional imaging of abdomen and pelvis, in the form of a computed tomography (CT) scan (FIG 2) with
oral and intravenous (IV) contrast or magnetic resonance imaging (MRI), evaluates for presence of distant
metastatic disease to the liver and bulky lymphadenopathy. Metastases to lungs should be evaluated by CT
scan of the chest. The presence of bulky adenopathy has a prognostic value. However, it should not preclude
resection unless patient presents with diffuse adenopathy involving the periportal area or mesenteric vessels.
Positron emission tomography (PET)/CT scan has evolved as an additional radiographic staging modality to
exclude the presence of distant metastatic disease (FIG 3).
Staging laparoscopy: Peritoneal spread is part of the natural history of gastric cancer. Up to a third of the
patients who have localized disease on staging evaluation have unsuspected hepatic and/or peritoneal
disease.5 Thus, staging laparoscopy can prevent a nontherapeutic laparotomy in the setting of M1 disease.
The timing of staging laparoscopy may depend on the institutional preference with respect to neoadjuvant
versus adjuvant therapy. We recommend neoadjuvant chemotherapy for patients with proximal gastric tumors
and perform staging laparoscopy (with peritoneal cytology) before initiation of neoadjuvant therapy. We
selectively place feeding jejunostomy during staging laparoscopy, especially in persons who are old, frail,
have suboptimal performance status, or present with malnutrition. The patient then returns after completion of
neoadjuvant chemotherapy for restaging and definitive surgical treatment (i.e., gastrectomy).
Peritoneal cytology: The addition of peritoneal washing for cytology is an area of debate.6,7 We use this
diagnostic modality in patients at risk of undeclared metastatic disease or suboptimal performance status, as
patients with positive peritoneal cytology have unfavorable overall prognosis compared to those with negative
peritoneal cytology.
FIG 1 • Endoscopy and EUS are critical for the diagnosis and staging of gastric cancer. A. Endoscopic findings
in a 68-year-old male who presented with iron deficiency anemia and anorexia. An ulcerated adenocarcinoma of
the proximal third of the stomach was discovered. Patient underwent R0 total gastrectomy with
lymphadenectomy, and the final pathology report showed pT2 N0 (0/23) M0 disease. B. A retroflexed
endoscopic view of T2 gastric adenocarcinoma in gastric fundus. C. EUS helps with accurate preoperative T
staging of the lesion.
FIG 2 • Cross-sectional imaging with CT or MRI evaluates for distant metastatic disease and bulky adenopathy.
Abdominal CT scan in a patient with known high-grade neuroendocrine tumor. No liver metastases were noted.
Note diffuse nodular heterogeneous thickening of the stomach (white arrow).
SURGICAL MANAGEMENT
A complete margin-negative resection with an adequate lymphadenectomy is the most critical component of
therapy for operable gastric cancer.
Addressing preoperative malnutrition: Patients with proximal gastric cancer are at an increased risk of
being nutritionally compromised due to cancer-induced anorexia and dysphagia. These patients benefit from
preoperative enteral nutrition through a jejunostomy tube placed preoperatively during the staging
laparoscopy. The enteral nutrition through jejunostomy tube also helps with hydration and nutrition during
neoadjuvant therapy. A consultation with a dietitian with regard to nutritional optimization is recommended.
Evaluation of the patient's ability to tolerate the surgery: A careful review and optimization of underlying
comorbidities (e.g., cardiac, pulmonary, diabetes) and performance status should be considered in conjunction
with other supporting specialties. A subset of high-risk individuals may benefit from preoperative admission to
optimize nutrition, electrolyte imbalance, and performance status (e.g., physical therapy) in preparation for
their oncologic resection.
Evaluation of response to neoadjuvant therapy: At times, when neoadjuvant therapy is employed to
increase rates of R0 resection or spare the GE junction, a repeat posttherapy preoperative EGD provides
additional information on tumor response and the proximal extent of the tumor.
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Preoperative antibiotics: Patients should be given one dose of first- or second-generation cephalosporin for
perioperative antibiotic prophylaxis.
Positioning
In most patients, an upper midline incision provides optimal exposure for the procedure. The chest should be
prepped into the operative field for the possibility of needing a thoracotomy for GE junction tumors. A sandbag
can be placed under the left chest to facilitate thoracotomy.
FIG 3 • PET scan may help in the evaluation of disease spread. PET scan in a patient with known high-grade
neuroendocrine tumor demonstrates hypermetabolic activity (white arrow) in the stomach but no other organ.
This patient required total gastrectomy for complete disease clearance.
STAGING LAPAROSCOPY
Pneumoperitoneum is created by either an open technique or verse needle. A 30-degree scope is
inserted at the umbilicus. One to two additional 5-mm ports on either side of the umbilicus are needed for
optimal visualization, grasping of tissue, and biopsy of suspicious tissues. A complete survey of the
peritoneal cavity is performed, including undersurface of the diaphragm, liver surface, spleen, lining of
peritoneal cavity, pelvis, small bowel surface, and omentum for any metastatic disease. If any suspicious
lesion is observed, it is biopsied and sent for frozen section. In the setting of biopsy-proven peritoneal
disease, gastrectomy should not be performed and nonsurgical treatments should be initiated. However,
at times, surgeons are faced with a situation to carefully and selectively consider palliative surgical
procedures in the setting of metastatic disease, for example, bleeding or obstructing cancer not palliated
by endoscopic means. These decisions need to be individualized based on the performance status of the
patient, extent of metastatic burden, the projected survival, and the availability of adjunctive therapy such
as endoluminal stenting.
Peritoneal cytology: If the staging laparoscopy is negative for peritoneal spread, the procedure is
continued. We perform peritoneal cytology in the patients who do not have gross peritoneal metastasis.
For peritoneal cytology, 500 mL of normal saline is instilled into the abdominal cavity and allowed to dwell
for 10 to 15 minutes. During this time, the patient's table is moved from left to right to expose the
peritoneum to this fluid. After 10 to 15 minutes, the fluid is aspirated with a suction device, which has a
mechanism to trap the fluid. The fluid is then sent to the pathology lab, and in those with positive
peritoneal cytology, we favor not proceeding with resection.
When a laparoscopic feeding jejunostomy is to be placed, it is imperative that the surgeon performing the
staging laparoscopy and jejunostomy tube placement is cognizant of the need to construct a Roux limb
for the restoration of gastrointestinal continuity at the time of definitive surgery. Thus, the loop of jejunum
just distal to the ligament of Treitz, which would be used for fashioning the Roux limb, should not be used
for the placement of jejunostomy tube.
EXPLORATORY LAPAROTOMY AND MOBILIZATION OF THE LIVER
The abdomen is entered through a midline incision extending from the xiphoid process to just below the
umbilicus. A bilateral subcostal incision, approximately 2 cm below the costal margin, also provides good
exposure. During entry into the abdomen, the falciform ligament should be preserved as it can be used to
buttress the duodenal closure. A careful exploration of the peritoneal cavity is performed to exclude the
presence of subradiographic peritoneal or distant metastatic disease. The liver is carefully inspected and
palpated for any suspicious nodules.
For better access and visualization of the GE junction, we typically divide the left triangular ligament thus
mobilizing the left lobe of the liver. Once mobilized, the left lobe of the liver can be folded on itself thus
allowing better visualization of the GE junction and the right crus of the diaphragm.
MOBILIZATION OF THE GREATER CURVATURE OF THE STOMACH
In this step, the attachments of the greater omentum to the transverse colon are divided in an avascular
plane. The stomach and the greater omentum are reflected superiorly and the transverse colon is
reflected inferiorly. The plane of fusion between the greater omentum and the transverse mesocolon is
identified as a faint white line. This plane is entered by incising with electrocautery and, once properly
developed, allows access to the lesser sac (FIG 4). This plane of separation is then developed toward
both proximal and distal parts of the transverse colon thus completely separating the greater omentum
from the transverse colon and mobilizing it with the specimen.
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FIG 4 • Division of attachments of greater omentum to the transverse colon. Incision of avascular fusion
plane of greater omentum with the transverse colon/mesocolon separates greater omentum from the
transverse colon and provides access to lesser sac.
FIG 6 • Dissection of the infrapyloric nodal packet at the level of right gastroepiploic vessels.
The hepatic flexure of the colon is mobilized by division of the avascular attachment of the hepatic flexure
to the retroperitoneum. The separation of the greater omentum from the transverse mesocolon is carried
toward the hepatic flexure. This exposes the gastrocolic trunk, which is formed by the confluence of right
gastroepiploic vein with middle colic vein and drains into the superior mesenteric vein. The right
gastroepiploic vein is divided at its junction with the gastrocolic trunk (FIG 5). Alternatively, the
gastrocolic trunk can be divided with a single fire of a vascular stapler. At this stage, the right
gastroepiploic artery is divided at its origin from the gastroduodenal artery at the infraduodenal level. We
recommend additional time spent when performing this dissection in obese patients given the potential
difficulty in identifying this artery. Infrapyloric nodes, located adjacent at the origin of gastroduodenal
artery, are mobilized with the specimen (FIG 6).
Toward the left, the greater curvature of the stomach is mobilized up to the GE junction by division of the
short gastric vessels. These vessels are divided carefully to avoid troublesome bleeding or iatrogenic
splenic injury that may lead to splenectomy (FIG 7).
FIG 5 • Ligation of right gastroepiploic vein at its confluence with colonic veins. Alternatively, the gastrocolic
trunk can be divided with the single fire of a vascular stapler.
FIG 7 • Division of short gastric arteries. Short gastric arteries are divided between ligatures or using energy
devices. Care is taken to avoid iatrogenic splenic injury.
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MOBILIZATION OF THE LESSER CURVATURE OF THE STOMACH
Now, the lesser curvature is mobilized by dividing the lesser omentum as close to the liver as possible
(FIG 8). Care is taken to identify the presence of a replaced or accessory left hepatic artery. This
dissection is carried toward the portal triad. The right gastric artery arising from the common hepatic
artery is divided carefully, mobilizing the lymphatic tissue toward the specimen. At this point, duodenum is
circumferentially dissected about 2 to 3 cm distal to the pylorus, encircled with a Penrose drain and
divided with a stapler (FIG 9). Care is taken not to injure the bile duct, hepatic artery, and portal vein
while encircling the duodenum. The stapled duodenal line could be oversewn with 3-0 silk Lambert
sutures and buttressed with a healthy piece of falciform ligament (Moossa's patch). However, in the
setting of extensive inflammation around the periduodenal area (e.g., in the setting of chronic scarring
due to duodenal ulcer), consideration should be given to dividing the duodenal stump in between two
straight bowel clamps and suture closure of the duodenal stump.
Next, the gastrectomy specimen, which is disconnected distally, and the right gastric and right
gastroepiploic vessels have been divided, is lifted upward. The left gastric artery is identified, suture
ligated, and divided at its origin (FIG 10). The lymph-areolar tissue with the left gastric artery is mobilized
with the specimen.
FIG 8 • Division of lesser omentum. Lesser omentum is divided as close to the liver as possible. Presence
of a replaced or accessory left hepatic artery arising from the left gastric artery is carefully sought for.
FIG 9 • Division of the duodenum. Duodenum is circumferentially dissected, encircled with a Penrose, and
divided with GIA stapler blue or green load.
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FIG 10 • Division of the left gastric artery. The left gastric artery is divided at its origin. The lymph areolar
tissue around the origin of the left gastric artery is mobilized with the specimen.
ESOPHAGEAL TRANSECTION
After the division of the left gastric pedicle, the dissection continues upward, along the lesser curvature
and the ascending branch of the left gastric artery. The peritoneum anterior to the GE junction is divided.
The lymphoareolar tissue along and anterior to the upper part of the lesser curvature and the right aspect
of abdominal esophagus is mobilized to the left with the specimen. At this point, the gastrectomy
specimen is only anchored at the esophagus. Enough intrathoracic esophagus should be freed so that a
proximal margin of 4 to 5 cm from the tumor can be obtained and an anastomosis can be fashioned
without tension. At an appropriate point, the esophagus is divided between noncrushing clamps (FIG 11).
We do not preserve the vagus nerve and both anterior and posterior vagi are divided with the
esophagus. This allows for additional mobilization of the distal esophagus into the abdomen.
FIG 11 • Division of esophagus. Esophagus is divided at least 5 cm proximal to the most proximal extent of
the gastric tumor.
SPECIMEN PROCESSING
The operating surgeon is encouraged to hand carry the specimen to the pathologist to orient him/her with
the details of the resection and to perform frozen section assessments of the proximal and distal margins.
We typically send the resected specimen in separate containers in the following manner: (1) stomach
with a marking stitch on proximal end, (2) greater omentum, (3) infrapyloric nodal packet, and (4) lesser
curvature nodal packet with a long stitch on the left gastric artery.
Once the frozen section of the proximal margin comes back negative for malignancy, we proceed with
restoration of intestinal continuity.
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LYMPHADENECTOMY
The extent of lymphadenectomy in patients with operable gastric cancer is an area of controversy.
Western trials8,9 did not demonstrate the same survival advantage of D2 lymphadenectomy over D1
lymphadenectomy as demonstrated in eastern gastric cancer surgery trials. However, it has been
suggested that the excess mortality in the D2 lymphadenectomy arm in the Dutch gastric cancer trial8 and
the Medical Research Council Trial9 was due to the distal pancreatectomy and splenectomy. Thus, at
this time, we typically perform a pancreas-spleenpreserving D1 lymphadenectomy; that is, taking the right
gastric, right gastroepiploic artery, and left gastric arteries at their origin. We acknowledge that the
addition of a celiac axis dissection is an area of controversy.
RESTORATION OF INTESTINAL CONTINUITY
After total gastrectomy, the intestinal continuity is restored by Roux-en-Y esophagojejunostomy. The
length of the Roux limb from the esophagojejunal anastomosis to jejunojejunal anastomosis should be 40
to 60 cm to avoid biliary reflux esophagitis.
Construction of the Roux limb: While the pathology team is performing their frozen section on the
gastric margin, we simultaneously proceed with the reconstruction. A loop of jejunum distal to the
ligament of Treitz that will reach the transected esophagus without any tension is identified. Jejunum at
this point is divided with a blue gastrointestinal anastomosis (GIA) stapler. The staple line on the end of
the Roux limb is oversewn with 3-0 silk stitches in Lambert fashion. The Roux limb needs to be at least
40 cm (i.e., from its beginning at the level of anastomosis with esophagus to the jejunojejunostomy). A
defect is created in the transverse mesocolon to the left of the middle colic vessels (FIG 12). We then test
that the Roux limb can easily reach the esophagus in retrocolic manner without tension. Our preference
is to first perform the stapled side-to-side anastomosis between the biliopancreatic limb and the jejunum.
Our rationale behind this order is to allow for an easier reconstruction of this anastomosis away from the
mesenteric defect, which is typically the case once the Roux limb has been passed through the mesocolic
defect and esophago-jejunostomy has been done. Stay sutures are placed between the biliopancreatic
limb and the jejunum and enterotomies for insertion of the limbs of stapler are made. One limb of the blue
GIA stapler is introduced into the biliopancreatic limb and the other in the jejunum. The blue load is fired,
and the common enterotomy is either closed in a hand-sewn fashion or with a single fire of GIA or
thoracoabdominal (TA) stapler.
Esophagojejunal anastomosis: Next, the Roux limb is passed through the mesocolic defect to the left
of middle colic vessels, and esophagojejunal anastomosis is performed. The esophagojejunal
anastomosis can be fashioned either in hand-sewn or stapled fashion. We favor the hand-sewn
anastomosis as it is consistent with our academic mission of training residents in complex intestinal
anastomosis techniques. Also, we find the hand-sewn anastomosis more controlled with respect to
placement of sutures.
Hand-sewn anastomosis: Two seromuscular stay sutures, passing through the 3 o'clock and 9 o'clock
position on the esophagus and antimesenteric aspect of Roux limb, are placed to keep esophagus and
the Roux limb together while the anastomosis is being created. We prefer singlelayer end-to-side
anastomosis. An enterotomy is made on the antimesenteric border of the Roux limb with the help of the
electrocautery. The opening in the jejunum is kept smaller than that of the esophagus because the
jejunal opening tends to stretch and become bigger. A stay stitch on the anterior lip of the esophagus
helps to keep it open thus facilitating the anastomosis. First, the posterior layer of equally spaced
interrupted full-thickness 3-0 silk (or absorbable) sutures are placed (FIG 13A). Special attention should
be given to the corner stitches. All the sutures should be placed before tying. Once the posterior layer is
complete, the anterior layer is then performed with the placement of interrupted 3-0 silk (or absorbable)
sutures (FIG 13B). The knots on the anterior-layer sutures can be extraluminal. Before completion of the
anterior layer, a nasogastric (NG) tube is passed into the Roux limb and a small piece of Gelfoam is
placed in the lumen to help with hemostasis and to prevent inadvertent placement of anterior stitches
through the posterior wall. The jejunum could be tacked to the diaphragm to reduce the tension on the
anastomosis from the weight of the Roux limb.
FIG 12 • Creation of the defect in mesocolon. A defect is created in the mesocolon to the left of middle
colic vessels. The Roux limb is passed through this defect in a retrocolic fashion.
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FIG 13 • Hand-sewn esophagojejunal anastomosis. An end-to-side anastomosis is created between the

esophagus and the Roux limb. An enterotomy, smaller than the opening in the esophagus, is made in the
antimesenteric border of the Roux limb. First, the (A) posterior layer of interrupted absorbable sutures is
placed followed by (B) anterior layer of sutures.
Stapled anastomosis: For stapled anastomosis (FIG 14), an end-to-end anastomosis (EEA) stapler is
used. First, the size of the esophageal opening is measured by using calibrated sizers and the EEA
stapler is chosen on the basis of this measurement. Esophagus can also be gently dilated using a Foley,
which is inserted into the esophagus and then withdrawn gently with balloon inflated. In general, a 25-mm
EEA stapler is used for the esophagojejunostomy. A purse string is placed at the end of esophagus with
a 2-0 Prolene (FIG 14A). The anvil of the EEA stapler is now introduced into the esophagus and the
purse string is tied (FIG 14B). Next, the EEA stapler is introduced into the Roux limb preferably through
the end of the jejunum or through an opening created in the Roux limb and directed toward the
antimesenteric border of the Roux limb (FIG 14C). The pin of the EEA stapler is now opened with
anticlockwise rotation of the knob and brought out through the point on the antimesenteric border of the
Roux limb where the anastomosis is planned. This pin is attached to the anvil, stapler closed, and fired.
The operator of the stapler should familiarize himself/herself to the operation of the stapler as these may
differ from one company to the other. The doughnuts are checked for completeness and integrity. If the
stapler was inserted through the blind end of the jejunum, this can be stapled close after the anastomosis
is created.
Although we do not routinely employ the following additional step, some surgeons assess the integrity of
the anastomosis using an instilled methylene blue or air into the esophagus (through a tube in the
esophagus) while the Roux limb is clamped.
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FIG 14 • Stapled esophagojejunal anastomosis. A. Purse string is placed at the end of esophagus with a 2-
0 Prolene. B. The anvil of the EEA stapler is introduced into the esophagus and the purse string is tied. C.
The EEA stapler is introduced into the Roux limb through the end of the jejunum and directed toward the
antimesenteric border of the Roux limb. The pin of the EEA stapler is now opened with anticlockwise
rotation of the knob and brought out through the point on the antimesenteric border of the Roux limb where
the anastomosis is planned. This pin is attached to the anvil, stapler closed, and fired. The doughnuts are
checked for completeness and integrity.
CLOSURE
After the restoration of gastrointestinal continuity, a feeding jejunostomy is placed distal to the
jejunojejunal anastomosis. The patient may already have a feeding jejunostomy if one was placed during
staging laparoscopy before neoadjuvant therapy.
Prior to abdominal wall closure, we typically ensure absence of kinks, twists, or tension in the
reconstructed intestinal continuity.
PEARLS AND PITFALLS
Mobilization of ▪ Short gastric vessels should be carefully divided to avoid troublesome bleeding or
the greater iatrogenic splenic injury leading to inadvertent splenectomy.
curvature
Dissection of ▪ The origin of the right gastroepiploic artery from the gastroduodenal artery should
the infrapyloric be carefully dissected, especially in the obese patients, due to difficulty in
region identifying this vessel.
Dissection of ▪ Adequate length of the esophagus should be dissected to yield a tension-free

the GE junction esophagojejunal anastomosis.
Construction of ▪ The esophagojejunal sutures should be full thickness to ensure a robust

esophagojejunal anastomosis.
anastomosis
Feeding ▪ If the feeding jejunostomy tube is placed during the staging laparoscopy, the
jejunostomy surgeon should be cognizant of the need of constructing a Roux limb for the
tube restoration of gastrointestinal continuity at the time of definitive surgery. Thus, the
loop of jejunum just distal to the ligament of Treitz, which would be used for
fashioning the Roux limb, should not be used for the placement of jejunostomy tube.
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POSTOPERATIVE CARE
Similar to other major abdominal operations, patients who undergo total gastrectomy require close attention to
hemodynamics, optimization of fluid and electrolyte status, pain management, and pulmonary toilet.
We increasingly use pain blocks (epidural, paravertebral blocks) in the care of these patients.
NG tube is typically left to suction and is removed on postoperative days 3 to 4. If NG tube accidentally comes
out, it should not be replaced due to the concern for anastomotic disruption. If NG tube needs to be replaced,
it should be done under fluoroscopic guidance.
If patient does not demonstrate any symptoms and signs of anastomotic leak by days 5 to 7, then they can be
started on a clear liquid diet and then advanced to a postgastrectomy diet based on return of bowel function.
Postgastrectomy diet consists of six small meals instead of three large meals. Most patients with time are able
to liberalize the food choices as well as portion size.
OUTCOMES
Although older data from gastric cancer trials quote an 8% in-hospital mortality for patients with total
gastrectomy,2 in recent series, in-hospital mortality of 1% to 2%, anastomotic leak rate of 1% to 3%, and
duodenal stump leakage of less than 1% have been reported.10,11 The cancer-specific outcomes depend
on the stage of gastric cancer. Stage-specific 5-year survival of 57% to 71% for stage I, 33% to 45% for
stage II, 14% to 20% for stage III, and 4% for stage IV M0 (AJCC 1988) has been reported12 in the era
prior to widespread acceptance of adjuvant or perioperative therapies. In a landmark study evaluating the
role of adjuvant therapy in the treatment of stage Ib to IV resectable gastric cancer, addition of
chemoradiation to surgery alone improved the 3-year overall and relapse-free survival from 41% to 50%
and 31% to 48%, respectively. Similarly, perioperative chemotherapy without radiation for gastric cancer
leads to improvement of overall 5-year survival from 23% to 36%.13,14
COMPLICATIONS
Early surgical complications: Given the magnitude of surgery, total gastrectomy is associated with
multiple systemic complications such as pulmonary embolism, pneumonia, atelectasis, myocardial
infarction, and deep venous thrombosis. The diagnosis and management of these complications is no
different from that after other major operations. Complications related to technical, physiologic, and
anatomic aspect of total gastrectomy are described below.
Anastomotic leak
Presentation: Leak rates of 2% to 8% have been reported for esophagojejunal anastomosis. The
type of reconstruction (stapled vs. hand sewn) has not been shown to influence this complication.
This complication presents around postoperative days 6 to 9 and is heralded by unexplained fevers,
tachycardia, and systemic inflammatory response.
Investigation: When suspected, a gastrografin swallow (followed by use of barium if needed) is used
to evaluate for a leak. A CT scan with oral and IV contrast to evaluate for intraabdominal collections
should be obtained.
Management: Initial management consists of NPO, IV antibiotics, nutrition, either enteral through
feeding jejunostomy or parenteral, and drainage of any intraabdominal collection. Surgeons are
increasingly using placement of a stent to help seal operative anastomotic leaks. Presence of
feeding jejunostomy, which can help support the patient through enteral feeding, is very helpful in
this situation. The resolution of the leak can be monitored by weekly gastrografin study. Operative
exploration and repair is rarely required.
Postoperative intraluminal bleeding
Presentation: Bleeding from the anastomosis may present as sanguineous drainage from NG tube,
melena, and/or drop in hematocrit or hemodynamic alteration.
Management: Most bleeding episodes resolve in response to conservative management with limited
transfusion and correction of coagulopathy. Rarely, upper endoscopy with identification of bleeding
site and its control with electrocautery or clips is required. We typically use endoscopic intervention as
a last resort because of the fear of potential perforation.
Postoperative extraluminal bleeding
Presentation: Extraluminal bleeding presents in the early postoperative period as hemodynamic
instability and falling hemoglobin. Although many etiologies are likely, unrecognized injury to the
spleen, in the form of capsular tears or unligated short gastric arteries, is the most common reason for
significant extraluminal bleed.
Management: If splenic injury is recognized during the gastrectomy, then splenic capsular tears can be
managed by topical hemostatic preparation. Bleeding short gastric vessels can be managed with the
use of surgical clip placement or use of energy devices. Uncontrolled bleeding may warrant a
splenectomy. Postoperative bleeding that was not recognized during the procedure and is
unresponsive to hemodynamic support with correction of coagulation parameters mandates return to
the operating room with correction of underlying cause.
Duodenal stump breakdown
Presentation: Duodenal stump leak presents as signs and symptoms suggestive of intraabdominal
sepsis such as fever, tachycardia, increasing abdominal pain, and leukocytosis.15 An abdominal and
pelvic CT scan with oral and IV contrast reveals an intraabdominal collection in the vicinity of
duodenum requiring a percutaneous drain placement. If the drain output is bilious, it heightens the
suspicion of duodenal fistula, which is confirmed by performing a drain study once the drain output
does not decrease with time. Duodenal suture line failure can also present much more acutely in form
of duodenal stump blowout if there is a downstream obstruction. The fistula may be an end fistula
when it forms at the duodenal staple line or a lateral fistula when duodenum perforates laterally.
Management: Duodenal fistula is a difficult problem due to high volume loss of biliary and pancreatic
secretions. Management involves supportive treatment with parenteral nutrition, correction of
electrolyte abnormalities, antibiotics in early phase, and control of drainage with
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special attention to skin care. Supportive treatment for as long as 6 weeks may be attempted. If
resolution of duodenal fistula is not achieved, a percutaneous transhepatic tube can be advanced
through the bile duct and into the duodenum to allow for retrograde drainage and control. Surgical
management includes the take down of fistula, and duodenal reconstruction with Roux-en-Y end-to-
side duodenojejunostomy. If the duodenal blowout presents as acute abdomen, then exploratory
laparotomy, placement of a lateral tube duodenostomy, and wide drainage of right upper quadrant is
required.
Delayed complications
Nutritional deficiencies
Postgastrectomy diet: Patients postgastrectomy need to be started on postgastrectomy diet, which
involves taking six small meals a day due to the loss of storage capacity of the stomach. With time,
most patients can liberalize the volume and type of foods they consume. Some patients might be
able to tolerate a diet similar to what they consumed preoperatively.
Iron supplementation: Postgastrectomy patients need to be on iron supplementation as the
duodenum is the primary site of iron absorption and is bypassed. Also, the loss of gastric acidity
impairs the conversion of ferric iron to the more absorbable ferrous form; 150 mg to 300 mg per day
of elemental iron in three divided doses is recommended.
Vitamin B12 supplementation: Patients with total gastrectomy will develop vitamin B12 deficiency if
not supplemented. Reduction in intrinsic factor and loss of gastric acidity impairs its absorption. Oral
vitamin B12 (up to 100 μg per day) or monthly intramuscular vitamin B12 is recommended.
Supplementation of folate, calcium, and vitamin D is also recommended.
Presentation: Patients may present with dysphagia either early in postoperative period or many
years after the initial operation.
Management: The differential diagnosis for anastomotic stricture includes postoperative edema,
fibrosis/scarring, and local cancer recurrence. The diagnostic workup starts with contrast study
followed by endoscopy with biopsy. Dysphagia secondary to edema will resolve with no
interventions. Benign strictures can be managed by endoscopic or fluoroscopic balloon dilation.
There is an increasing role of self-expanding metal stent for this condition. If the stricture is due to
recurrent cancer, then the patient should be restaged and managed accordingly.
REFERENCES
1. Siewert JR, Stein HJ. Classification of adenocarcinoma of the oesophagogastric junction. Br J Surg.
1998;85(11):1457-1459.
2. Viste A, Haugstvedt T, Eide GE, et al. Postoperative complications and mortality after surgery for gastric
cancer. Ann Surg. 1988;207(1): 7-13.
3. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative
Oncology Group. Am J Clin Oncol. 1982;5(6):649-655.
4. Abdalla EK, Pisters PW. Staging and preoperative evaluation of upper gastrointestinal malignancies.
Semin Oncol. 2004;31(4):513-529.
5. Sarela AI, Lefkowitz R, Brennan MF, et al. Selection of patients with gastric adenocarcinoma for
laparoscopic staging. Am J Surg. 2006;191(1):134-138.
6. Abe S, Yoshimura H, Tabara H, et al. Curative resection of gastric cancer: limitation of peritoneal lavage
cytology in predicting the outcome. J Surg Oncol. 1995;59(4):226-229.
7. Bentrem D, Wilton A, Mazumdar M, et al. The value of peritoneal cytology as a preoperative predictor in
patients with gastric carcinoma undergoing a curative resection. Ann Surg Oncol. 2005;12(5): 347-353.
8. Bonenkamp JJ, Hermans J, Sasako M, et al. Extended lymph-node dissection for gastric cancer. N Engl J
Med. 1999;340(12):908-914.
9. Cuschieri A, Weeden S, Fielding J, et al. Patient survival after D1 and D2 resections for gastric cancer:
long-term results of the MRC randomized surgical trial. Surgical Co-operative Group. Br J Cancer.
1999;79(9-10):1522-1530.
10. Haverkamp L, Weijs TJ, van der Sluis PC, et al. Laparoscopic total gastrectomy versus open total
gastrectomy for cancer: a systematic review and meta-analysis. Surg Endosc. 2013;27(5):1509-1520.
11. Kim HS, Kim BS, Lee IS, et al. Comparison of totally laparoscopic total gastrectomy and open total
gastrectomy for gastric cancer. J Laparoendosc Adv Surg Tech A. 2013;23(4):323-331.
12. Stephen B, Edge DRB, Compton, CC, et al, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY:
Springer; 2010.
resectable gastroesophageal cancer. N Engl J Med. 2006;355(1):11-20.
14. Macdonald JS, Smalley SR, Benedetti J, et al. Chemoradiotherapy after surgery compared with surgery
730.
15. Mulholland MW. Complications in General Surgery. Philadelphia, PA: Lippincott Williams & Wilkins;
2006.
Chapter 24
Gastrostomy
John Daniel Hunter III
John Roland Porterfield Jr.
DEFINITION
A gastrostomy tube (G-tube) is a transcutaneous tube that is positioned in the lumen of the stomach. The
primary functions of the G-tube are enteral access for nutrition and gastric decompression. They can be
temporary or permanent depending on the patient’s underlying pathology and clinical needs.
A G-tube can be placed with an open, laparoscopic, endoscopic, or image-guided percutaneous
approach.

The history and physical exam should focus on the indication for enteral access, hemodynamic stability of the
patient, current functional status of the gastrointestinal (GI) tract, and previous GI or upper abdominal
surgeries.
Indications for G-tube include feeding access and gastric decompression. They also play a role as an
additional method of gastropexy following antireflux procedures or to prevent gastric torsion.
Patients who are hemodynamically unstable should not undergo elective G-tube placement. In these
scenarios, gastric access can be maintained through a nasogastric route.
Assessing the status of the GI tract is essential for operative planning and patient benefit.
If the G-tube is to be used for feeding, the patient should have a functional GI tract distal to the stomach and
without evidence of mechanical bowel obstruction, adynamic ileus, GI ischemia, or peritonitis.
Safe access to the stomach via the oropharynx and esophagus needs to be verified prior to proceeding with
percutaneous endoscopic gastrostomy (PEG) tube placement. If this route is obstructed or otherwise
unsafe, an open, laparoscopic, or image-guided percutaneous technique should be used.
In patients with esophageal pathology that may necessitate an esophagectomy, a G-tube should be avoided
because the stomach may be used as a conduit for reconstruction following esophagectomy. In this
scenario, a feeding jejunostomy is our preferred route of enteral nutrition.
A thorough surgical history is imperative prior to G-tube placement. Patients with a history of previous upper
abdominal or gastric surgery will be at higher risk for inadvertent colon or small bowel injury during PEG tube
placement. An extensive abdominal surgical history may prohibit safe laparoscopic or endoscopic G-tube
placement and thus an open technique may be the safest route.

Specific imaging or other diagnostic studies are generally unnecessary for G-tube placement. However, it is
often the case that patients have had a plethora of upper abdominal imaging for other reasons that may
provide valuable information or clues to previous unknown surgical procedures or unexpected anatomic
findings.
For PEG tube placement, it is important to look for structures, particularly the liver and transverse colon, which
may be resting anterior to the stomach along the line of the proposed G-tube tract. In patients with increased
risk of abdominal adhesions (i.e., previous operations, history of peritonitis) and radiographic evidence of
abdominal structures lying between the abdominal wall and stomach, PEG placement should be avoided in
favor of a laparoscopic or an open approach.
SURGICAL MANAGEMENT
The patient should be NPO for a minimum of 6 hours prior to the procedure.
Antibiotics should be given within 30 minutes of incision to reduce the incidence of abdominal wall infection
around the tube site. First-generation cephalosporins are our preference when not contraindicated by a
patient’s known allergies.
For patients undergoing a PEG tube placement, the patients should be provided an antiseptic mouth rinse to
reduce oral flora being carried into the abdominal wall soft tissues.
Positioning
For endoscopic or surgical G-tube placement, the patient should be positioned supine.
For laparoscopic placement, the patient should be supine with the right arm tucked to allow adequate room for
the surgeon and assistant to both work comfortably on the right side.
TECHNIQUES
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE PLACEMENT
Equipment
There are several PEG kits available. These vary depending on technique (push or pull) and tube
size (20 French [Fr] or 28 Fr). Most of these kits come with everything needed for placement,
including prep and sterile drapes. We use the Bard Ponsky PEG kit, 20 Fr.
A standard adult or pediatric endoscope is required, preferably with an external display so that both
operating surgeons can see the endoscopic view.
Endoscopy and Tube Site Selection by Transillumination

With an endoscopist at the patient’s head and surgeon scrubbed at the patient’s abdomen, the room
lights are dimmed and the endoscopist introduces the endoscope into the stomach.
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A quick look around the entire stomach is performed to rule out occult gastric pathology.
The endoscopist should fully insufflate the stomach.
The endoscopist should advance the polypectomy snare to the end of the scope then withdraw 2 cm so
that it is ready for the ensuing steps.
Transillumination will allow the surgeon to locate the appropriate place on the abdominal wall for the G-
tube to be placed. This is done by retracting the scope into the body of the stomach several centimeters
distal to the gastroesophageal junction and then directing it toward the anterior stomach.
Some endoscopic light sources offer a transilluminate feature that temporarily increases the light
intensity to enhance visualization through the abdominal wall by the surgeon.
Palpation is sometimes required to compress the tissue between the stomach and skin to better reveal
the light.
It is often necessary to darken the room to visualize the light.
Carefully palpate multiple areas and choose the spot with the brightest area of transillumination (FIG 1).
Ensure that the sight is at least 2 to 3 cm from the left costal margin for patient comfort.
Mark the spot with a marking pen or press the needleless tip of a Luer lock syringe into the skin to leave
an indentation mark.
Insertion of a fine 25-gauge or 27-gauge needle, as used for infusion of local anesthesia, may be used to
best identify the perfect placement position and tube track.
Optional Technique for Site Selection
For additional assurance that there is no intervening bowel between the tube site chosen by
transillumination and the stomach, the following technique can be used.1
Using a 10-mL syringe with several milliliters of saline and a small-gauge needle, advance the needle
perpendicularly through the abdominal wall at the spot previously chosen, keeping the plunger drawn
back.
FIG 1 • Transillumination of the abdominal wall.
Watch the saline in the syringe for air bubbles. If the initial presentation of bubbles is seen at the same
time the endoscopist sees the needle from inside the stomach, you can safely assume you have not
passed through any bowel before entering the stomach.
If you see bubbles before the endoscopist sees the needle from inside the stomach, you may be
passing through bowel and thus should choose another point of entry and repeat (FIG 2).
During this process, it is important to limit the force applied to the abdominal wall as this may compress
a portion of an unexpected piece of bowel lying along the proposed track.
Tube Placement
Infiltrate the site chosen with local anesthetic and make an approximately 0.5-cm skin incision with a no.
11 blade.
The endoscopist should advance the previously positioned polypectomy snare and center the loop over
the area of the mucosa that was identified during abdominal wall site selection. This type of
synchronization and planning not only facilitates a timely procedure but also avoids visceral movement
once the best site is selected (FIG 3).
The needle with the angiocath is then placed through the abdominal wall at the designated site and
advanced into the stomach under direct visualization into the loop created by the polypectomy snare. The
needle is then removed while the angiocath is left in place (FIG 4A).
The snare is left loose.
The looped wire or the stiffer guidewire (see “Push Technique”) is advanced through the angiocath.
After several centimeters are passed through the snare, the snare loop is tightened around the wire (FIG
4B).
The scope is then completely withdrawn while the polypectomy snare is held snug around the wire,
pulling the wire through the abdominal wall. This leaves the wire passing through the abdominal wall via
the angiocath, into the stomach, through the esophagus, and out of the mouth.
At this point, there are two techniques available— “push” and “pull”—that can be chosen based on
available supplies and surgeon’s preference.
Pull Technique
The looped wire that was pulled through the stomach to the mouth is connected to the looped wire at the
tapered external end of the PEG tube (FIG 5).
The surgeon then pulls the suture from the abdominal wall end, advancing the PEG tube through the
esophagus into the stomach. The endoscopist should follow the tube down to visualize from within the
stomach. To save time, the polypectomy snare can be cinched around half of the button of the PEG tube
to allow the scope to easily follow the tube while it is being pulled by the surgeon (FIG 6).
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FIG 2 • A. Bubbles are seen at the same time as the endoscopist sees the needle, confirming intragastric
positioning without intervening bowel. B. Bubbles are seen before the needle is seen by the endoscopist,
suggesting bowel between the stomach and abdominal wall.
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FIG 3 • The snare is positioned against the mucosa where the needle is intended to pass.
When the tapered end of the PEG tube begins to come through the abdominal wall, additional force
directed perpendicular to the abdominal wall is required to pull the tube through (FIG 7).
The tube should be pulled until the button is resting loosely against the gastric mucosa.
FIG 4 • A. The needle and angiocath are advanced into the stomach in the center of the snare by the
surgeon. The needle is removed. B. The wire is passed through the angiocath into the stomach and
through the center of the snare. The snare is then tightened around the wire.
FIG 5 • With the looped wire exiting the patient’s mouth, the tapered end of the PEG tube is secured to
the wire. There is often a wire loop on the PEG to facilitate this attachment. Pass the wire through the
loop (A) and around the button end of the tube (B). Pull the rest of the tube through the wire (C) so that
they are now secured together (D).
The endoscopist should confirm position of the button to rule out bleeding while the surgeon notes the
thickness of the abdominal wall when securing the bolster.
Push Technique
This technique requires a stiffer guidewire to be used.
The G-tube is inserted over the wire by the endoscopist and advanced while tension is held on the wire
by both the surgeon and endoscopist.
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FIG 6 • The snare can be tightened around half of the PEG flange to facilitate prompt scope reentry into
the stomach.
The tube is then pushed until the surgeon is able to grasp the tapered end as it emerges through the
skin.
The surgeon then pulls the tube until the button rests loosely against the gastric mucosa, as described
earlier.
Securing the Tube
The outer bolster included in the kit is then applied to the external portion of the tube and directed toward
the skin.
The bolster should rest about 2 to 3 mm above the skin.
Avoid compressing the abdominal and gastric wall between the bolster and button (FIG 8). This can
cause ischemic necrosis to these tissues, potentially leading to abdominal wall infection, tube extrusion,
or the stomach falling away from the abdominal wall.
The kit manufacturers often recommend and provide antibiotic ointment to be applied to the interface of
the tube as it enters the skin to decrease the formation of an abdominal wall infection.
The tube is then cut to the appropriate length and an adapter is secured to the end to allow a sealed
connection for feeding, drainage, or to secure the cap to prevent leakage.
We connect a collection bag during the immediate postoperative period to allow the GI tract to be
decompressed of any gas that was insufflated during the procedure and to decrease the risk of reflux
during emergence from sedation.
FIG 7 • Once the tapered end of the PEG is seen exiting through the abdominal wall, a steady pull directed
toward the ceiling by the surgeon is required to advance the PEG tube to its final position.
FIG 8 • The bolster is advanced so that it is just touching and depressing the skin.
OPEN GASTROSTOMY TUBE
Equipment
A standard laparotomy setup should be used.
For the G-tube, a 22-Fr Foley catheter or the G-tube from a laparoscopic G-tube kit can be used.
There are commercially available G-tubes that allow simultaneous gastric decompression and
jejunal feeding, which may be beneficial in some scenarios.
Incision
When done as a single procedure, a 4-cm upper midline incision to expose the stomach should be used
(FIG 9).
Just beneath the linea alba, the extraperitoneal fat and the falciform ligament should be retracted to the
right to assist with visualization of the left upper quadrant.
A small wound protector functions well as a retractor and limits the subcutaneous tissues exposure to
contamination from the gastric flora.
Gastrotomy and Tube Placement
The location of the gastrotomy should be on the anterior surface of the midportion of the stomach, close
to the greater curve (FIG 10). Mark this point with the cautery or a surgical marking pen.
Using a 3-0 absorbable monofilament suture on a taper needle, sew a circular purse string around the
gastrotomy site with a diameter of about 1 cm. Place a second purse string around the first one
concentrically taking care to create a purse string diameter of approximately 2 cm. This allows the gastric
wall to partially intussuscept, creating nice track for the tube (FIG 11).
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FIG 9 • Open G-tube incision.
Next, grasp the left linea alba at the exposed incision with an atraumatic clamp and elevate the left
abdominal wall. Pick a point through the middle of the left rectus muscle where the tube will exit the
abdominal wall. Make sure that this is at least two fingerbreadths below the left costal margin and at the
approximate level of the gastrotomy. Make a 5-mm incision in the overlying skin and pass a fine clamp
through the rectus from the peritoneum through the 5-mm incision in the skin. Grasp the end of the
catheter and bring it through the abdominal wall (FIG 12). Care should be taken during this process to
avoid injury to the balloon on the tip of the catheter and its integrity should be checked at this point by
infusing sterile water ( not saline) into the balloon.
FIG 10 • Preferred location of gastrostomy on anterior surface of the stomach.

FIG 11 • Using nonabsorbable suture, a double purse-string stitch is placed around the enterotomy site.
The inner circle should be about 1 cm in diameter and the outer should be about 2 cm in diameter.
Using the point of a cautery device, make a small gastrotomy in the center of the purse string and confirm
entry into the stomach. Do not dilate the gastrotomy (FIG 13).
Place the catheter through the gastrotomy into the stomach. Starting with the inner stitch, tie the two
purse-string sutures down around the catheter. Inflate the balloon with 10 mL of water. Do not secure too
tight as to close off the catheter or cause ischemia to the gastric wall (FIG 14).
Fixation (Optional)
In some scenarios, the stomach or gastric remnant in patients with a history of a gastric bypass may not
reach the abdominal wall; in this case, fixation should be avoided. When this is the case, it is
advantageous to pass the tube through a small portion of omentum prior to insertion through the
gastrotomy so that the omentum is readily able to begin forming a healthy track between the abdominal
wall and the gastric lumen.
FIG 12 • The left linea alba is grasped and retracted medially. A skin incision is made at the G-tube site
and a Kelly clamp is passed through the abdominal wall and out through the skin incision. The enteral
end of the G-tube is then pulled through the abdominal wall.
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FIG 13 • Cautery is used to create a gastrotomy at the center of the purse string.
When fixation is desired, the goal is to secure the stomach to the abdominal wall at the point where the
tube passes through the rectus. This seals the tract made by the tube and helps to prevent gastric
content spillage into the peritoneal cavity.
Using a 3-0 absorbable suture on a taper needle, place four separate stitches through the seromuscular
layer of the stomach and peritoneum of the abdominal wall. This should be done four times around the
point where the tube enters the abdominal wall. Start with the lateral (furthest) stitch first, then superior,
inferior, and finally medial. Secure each suture after it is placed and do not tie them until the end. Once
all four sutures have been placed, tie them down in the order they were placed while relaxing on the
retraction of the left abdominal wall.
Before tying, ensure that the stomach is not on too much tension or twisted in any way.
Closure
Close the abdomen in standard fashion.
Secure the tube to the skin with a 3-0 nylon suture to prevent the tube from being dislodged.
If a manufactured G-tube was used, the supplied bolster may be used to secure the tube along with a
nylon suture. Make sure that the bolster is not too tight to prevent abdominal wall or gastric wall ischemia.
The bolster should rest without tension 2 to 3 mm above the skin (FIG 8).
FIG 14 • The tube is inserted into the stomach through the gastrotomy and the purse strings are tied,
starting with the inner circle.
We connect a collection bag during the immediate postoperative period to allow the GI tract to be
decompressed of any gas that was insufflated during the procedure and to decrease the risk of reflux
during emergence from sedation.
LAPAROSCOPIC GASTROSTOMY TUBE
Equipment and Port Placement
Several commercial laparoscopic G-tube kits are available. We use the Flexiflo Lap G™ by Abbot
Nutrition. This section will describe G-tube placement using this kit. The steps described can be modified
for other kits and the package inserts for each kit should be read as they often pertain pertinent pearls for
success.
A standard laparoscopic setup including a 5-mm 0-degree or 30-degree laparoscope and a single 5-mm
port is used.
The procedure can be accomplished with only one periumbilical port for the camera so long as there are
no adhesions that need to be taken down and the stomach can be insufflated by anesthesia via an
orogastric tube. If these conditions cannot be met, additional ports may be needed to lyse adhesions
and/or manipulate the stomach. The ports should triangulate toward the stomach in the left upper
quadrant (FIG 15).
The T-fasteners used in this procedure aid in providing traction for the stomach while the tract is being
dilated and the G-tube is being placed. This is very helpful when only a single laparoscopic port is used
for the
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camera and no additional laparoscopic instruments are used. However, if an additional instrument port
has to be placed for adhesions or stomach manipulation as mentioned earlier, the T-fasteners can be
eliminated from the procedure and the extra instrument port can provide the traction on the stomach
during the dilation and tube placement steps.
FIG 15 • Port placement for laparoscopic G-tube.
Tube Placement
Once laparoscopic access has been gained and all necessary adhesions have been cleared, anesthesia
should insufflate the stomach via an orogastric tube. Pick a site in the left upper quadrant where the G-
tube should enter the abdomen. The entry point should be at least two fingerbreadths below the left
costal margin. The surgeon should palpate in this general area while watching the laparoscopic screen to
find the place where the depressed abdominal wall lines up with the stomach. Avoid placing the tube too
close to the gastroesophageal junction or antrum to avoid obstruction. The anterior surface of the
midbody closer to the great curvature is the preferred location (FIG 10).
Mark the tube site on the skin and then mark points 2 cm in four directions around the tube site for the T-
fasteners.
Starting with the most superior mark, insert the needle with the loaded T-fastener through the abdominal
wall angled slightly toward the center mark. Once the needle is seen in the peritoneal cavity, direct it to
point around the proposed gastrostomy site that corresponds to the skin location. Advance the needle
with the loaded T-fastener into the stomach up the double-line marking. Press the plunger on the needle
to deploy the T-fastener (FIG 16). Place a clamp on the T-fastener tail approximately 1 to 2 cm from the
skin.
FIG 16 • The sequence of steps for T-fastener placement is shown here. Note the insertion of the needle
to the double black bar marking before deployment of the T-fastener.
Repeat the step to deploy the remaining three T-fasteners. Ask anesthesia to remove some air from the
stomach so that the stomach begins to fall away from the abdominal wall. The anterior wall of the
stomach should be visible with the four T-fasteners entering in
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an approximate diamond shape (FIG 17). The center of diamond will be the tube insertion site.
FIG 17 • Final view after all T-fasteners have been placed.
Make a 5-mm skin incision at the chosen tube site and direct the 18-gauge needle with a 40-mL slip-
tipped syringe through the abdominal wall and into the peritoneal cavity. Under direct visualization with
the laparoscope, direct the needle into the stomach through the point at the center of the diamond
created by the T-fasteners (FIG 18). The T-fasteners can be used to manipulate the stomach to guide
entry of the needle. Insufflate air to be absolutely certain that the tip of the needle is intraluminal.
Pass the supplied wire into the stomach and remove the needle.
Using the supplied serial dilators, dilate the tract through the abdominal and gastric wall. The stomach
should be just off the abdominal wall during this step so that the dilators can be seen exiting the
abdominal wall and passing into the stomach. A back-and-forth twisting motion can help when advancing
the dilators through the tissue (FIG 19).
FIG 18 • The large-bore needle is directed into the stomach through the center of the T-fasteners.
FIG 19 • The dilator is passed over the wire though the abdominal wall and into the stomach.
Once the track is sufficiently dilated, insert the smallest dilator through the tube and guide the tube over
the wire into the stomach (FIG 20).
FIG 20 • The smallest dilator is inserted into the G-tube and two are guided over the wire through the
tract and into the stomach. The wire and dilator are removed together leaving the tube in place.
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Remove the wire and dilator together. Inflate the balloon port with 18 to 20 mL of water and pull back the
tube back so the stomach rests against the abdominal wall. The outer flange should be advanced so that
it rests just on the skin. Too much squeeze between the outer flange and intraluminal balloon can result
in gastric and/or abdominal wall necrosis (FIG 8).
In a similar manner, gently pull the T-fasteners individually so that the stomach rests just on the
abdominal wall and crimp them into position using a needle driver. This will leave small cotton bolsters
against the skin that may be removed by cutting the sutures below the bolsters 2 weeks after the
procedure (FIG 21).
FIG 21 • The T-fasteners are gently retracted so that the stomach is secured against the abdominal wall
and crimped into place.
PEARLS AND PITFALLS
Indications ▪ Be certain that a G-tube best fits the needs of the patient. Frequently, physicians
may request a G-tube when in reality the patient needs a jejunostomy tube (J-tube) or
vice versa.
Preprocedure ▪ Review previous upper abdominal procedures or history of peritonitis that may have
planning scarred another piece of bowel along the proposed track of the G-tube.
▪ Be prepared to sufficiently darken the room for transillumination.
Patient ▪ Position the patient supine with the entire abdomen exposed to be prepped once a
position suitable site is identified for tube placement.
Tube site ▪ The skin incision should be at least 2 cm inferior to the costal margin.
selection
▪ The gastrotomy site should nicely line up without tension with the site for the tube to
course through the abdominal wall.
PEG ▪ Enter slowly with the needle watching for any bubbles in the syringe before the tip
of the needle is seen by the endoscopist, which would indicate the traverse of
another hollow viscus.
Laparoscopic ▪ Position the patient supine with the right arm tucked to allow a comfortable working
G-tube space for the surgeon and the laparoscopic assistant on the right side of the patient.
Open G-tube ▪ Place the second purse-string suture at least 1 cm outside the first so that the
gastric wall will intussuscept into the gastric lumen thereby creating a secure track
around the tube.
Securing the ▪ Do not secure the bolster on the tube too tightly against the skin as it may result in
tube necrosis of the skin or the gastric wall.
Postprocedure ▪ Leave the tube to gravity drainage initially to decompress any excess gas within the
care proximal GI tract and to reduce the risk of reflux upon emergence of sedation.
▪ An abdominal binder is helpful for securing the tube and preventing premature or
inadvertent removal during patient movement or in a patient with impaired mental
status.
POSTOPERATIVE CARE
For gastric decompression, the tube should be left to gravity drainage via a collection bag. The gastric tube
should never be hooked up to low wall suction. The tube does not have a sump port and if suction is applied,
it will adhere to the posterior gastric wall and cause suction necrosis, bleeding, and/or perforation.
Tube feedings may be started the evening of the procedure at a low rate, usually about 10 mL per hour. If the
patient tolerates this, he or she can advance by 10 mL per hour every 4 hours until the nutritional goal is
reached.
Care should be taken to avoid the tube catching or pulling while the patient is moving or if the patient’s
neurologic status is such that he or she can grasp and pull the tube. An abdominal binder or gauze dressing
can be used to cover the tube. Hand mittens can be used in the high-risk patient.
The patient and their caregiver should receive education regarding proper tube care and simple
troubleshooting.
For patients going home with a G-tube for gastric decompression, they should be taught how and when to
intermittently vent the tube. This will allow them to not have to keep the tube attached to a drainage bag at all
times.
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OUTCOMES
Not applicable
COMPLICATIONS
Clogged tube
A clogged tube can be flushed clear in essentially every case with a small syringe. Due to the laws of
hydraulics, the smaller the diameter of the syringe the more pressure that can be generated. We
recommend the smallest syringe that will tightly fit into the opening in the tube. When a Foley catheter
is used as the G-tube, the entire end of a 3-mL syringe will fit snugly and will often clear the
obstruction when flushed with water. Carbonated acidic beverages such as Coke™ may also aid in
clearing an obstruction and should be allowed to stay in the tube for an hour or more before attempting
to flush the tube.
Dislodged tube
It is imperative that patients and caregivers are taught to reinsert the tube immediately if they become
dislodged so that the tract does not close. If they are unable to reinsert, then they should immediately
go to an emergency department where a smaller catheter could be temporarily advanced into place
preserving the tract, which could be later dilated and the proper tube placed.
If a tube is reinserted easily without resistance and flushing with water causes no discomfort, the tube
may be used per the patient’s routine without a confirmational radiologic study.
However, if the replacement is complicated or if there is discomfort with flushing, the tube position
should be checked to ensure proper positioning.
Fractured tube
If a tube is fractured with or without leakage, it may be temporarily patched with waterproof occlusive
tape such as electrical tape or Duct® tape. The tube should be electively exchanged for a new tube
during a regular clinic appointment. If the tube is new or in complex scenarios, it may need to be
exchanged over a glide wire by a gastroenterologist, interventional radiologist, or a surgeon.
Abdominal wall abscess
Tube site infections rarely lead to significant abscess formation, but if this occurs, it should be treated
with incision and drainage leaving the wound open as with any infected open wound. The tube may
need to be removed to allow the infection to heal.
Tube placed through another piece of bowel
If the tube has penetrated the colon or small bowel, a surgical consult is indicated.
If the tube remains essential to the patient’s care, then proceed to operating room (OR) for
laparoscopic or open abdominal exploration with repair of the injury and placement of an open G-
tube.
If the tube has been in place and functional for months but is no longer necessary, the tube may be
removed realizing there is a potential need for repair of the gastric to colon or small bowel fistula. It
has been our experience that most of these gastroenteric fistulas will close on their own or prove to
be asymptomatic and inconsequential.
Gastric outlet obstruction
Gastric outlet obstruction is most frequently associated with an overinflated balloon. When this is
suspected, decreasing the amount of fluid in the balloon and being certain that the balloon is up
against the gastric wall instead of free floating within the gastric lumen where it could be passed
through the pylorus are important aspects to consider.
REFERENCE
1. Foutch GP, Talbert GA, Waring JP, et al. Percutaneous endoscopic gastrostomy in patients with prior
abdominal surgery: virtues of the safe tract. Am J Gastroenterol . 1988;83:147.
Chapter 25
Feeding Jejunostomy
John Daniel Hunter III
John Roland Porterfield Jr.
DEFINITION
A jejunostomy tube (J-tube) is a flexible soft tube that connects the intraluminal jejunum with the outside
world through the abdominal wall. The main function is to provide long-term access to the proximal
gastrointestinal (GI) tract for enteral nutrition when oral intake is not possible or inadequate.
A J-tube can be placed through an open or a laparoscopic approach. Often, they are placed in
conjunction with a larger operation when it is anticipated that the patient will not progress to adequate
oral intake in a timely fashion during the early postoperative course. The J-tube affords the advantage of
early enteral nutrition even when the upper GI tract cannot be used.

The history and physical exam should focus on the indication for enteral access J-tube, hemodynamic stability
of the patient, current functional status of the GI tract, and previous surgeries.
Patients who are hemodynamically unstable generally should not undergo elective J-tube placement.
The patient should be assessed for a functional GI tract distal to the ligament of Treitz (LOT) and should not
have evidence of mechanical bowel obstruction, adynamic ileus, GI ischemia, or peritonitis.
A thorough surgical history is imperative prior to J-tube placement. Preexisting tubes, drains, mesh from
previous hernia repairs, or stomas may require alternative planning. An extensive abdominal surgical history
may prohibit safe laparoscopic J-tube placement and an open technique may be employed.

Radiologic workup is generally not necessary for J-tube placement. However, it is often the case that patients
have had a plethora of upper abdominal imaging for other reasons that may provide valuable information or
clues to previous unknown surgical procedures or unexpected anatomic findings.
SURGICAL MANAGEMENT
The patient should be NPO for a minimum of 6 hours prior to the procedure.
Antibiotics should be given within 30 minutes of incision to reduce the incidence of abdominal wall infection
around the tube site. First-generation cephalosporins are our preference when not contraindicated by the
patient’s known allergies.
Generally, the jejunostomy feeding tube will exit the patient’s abdomen in the left upper quadrant (LUQ). As
mentioned previously, preexisting tubes, drains, implanted mesh, and stomas may require tube site
adjustment.
Positioning
For an open J-tube, the patient should be placed in the supine position. Usually, this procedure is done in
addition to a larger procedure and thus the patient is already positioned accordingly.
For a laparoscopic J-tube, the patient should be positioned supine with the right arm tucked to allow for
adequate room for the surgeon and assistant to both work comfortably on the right side.
It is important to be certain the patient is secured to the bed for intraoperative bed tilting, which may assist with
exposure of the proximal jejunum.
TECHNIQUES
OPEN JEJUNOSTOMY TUBE PLACEMENT
Equipment
The type of tube used for the feeding jejunostomy is decided upon by the surgeon to optimize the
longevity, comfort, and function for the patient. There are many commercially available tubes that
vary widely in features, availability, and cost.
If a tube is being placed as part of a larger procedure and will likely be removed within 6 to 8 weeks,
a standard 14-French (Fr) “red rubber Robinson” catheter is economical, time tested, and very
functional.
The most important tube characteristics are that it should be soft, pliable, and preferentially not
containing a balloon unless it is a small balloon, less than 5 mL, and specifically designed to be
placed within the jejunum. Balloon catheters within the small bowel are a frequent cause of recurrent
bowel obstructions and should be avoided.
The enteral end should be free of sharp edges that could damage the mucosa or promote migration
or perforation. The holes should be of adequate size to allow feedings to pass through with minimal
risk of clogging. The external portion should be tapered up to allow standard feeding pump tubing to
be attached.
At our institution, a 12- to 18-Fr “red rubber Robinson” catheter is often used. Extra holes can be cut
into the distal portion to allow tube feeds to flow with less resistance. These holes may be created
by folding the tube over and cutting the corner of the fold (FIG 1). Alternatively, the tube from a
laparoscopic jejunostomy kit can be used (Flexiflo Lap J™ laparoscopic jejunostomy kit by Abbott
Nutrition).
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FIG 1 • Cutting extra holes in a red Robinson tube will reduce resistance of flow to the tube feeds.
Incision
If the open J-tube placement is being done as a standalone operation, the incision should be centered in
the midline at the level of the LOT.
The supraumbilical vertical midline incision should be carried through the linea alba with enough length to
locate the LOT, mobilize 20 to 30 cm of jejunum, and allow for fixation of the jejunal segment to the
peritoneum of the abdominal wall around the tube exit site. If there are minimal adhesions, this incision
may be kept relatively small, 5 to 7 cm, and the majority of the operation can be done on eviscerated
jejunum (FIG 2).
A limitation of an incision that is too small is that it may prove difficult to fix the bowel to the abdominal
wall through the small incision. Exposure of this step should not be compromised in anyway to avoid
lengthening the incision.
Mobilization of Jejunum
Once the peritoneal cavity has been entered, the omentum and transverse colon are retracted cephalad
to expose the small bowel. A segment of small bowel is chosen in the LUQ and traced proximally until the
LOT is identified.
Once the LOT is identified, the small bowel is examined all the way to the ileocecal valve to ensure no
occult pathology, obstruction, or torsion is present.
The tube insertion site is chosen where the tube will pass through the abdominal wall. This will generally
be in the LUQ. The surgeon must ensure the chosen segment of jejunum will reach the parietal surface
of the abdominal wall without any tension or torsion. Lysis of adhesions may be needed to make sure the
jejunum can reach the abdominal wall without tension.
Placement of atraumatic clamps on the left side of the fascia allows the abdominal wall to be retracted
anteriorly for exposure of tube placement. While keeping retraction, a strong fine clamp is passed from
inside the abdomen through the point chosen in the abdominal wall. A 3-mm skin incision, at the clamp
exit site, is created and the tube is grasped and the distal end is pulled through the abdominal wall into
the peritoneal cavity. Both ends of the tube are clamped together and positioned out of the way (FIG 3).
FIG 2 • Open incision diagram with tube exit site marked.
Enterotomy and Placement of the Jejunostomy Tube

A segment of jejunum approximately 30 cm from the LOT is chosen as the site for the J-tube placement.
This portion of jejunum can be eviscerated for the next steps if a smaller incision has been used. Using a
3-0 nonabsorbable or absorbable suture, place an approximately 4-mm purse-string suture in a box
formation on the antimesenteric side of the small bowel (FIG 4). A double pursestring stitch may be used
for additional security (FIG 5).
At this point, it is essential to note the proximal and distal ends of the jejunum and to ensure the
orientation is maintained through the entire procedure.
Using cautery, create a small enterotomy in the center of the purse-string suture. It is helpful to grasp the
bowel by the mesentery during this step. Inadvertent cautery injury to the opposite side of the small bowel
can be avoided by cutting the serosa and muscularis with the cautery but “popping” into the lumen with a
fine clamp (FIG 5).
Place the distal end of the feeding tube through the enterotomy into the lumen and direct it distally. The
catheter is advanced until at least 10 cm is intraluminal. It can be advanced further if there is an
excessive amount of tubing left externally (FIG 6).
Tie down the purse-string suture, taking care not to overtighten and occlude the tube (FIG 7).
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FIG 3 • Facial retraction anterior and midline with stab incision being made for the feeding tube.
FIG 4 • Placement of purse-string stitch on antimesenteric jejunum.
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FIG 5 • The enterotomy is made with a cautery and then a hemostat is used to “pop” into the lumen. Note
the double purse-string stitch used.
The tube entry sight is then imbricated using a threepoint triangular technique (FIG 8).
Next, a Witzel tunnel is created. Starting at the enterotomy, the small bowel is imbricated over the feeding
tube using interrupted 3-0 absorbable suture on a taper needle (FIG 9) for a distance of about 5 cm.
These are seromuscular bites spaced approximately 5 to 10 mm apart, ensuring the tube is not exposed.
Care should be taken not to place the bites too far from the tube, as this will draw more bowel into the
Witzel tunnel and narrow the jejunal lumen (FIG 10).
The jejunal segment must now be secured to the parietal peritoneum. This will allow the formation of a
tract so that if the tube is inadvertently removed, it can be replaced without reentering the abdomen. This
should be done in a way that the bowel is flush with the abdominal wall. Four “tacking” sutures of
absorbable 3-0 suture can be placed around the tube exit site. The first is placed lateral to the tube, away
from the operating surgeon. A seromuscular bite is taken and then a bite of peritoneum is taken at the
corresponding location in the abdominal wall (FIG 11). Start with the lateral (furthest) suture first, then
superior, inferior, and finally medial. Secure each suture with a clamp after it is placed and do not tie until
they are all appropriately placed.
FIG 6 • Directing end of feeding tube into distal jejunum.
FIG 7 • Tying down purse string to secure the feeding tube.
Once all four sutures have been placed, it is best to tie them in the order they were placed (FIG 12). An
additional tacking suture may be placed 5 to 10 cm distally to secure a longer segment of bowel to the
abdominal wall. This may help prevent torsion on the bowel around a single fixed point. The small bowel
should now be adherent to the LUQ abdominal wall (FIG 13).
The external portion of the tube should be secured to the skin using a 2-0 nonabsorbable monofilament
suture (FIG 14).
The abdomen is then closed in layers.
The tube may be capped or placed to gravity drainage via a bag. Covering the tube with a dressing and
tape or abdominal binder will help prevent it from being inadvertently dislodged during patient movement.
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FIG 8 • Triangle stitch to imbricate the tube entry site.
FIG 9 • Creation of the Witzel tunnel.

FIG 10 • Cross section of Witzel tunnel. The left shows the correct placement of sutures with adequate
lumen diameter. The right shows a narrowed lumen from suture bites placed too far from the tube.
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FIG 11 • Placement of first tacking suture.

FIG 12 • Final appearance of bowel attached to the abdominal wall. The sutures should be placed in order
from A to E.
FIG 13 • Final view of small bowel fixed to abdominal wall after the four tacking sutures have been placed.
Note the feeding tube is not visible.
FIG 14 • Securing the external portion of the tube to the abdominal wall.
LAPAROSCOPIC JEJUNOSTOMY
Equipment and Port Placement
Several commercially available laparoscopic jejunostomy kits are available. We use the Flexiflo Lap J™
laparoscopic jejunostomy kit by Abbott Nutrition. This section will describe J-tube placement using this
kit. The steps described can be modified for other kits, and the package inserts for each kit should be
read as they often contain pertinent pearls for success.
A standard laparoscopic setup including a 5-mm 0-degree or 30-degree laparoscope and two to three 5-
mm ports is used.
Port placement should triangulate toward the proposed tube exit site in the LUQ (FIG 15). The J-tube site
should be at least two fingerbreadths below the left costal margin at approximately the midclavicular line.
Jejunal Mobilization and Tube Placement
Once the ports are placed, the abdomen should be inspected to rule out occult pathology or evidence of
a distal obstruction.
The upper port should be used to retract the colon and omentum cephalad. The middle port is used for
the camera. The lower port should be used to expose the small bowel.
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FIG 15 • Port placement diagram for laparoscopic J-tube. The tube site is represented by the target.
To identify the LOT, the transverse colon is retracted anteriorly as the patient is placed in Trendelenburg
position and the mesentery of the transverse colon is followed toward its origin. The proximal most
portion of the jejunum can be seen exiting the retroperitoneum at the LOT. Alternatively, if this exposure
is unable to be obtained, the small bowel may be followed in the LUQ until the LOT is reached (FIG 16).
Once the proximal jejunum is convincingly identified, it should be traced distally 20 to 30 cm to identify the
tube site. Once the tube site is identified, it is essential to keep the proper orientation of the bowel
throughout the completion of the procedure.
The tube site on the abdominal wall should be chosen by identifying the area on the inner abdominal wall
where the selected jejunal segment most easily reaches. The bowel should be free of tension at this
point. The point on the abdominal wall should also be at least 2 cm below the costal margin. Placement
of a fine needle through the abdominal wall into the peritoneal cavity often facilitates identifying and
maintaining the best placement (FIG 17).
The T-fasteners supplied in the kit are placed next. They are placed in a diamond configuration around
the tube entry site, marked with the fine needle. They should be placed 2 cm from the needle at the skin
level, pass through the fascia, and exit approximately 1 cm from the needle in the peritoneal cavity (FIG
18).
To start, the assistant grasps the chosen segment of jejunum and pulls it to the tube site, holding it in
proper orientation. The first T-fastener is passed through the superior point of the diamond. Once
intraabdominal, the needle/T-fastener is advanced through the bowel wall. It is easy to inadvertently pass
the needle through the “back wall” of the bowel at this point. The assistant should orient the bowel so
that the mesenteric side is as far from the needle as possible during placement.
The needle should be advanced to the 2-cm (double) mark and then deployed (FIG 19). Pull back on the
fastener to ensure the bowel catches, retract it to the abdominal wall, and then apply a clamp to the
external portion of the suture to keep the bowel in position.
The next three T-fasteners are placed in a similar manner. The far lateral one should be deployed after
the superior one, followed by the inferior, and then finally the medial fastener.
FIG 16 • The small bowel is followed in the LUQ to the LOT.
FIG 17 • There should be no tension when the small bowel is retracted toward the chosen area on the
abdominal wall. A needle can be placed through the abdominal wall to easily mark the area from the
peritoneal cavity.
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FIG 18 • A. Diamond configuration of T-fasteners around the tube entry site as seen on the abdominal
wall. B. Cross-sectional view of trajectory of T-fasteners as they pass through the abdominal wall. Note
they enter 2 cm from the tube site at the skin and exit 1 cm from the tube site at the peritoneum.
At this point, the antimesenteric side of the bowel should be almost flush with abdominal wall in four
places (FIG 20). A small gap should be left for the next step.
The 18-gauge needle is then advanced into the small bowel in the center of the four T-fasteners. Saline,
air, or a brief insufflation with carbon dioxide from the laparoscopic insufflator will ensure that the needle
is intraluminal. A fluid wave should be seen passing though the bowel. If the needle is submucosal, a
local infiltration of saline in the bowel wall will be seen, but it will not pass as a fluid wave within the
bowel.
The wire is then advanced through the needle into the bowel while the assistant uses a blunt grasper to
direct the wire into the distal limb of the jejunum. The wire can coil in the bowel easily during this step.
This may be avoided if the assistant stretches the distal limb as the wire is passed (FIG 21).
FIG 19 • The needle is advanced into the small bowel up to the double marking and the T-fastener is
then deployed. Gentle traction after deployment will ensure the T-fastener has engaged the bowel
properly.
FIG 20 • A view of the bowel after all four T-fasteners have been placed. Note the small gap to allow
visualization during placement of the J-tube.
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FIG 21 • As the wire is being advanced, the assistant can provide gentle traction on the distal bowel to
allow the wire to pass easily.
The needle is then removed.

Pull up on the fasteners gently so that the jejunal segment is anchored to the abdominal wall. Pull just
enough that the bowel makes contact with the wall. The wire should not be visible at this point.
A skin nick is made at the wire entry site, and the dilator along with the peel-away sheath is passed over
the wire, through the abdominal wall, and into the distal limb of the small bowel (FIG 22).
Care must be taken during this step so that the opposite side of the small bowel is not perforated and that
the dilator and sheath should easily follow the path of a gently curved wire.
The wire and dilator are then removed.
The J-tube is passed in to the distal limb through the peel-away sheath. The tube should be at least 10
cm into the jejunum. Avoid leaving too much of the tube externally to reduce the risk of it being
inadvertently pulled out.
While an assistant holds the tube in place at the skin, the sheath is cracked and removed by peeling it
apart slowly, making certain that the J-tube remains in proper position (FIG 23).
Inject 10 mL of saline or air through the small port to ensure the tube is patent. This also again allows for
conformation that the tube is in fact intraluminal. A fluoroscopy study could be used with similar contrast
to that used for a cholangiogram if there is any question regarding the intraluminal nature of the tube.
FIG 22 • The dilator and sheath are passed over the wire, through the abdominal wall, and into the
jejunal lumen.
At this point, the fasteners, which were pulled up and held gently to anchor the jejunal segment to the
abdominal wall, may be secured. Crimping the fasteners on the suture just above the skin bolsters
secures them in place (FIG 24). Care must be taken to avoid these fasteners being pulled too tight as this
could lead to erosion through the bowel. The tube should not be visible at this point from inside the
abdominal cavity.
FIG 23 • After the dilator and wire are removed, the J-tube is passed through the sheath and into the
jejunum. The sheath is then peeled away while the tube is held in place.
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With the T-fasteners entering the skin 2 cm from the tube, there is plenty of room to slide the flange down
to the skin and secure it with one or multiple sutures. Be careful not to inadvertently pull the tube out at
this step.
A final evaluation with the laparoscope should reveal no tension or torsion on the bowel as it rests on the
anterior abdominal wall.
The trochar sites are closed in standard fashion and the procedure is complete.
An abdominal dressing with tape or abdominal binder is placed over the tube to avoid it snagging during
patient transport.
FIG 24 • The T-fasteners are crimped into place at the skin level.
PEARLS AND PITFALLS
Indications ▪ Be certain that a J-tube best fits the needs of the patient. Frequently, physicians
may request a J-tube when in reality the patient needs a gastrostomy tube (G-tube)
or vice versa.
Preprocedure ▪ Review previous upper abdominal procedures or history of peritonitis that may have
planning scarred another piece of bowel along the proposed track of the J-tube.
Patient ▪ Position the patient supine with the entire abdomen exposed and prepped and
position draped.
Open G-tube ▪ Place the triangle suture and the imbricating sutures carefully to avoid excessively
narrowing the lumen of the bowel.
Tube site ▪ The tube site should be at least 2 cm inferior to the costal margin.
selection
▪ Keeping midline retraction on the fascia with clamps while making the incision
through the abdominal wall will ensure that the tube does not get kinked as it
traverses the abdominal wall once the fascia is closed.
Laparoscopic ▪ Position the patient supine with the right arm tucked to allow a comfortable working
J-tube space for the surgeon and the laparoscopic assistant on the right side of the patient.
▪ Take special care to avoid penetration of the back wall of the jejunum with the
needle.
▪ Ensure, without question, that the wire and the tube pass intraluminally.
Securing the ▪ Do not slide the bolster on the tube down tightly against the skin as it may necrose
tube the skin or lead to pulling of the base of the tube through the jejunal wall and into the
peritoneum.
Postprocedure ▪ An abdominal binder is helpful for securing the tube and preventing premature or
care inadvertent removal during patient movement or in a patient with impaired mental
status.
POSTOPERATIVE CARE
Tube feedings can be started the evening of the procedure at a “trophic” or low rate, usually about 10 mL per
hour. If the patient tolerates this, they can be advanced by 10 mL per hour every 4 hours until the nutritional
goal is reached.
Care should be taken to avoid the tube catching or pulling while the patient is moving or if the patient’s
neurologic status is such that they can grab and pull the tube. An abdominal binder or gauze dressing can be
used to cover the tube. Hand mittens can be used in the high-risk neurologic patient.
The patient and his or her caregiver should receive education regarding proper tube care and simple
troubleshooting.
OUTCOMES
Not applicable
COMPLICATIONS
Clogged tube
A clogged tube can be flushed in essentially every case with a small syringe. Due to the laws of
hydraulics, the smaller the diameter of the syringe the more pressure. We recommend the smallest
syringe that will tightly fit into the opening in the tube. Carbonated acidic beverages such as Coke™
may also aid in clearing an obstruction when they are allowed to sit within the tube for an hour or more.
Dislodged tube
It is imperative that patients and caregivers are taught to reinsert the tube immediately if it becomes
dislodged so that the tract does not close. If they are unable to reinsert, then they should immediately
go to an emergency department where a smaller catheter could be temporarily advanced into place,
preserving the tract that could be later dilated, and the proper tube placed.
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If a tube is reinserted easily without resistance and flushing with water causes no discomfort, the tube
may be used per the patient’s routine without a conformational radiologic study.
However, if the replacement is complicated or if there is discomfort with flushing, the tube position
should be checked to ensure proper positioning.
For tubes that have been in place for more than 1 month, it is exceptionally unlikely that the tube would
not reenter the same bowel and rest in the same functional position where it was dislodged from.
Fractured tube
If a tube is fractured with or without leakage, it may be temporarily patched with a waterproof occlusive
tape such as electrical tape or Duct® tape. This tube should be electively exchanged for a new tube
during a regular clinic appointment. If the tube is new or in complex scenarios, it may need to be
exchanged over a glidewire by a gastroenterologist, interventional radiologist, or a surgeon.
Tube site infections rarely lead to significant abscess formation, but if this occurs, it should be treated
with incision and drainage, leaving the wound open as with any infected open wound.
Small bowel obstruction
Small bowel obstruction is most frequently caused by a balloon on the J-tube or from torsion at the
tube insertion site.
When an obstruction is evident, any fluid in a balloon should be removed and the bowel obstruction
treated with nasogastric decompression as with any bowel obstruction.
If this does not resolve the obstruction, a computed tomography (CT) scan with oral contrast
administered 2 hours prior to the study may be of assistance in assessing torsion of the bowel around
the tube insertion site.
If torsion is confirmed, an operative exploration either in a laparoscopic or open approach is required to
relieve the obstruction.
Chapter 26
Laparoscopic Gastric Bypass
Elizabeth A. Dovec
Ronald H. Clements
DEFINITION
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an
adverse effect on health, leading to reduced life expectancy and/or increased health problems.1
The body mass index (BMI) is a measurement obtained by dividing a person’s weight in kilograms by the
square of the person’s height in meters.2
BMI greater than or equal to 30 kg/m2 is obesity.

BMI greater than or equal to 35 to 39.9 kg/m2 is severe obesity.
BMI greater than or equal to 40 to 49.9 kg/m2 is morbid obesity.
BMI greater than or equal to 50 kg/m2 is super obesity.
Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults and
children. Obesity is one of the most serious public health problems of the 21st century.3
The World Health Organization (WHO) predicts that overweight and obesity may soon replace more
traditional public health concerns such as malnutrition and infectious diseases as the most significant
cause of poor health.4 Before the 20th century, obesity was rare5; however, in 1997, the WHO formally
recognized obesity as a global epidemic.6 As of 2008, the WHO estimates that at least 500 million adults
(>10%) are obese.7

Patients should undergo comprehensive preoperative evaluation and have multidisciplinary support, with
attention to psychological issues and dietary intake, for optimum outcome.
A thorough history should be performed prior to treatment, including a detailed past medical and surgical
history, present medications and allergies, family history, social history, and discussions at previous attempts
at weight loss.
Obesity-related comorbidities include, but are not limited to, hypertension, dyslipidemia/hyperlipidemia,
diabetes mellitus, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), congestive heart
failure (CHF), coronary artery disease (CAD), vascular disease, renal failure, urinary stress incontinence,
polycystic ovarian syndrome (PCOS), back pain, joint pain, pseudotumor cerebri, and anxiety/depression.
SURGICAL MANAGEMENT
The goals of the surgical treatment of obesity include
Improving health
Improving quality of life
Increasing the life span
The American Society of Metabolic and Bariatric Surgery (ASMBS) and National Institutes of Health (NIH)
have reached several conclusions about bariatric surgery and formulated a consensus statement. These
organizations agree that bariatric surgery is the most effective treatment for morbid obesity.
Gastric bypass has been the gold standard in the treatment of the morbidly obese (BMI of ≥40 kg/m2) and
severely obese (≥35 to 39.9 kg/m2) patients with obesity-associated comorbidities. It is the most frequently
performed bariatric procedure in the United States.
A Roux-en-Y gastric bypass is a restrictive and malabsorptive procedure.
Preoperative education is a vital part to the success of the patient. Patients must be instructed on what to
expect both preoperatively and postoperatively.
All patients at our program undergo a surgical evaluation, medical clearances, insurance requirements,
psychological evaluation, nutrition education, online information seminars, and attend a support group prior to
their surgery.
A detailed bariatric diet guideline packet is provided to all patients describing each diet phase. Documented
understanding of the dietary expectations is imperative.
All medications are reviewed and anticoagulation discontinuation is discussed, as applicable.
Instruction on early ambulation beginning the afternoon of surgery and continuing every 1 or 2 hours while
awake thereafter
Sequential compression devices (SCDs) are on and verified to be functioning prior to the induction of
anesthesia. Routine prophylactic subcutaneous anticoagulation administration is not done unless the patient
has a known prior thromboembolic event or the procedure is expected to take longer than 2 hours.
Positioning
The patient is placed on the table in supine position. After satisfactory anesthesia had been administered, the
patient is first secured to the bed. A thick, wide strap is placed tightly above the knees and padded well. Two
pads are placed under the patient’s heels. A footboard is pushed firmly to the patient’s feet allowing the feet to
turn out slightly but being cognizant not to bow the knees (FIG 1).
The left arm is left out at a 75-degree angle and secured to the arm board with a gauze wrap. If the patient’s
body habitus allows, the right arm is ideally tucked at the side. The bed is positioned down as low as possible.
A standing stage is placed on the patient’s right side to be used by the operating surgeon. The assisting
surgeon stands on the patient’s left side.
A 34-Fr gastric lavage tube is placed in the patient’s stomach and allowed to drain. A glove may be placed at
the end of the lavage tube to prevent spillage of gastric contents. No other devices except the gastric lavage
tube and endotracheal tube should be in the patient’s mouth.
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FIG 1 • Patient positioning.
TECHNIQIUES
PLACEMENT OF INCISIONS
Sixteen centimeters is measured down in the left paramedian position. The skin and underlying fascia is
injected with local anesthetic, and a 10-mm visual port is inserted through the left rectus sheath,
identifying all layers of the abdominal wall. Pneumoperitoneum is then established. An inspection of the
abdomen and pelvis is then performed ensuring there was no injury from the initial trocar placement.
The remaining five ports are then placed. The first 5-mm trocar is placed just inferior to the xiphoid
process and to the left of the falciform for liver retraction. A second 5-mm trocar is placed approximately 2
cm to the right and inferior to the first 5-mm trocar placement. This 5-mm right paramedian port is also
placed to the left of the falciform. A 12-mm right paramedian trocar is placed to the left of the falciform
approximately one handbreadth from the second 5-mm trocar. A 5-mm left subcostal trocar is placed 2 cm
below the costal margin. A final 5-mm trocar is placed 1 or 2 cm below the level of the initial port, as far
lateral as possible (FIG 2).
FIG 2 • Port placement.
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LIVER BIOPSY
A needle biopsy of the liver is obtained because blood tests do not accurately predict the presence,
absence, or degree of histologic changes due to fatty liver disease. The liver is elevated by two bowel
graspers placed through the left lateral ports to ensure the biopsy needle does not go through the liver
and cause injury to underlying structures. Two core biopsies are obtained from the left lateral segment of
the liver for pathologic examination for the diagnosis and staging of nonalcoholic fatty liver disease
(NAFLD) and nonalcoholic steatohepatitis (NASH).
LIVER RETRACTION
The patient is placed in full reversed Trendelenburg position. The liver is retracted with a locking Allis
grasper clamp placed through the subxiphoid 5-mm port and secured to the diaphragm just anterior to the
gastroesophageal (GE) junction (FIG 3).
FIG 3 • Liver retraction and vertical 60-mm stapler.
GASTRIC POUCH CREATION

With the gastric lavage tube retracted into the esophagus by the anesthetist, the angle of His is exposed
and dissected with an ultrasonic dissector.
Identification, dissection, and primary posterior repair of a hiatal hernia is done at this time, if necessary.
Five centimeters is measured down from the GE junction along the lesser curve where the lesser sac is
entered immediately adjacent to the lesser curve of the stomach using the ultrasonic dissector to divide
branches of the left gastric artery.
A 45-mm laparoscopic stapling device with appropriatesized staples is oriented transversely to the lesser
curve and fired.
The 34-Fr gastric lavage tube is advanced to abut this newly placed horizontal staple line. Additional
firings of laparoscopic stapling devices are placed parallel to the lavage tube. Complete transaction of the
stomach and hemostasis are ensured by inspecting the entire staple line. Once divided, the gastric
lavage tube is retracted back into the esophagus.
The retrogastric and pancreatic adhesions are freed using the ultrasonic dissector to increase pouch
mobility (FIG 4).
FIG 4 • Completed pouch.
IDENTIFICATION OF THE LIGAMENT OF TREITZ

The table is taken out of reversed Trendelenburg and placed in the supine position. The omentum is
retracted cephalad, exposing the transverse mesocolon, which is also elevated and retracted cephalad.
The proximal jejunum is retracted to expose the ligament of Treitz and the inferior mesenteric vein (FIG
5).
FIG 5 • Identification of the ligament of Treitz.
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CREATION OF THE BILIOPANCREATIC LIMB
Starting at the ligament of Treitz, a marked grasper in the surgeon’s right hand is used to measure 40 cm
distally (FIG 6).
The jejunum is divided with a white 60-mm laparoscopic stapling device, with care being taken not to
undercut the biliopancreatic or Roux limb mesentery.
If necessary, further mesenteric division can be accomplished with an ultrasonic dissector.
FIG 6 • Measurement of the biliopancreatic limb.
JEJUNOJEJUNOSTOMY CREATION
A 2-0 undyed absorbable suture is placed on the tip of the distal jejunum to later identify the Roux limb
(FIG 7). The Roux limb is measured using the previous technique with a marked grasper in the surgeon’s
right hand. A 95-cm Roux limb is created if the patient’s BMI is less than 50. A 150-cm Roux limb is
created if the patient’s BMI is greater than 50.
The site chosen for the anastomosis is brought into apposition to the proximal jejunum with the cut end of
the biliopancreatic limb oriented toward the patient’s right side and cephalad to the distal Roux limb.
A pretied, 24-cm long, 2-0 absorbable suture is placed through the Roux limb and biliopancreatic limb
approximately 3 cm from the biliopancreatic tip. This suture will later be used for enterotomy closure.
A pretied, 26-cm long, 2-0 nonabsorbable suture is placed through the Roux limb and biliopancreatic limb
approximately 1 cm from the biliopancreatic tip. This suture will later be used for mesenteric closure.
An ultrasonic dissector is used to make enterotomies in the biliopancreatic and Roux limbs.
A white 60-mm laparoscopic stapling device is placed into the enterotomies to construct a side-to-side
jejunojejunostomy. Hemostasis of the staple line is assured.
The assistant distracts the absorbable and nonabsorbable sutures to orient the enterotomy into a slit
rather than a circle. The enterotomy is closed by running the absorbable suture in two layers (FIG 8).
FIG 7 • Roux limb identification suture.

FIG 8 • Closure of enterotomy defect before starting to sew.
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CLOSURE OF MESENTERIC DEFECT
The mesenteric defect is closed in a running, locking fashion with the previously placed 2-0
nonabsorbable suture (FIG 9).
FIG 9 • Closure of mesenteric defect.
DIVISION OF GREATER OMENTUM

The omentum is divided vertically, toward the direction of the liver retractor, with the ultrasonic dissector
to facilitate bringing the Roux limb up to the gastric pouch. This step can be omitted if the omentum is thin
or if the Roux limb is placed in the retrocolic retrogastric position.
CREATION OF GASTROJEJUNOSTOMY
With the Roux limb in the left upper quadrant, a pretied, 26-cm long, 2-0 absorbable suture is placed
between the antimesenteric side of jejunum and posterior wall of the gastric pouch approximately 2 cm
from the tip of the Roux limb. The patient is placed in full reversed Trendelenburg position.
An interrupted, undyed, 2-0 absorbable suture is placed 1.5 cm from the running suture on the
antimesenteric side of the Roux limb and posterior wall of the gastric pouch.
An adequate gastrotomy is created just posterior to the transverse staple line of the gastric pouch using
an ultrasonic device.
An adequate enterotomy is created by entering the Roux limb. Care should be taken not to injure the
posterior wall of the jejunum.
A side-to-side gastrojejunostomy is created by placing the cassette side of the stapler into the stomach
and the anvil side into the jejunum. The assistant orients the tip of Roux limb so that it is in line with the
stapler as it is inserted to the 20-mm mark. The stapler is closed and fired (FIG 10).
While the assistant continues to hold the tip of the Roux limb in approximation with the gastric pouch, the
surgeon places a 2-0 absorbable stitch between the Roux limb and the gastric pouch just beyond the
apex of the gastrojejunostomy staple line to suspend the jejunum to the pouch.
FIG 10 • Stapling the gastrojejunostomy.

The assistant distracts the absorbable and nonabsorbable sutures to orient the gastrojejunostomy into a
slit
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rather than a circle. The first layer of the gastrojejunostomy is closed using the previously placed, pretied
2-0 absorbable suture in a running fashion. The 34-Fr gastric lavage tube is then passed across the
gastrojejunostomy to prevent suturing the back wall and to calibrate the opening. After locking the final
suture on the first row, the same suture is used to place a second layer running back toward the knot.
The anesthetist periodically moves the lavage tube to prevent sewing it into place. The gastric lavage
tube is completely removed upon completion of the second layer, and the suture is tied to its tail (FIG 11).
FIG 11 • Closure of gastrojejunostomy.
CLOSURE OF PETERSEN DEFECT

The mesenteries of the biliopancreatic, Roux limb, and transverse mesocolon are all secured with a 2-0
nonabsorbable suture to obliterate a potential hernia site at Petersen defect.
UPPER ENDOSCOPY LEAK TEST
The Roux limb is occluded with a bowel clamp approximately 2 cm distal to the gastrojejunostomy. The
assistant retracts the distal gastric remnant and omentum to keep the gastrojejunostomy in view. With the
patient placed in Trendelenburg position, the gastric pouch, gastrojejunostomy, and tip of the Roux limb
are submerged under saline (FIG 12).
FIG 12 • Placement of bowel clamp. Submerged anastomosis with light transilluminating the jejunum.
An endoscope is passed across the gastrojejunostomy to ensure its integrity, hemostasis, and patency.
The scope is withdrawn into the pouch, which is inflated with air
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from the endoscope. The submerged areas are inspected for bubbling, which, if present, are identified
and repaired with 2-0 absorbable suture. The test is then repeated until there is no further leaking
observed. The length of the gastric pouch is confirmed by measuring the distance between the
gastrojejunostomy and the Z line. The endoscope is removed, saline is aspirated from the abdominal
cavity, all instruments are removed, and the trocars are removed under direct visualization to ensure
hemostasis.
SKIN CLOSURE
No fascial sutures are placed in the 10- and 12-mm trocar sites, because radially dilating trocars are used
and they are both placed off the midline.
The skin is closed with 4-0 absorbable monofilament suture in a subcuticular fashion. A waterproof sterile
adhesive is placed to close the epidermis.
PEARLS AND PITFALLS
Pearls:
▪ The use of sterile adhesive allows the patient to shower and have no dressings to change.
▪ Patients are maintained on proton pump inhibitor therapy for 30 days to reduce the risk of early
marginal ulceration.
▪ Initially, all medications should be administered in the crushed or elixir form.
▪ Extended-release medications (XR, XL, ER, or EC) often cannot be crushed, broken, or opened and
will need to be changed by their prescribing provider to an immediate release or alternate form that can
be crushed or opened.
▪ Daily supplements with an adult strength chewable or liquid multivitamin and at least 1,200 mg of
calcium citrate with vitamin D are recommended.
Long-term dietary goals should include 50 to 80 g of protein per day.
Pitfalls:
▪ Liquid calories and sweets can cause late dumping syndrome.
▪ Snacking should be avoided to prevent developing a pattern of eating called “grazing.”
▪ Pregnancy is not recommended in the first 18 months after surgery.

▪ Birth control pills alone may not be effective for birth control after surgery. Patients are instructed to
speak with their gynecologist regarding other methods of birth control.
▪ Patient’s fertility may increase after surgery and weight loss.
POSTOPERATIVE CARE
Diet
Patients remain NPO the night of surgery and are advanced to noncarbonated, low caloric, bariatric clear
liquid diet on postoperative day (POD) 1 if they are not tachycardic, tachypneic, or experiencing excessive
pain. If the patient tolerates this step, they are advanced to a pureed diet upon discharge home.
Activity
It is imperative that the patient walk on the evening of the operation, because we only use SCDs for deep
venous thrombosis (DVT) prophylaxis.
OUTCOMES
The long-term average weight loss after a Roux-en-Y gastric bypass is 60% to 70% excess body weight
(EBW).
There is usually rapid resolution of comorbidities such as diabetes mellitus, sleep apnea, hyperlipidemia,
and GE reflux disease.
COMPLICATIONS
Early serious complications (<30 days) include gastrointestinal bleeding, bowel obstruction, anastomotic
leak, intraabdominal abscess, DVT, pulmonary embolism (PE), wound infection, and mortality; all of
which should be less than 1% in experienced centers.
Late complications (>30 days) include bowel obstruction, anastomotic stenosis, marginal ulceration,
gastrointestinal bleeding, cholelithiasis, internal herniation, gastro-gastro fistula, vitamin deficiencies, and
mortality.
REFERENCES
1. Haslam DW, James WP. Obesity. Lancet. 2005;366(9492):1197-1209.
2. World Health Organization. Obesity and Overweight. Geneva, Switzerland: WHO; 2000:9.
3. Barness LA, Opitz JM, Gilbert-Barness E. Obesity: genetic, molecular, and environmental aspects. Am J
Med Genet A. 2007;143A(24): 3016-3034.
4. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and
Decrease Overweight and Obesity. Rockville, MD: U.S. Department of Health and Human Services, Public
Health Service, Office of the Surgeon General; 2001.
5. Fauci A, Braunwald E, Kasper D, et al. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY:
McGraw-Hill Medical; 2008.
6. Haslam D. Obesity: a medical history. Obes Rev. 2007;8(suppl 1):31-36.
7. Caballero B. The global epidemic of obesity: an overview. Epidemiol Rev. 2007;29:1-5.

Chapter 27
Laparoscopic Sleeve Gastrectomy
Ozanan R. Meireles
Eric G. Sheu
Matthew M. Hutter
DEFINITION
Sleeve gastrectomy or partial vertical gastrectomy is defined as the creation of tubular, sleeve-shaped,
lesser curve-based stomach by resection of the greater curvature of the gastric body and fundus.
Laparoscopic sleeve gastrectomy (LSG) has been an increasingly popular procedure due to its relative
technical simplicity and excellent safety and efficacy profile. With an increased number of insurers now
covering the sleeve gastrectomy, the number of LSG performed in the United States has grown rapidly in
the last several years.
LSG was initially performed as the first stage of the biliopancreatic diversion-duodenal switch procedure.
However, beginning in 2008, LSG has been performed as a stand-alone bariatric operation, and short-
and medium-term follow-up have documented its safety and efficacy.
In 2010, a Current Procedural Terminology (CPT) code was assigned to the procedure and, more
recently, the American Society for Metabolic and Bariatric Surgery has issued a statement with 3- and 5-
year data and robust experience acknowledging LSG as an approved primary bariatric procedure.

A complete history and physical examination should be obtained, with particular attention given to history or
identification of metabolic disorders such as diabetes, dyslipidemia, and fatty liver disease; cardiovascular
disease; obstructive sleep apnea; venous thromboembolism as well as a history of previous abdominal
operations.
Per National Institutes of Health (NIH) consensus guidelines, bariatric surgery is indicated for patients with a
body mass index (BMI) greater than 40 or a BMI greater than 35 with obesity-associated comorbidities.
Insurers and payers, though, may have other stipulations.
A detailed nutritional history, including prior attempts at weight loss through dietary, exercise, and medical
programs, and psychologic/psychiatric history should be obtained.
Multidisciplinary evaluation with registered dietitians, psychologists, and medical physicians is critical prior to
consideration for any bariatric surgery.

In the absence of history or physical findings suggestive of upper gastrointestinal (GI) pathology,
preprocedural imaging is not mandatory.
However, symptoms such as dysphagia, early satiety, or odynophagia should prompt further radiologic or
endoscopic evaluation.
In our practice, some find a preoperative barium swallow helpful to rule out gross esophageal motility disorder;
assess for hiatal hernias; and exclude mass lesions, stricture, diverticula, and other anatomic abnormalities.
Others get a swallow study only if the history and symptoms raise any concerns.
Subsequent upper endoscopy can then be selectively used to follow up any concerning findings from the
swallow study.
When esophageal dysmotility is suspected based on history or swallow study, preoperative esophageal
manometry is obtained.
SURGICAL MANAGEMENT
Preoperative laboratory, pulmonary, and cardiac evaluation are performed as indicated by patient history, age,
and comorbidities as with other major abdominal surgery.
Patients should be encouraged to lose as much weight as possible leading up to surgery. We place our
patients on a low caloric diet 2 to 3 weeks before surgery in order to decrease the volume and rigidity of the
left lobe of the liver, facilitate laparoscopic exposure, and allow for a less technically demanding and safer
operation.
Appropriate antibiotic and venous thromboembolism prophylaxis should be administered in a timely fashion.
Positioning
The patient is positioned supine or in the split-leg position according to the surgeon’s preference. Specialized
bariatric beds are available to accommodate the super obese and allow for ergonomic positioning of the
patient. The arms and legs should be well secured along with a footboard to allow steep reverse
Trendelenburg to facilitate visualization of the left upper quadrant intraoperatively. An orogastric tube should
be placed to decompress the stomach after endotracheal intubation.
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TECHNIQUES
PORT PLACEMENT
Initial peritoneal access is obtained using the surgeon’s preferred method. Pneumoperitoneum is created,
and subsequent ports are placed under direct visualization. Many geometric arrangements for port
placement will allow adequate exposure for the operation. In general, five ports in the upper abdomen will
allow adequate access and visualization for the operation. These will usually include two working ports
for the operating surgeon and ports for the camera, liver retractor, and assistant. At least one 12- or 15-
mm trocar is required to allow introduction of a stapler. Two example diagrams of port placement are
shown in FIG 1.
FIG 1 • Port placement. Schematic illustration of typical port placements for sleeve gastrectomy in supine
(A) and split-leg positioning (B).
MOBILIZATION OF THE STOMACH

After exploration of the peritoneal cavity, the patient is placed into steep reverse Trendelenburg position
to drop away the intestines and omentum, and a liver retractor is placed to expose the stomach and
hiatus.
The pylorus is identified and the distal margin of the sleeve is measured within 2 to 6 cm proximal to the
pylorus (FIG 2A,B). The greater curvature of the stomach is mobilized by transecting the gastrocolic
ligament and short gastric vessels. An ultrasonic or bipolar vesselsealing device speeds this dissection
(FIG 3). Proximally, the vessels are divided up to the highest short gastric, a reliable landmark which
often dives posteriorly toward the pancreas (FIG 4). We find that complete mobilization of the angle of His
from the left crus of the diaphragm and freeing of any lesser sac adhesions to the pancreas or posterior
gastric space facilitates subsequent formation of the gastric sleeve. These adhesions are often avascular
and can be taken sharply. Complete mobilization to allow adequate resection of the fundus is believed to
be a critical step of sleeve gastrectomy.1
The surgeon should look for a hiatal hernia and fix it should it be readily evident. We do not promote the
routine dissection of the hiatus to identify a “hiatal hernia” that is not readily apparent.
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FIG 2 • A. Measurement of distal margin of the sleeve. Division of the gastrocolic ligament has begun, 2 to 6
cm proximal to the pylorus but distal to the incisura angularis as illustrated in A. B. Measurement is
performed intracorporeally.
FIG 3 • Division of short gastrics and gastrocolic ligament. A. The gastrocolic ligament and short gastric
vessels are divided using an ultrasonic dissector. B. Final view of the distal margin of the dissection as
previously measured from the pylorus is shown.
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FIG 4 • A. Complete mobilization of gastric fundus from the diaphragm and lesser sac. The last short gastric
vessel often dives posterior and into the pancreas and is a reliable anatomic landmark. B. The gastric
fundus is fully mobilized up to the left crus of the diaphragm, and lesser sac adhesions are dissected to
facilitate subsequent stapling.
CREATION OF THE GASTRIC SLEEVE

Accurate and safe formation of the gastric sleeve is performed using a bougie introduced into the
oropharynx, down the lesser curvature, and into the gastric antrum as a guide (FIG 5). Choice of size and
type of bougie remains a surgeon’s preference. The recent sleeve consensus statement recommended
use of a 32- to 36-Fr bougie.1 Various Maloney dilators or flexible endoscopes may be used as a bougie.
Our practice is to use the therapeutic endoscope (36 Fr in caliber) to size the sleeve, which we find
helpful to later perform a provocative leak test and examine our staple line endoluminally.
With the chosen bougie in place, and after confirmation that no other intragastric tubes (e.g., orogastric
tubes, temperature probes) remain in place, transection of the greater curvature of the stomach begins 2
to 6 cm proximal to the pylorus using a linear cutting stapler. It is critical to avoid narrowing of the sleeve,
particularly at the incisura angularis, and to take equal portions of
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the anterior and posterior walls of the stomach to avoid “spiraling” the sleeve (FIG 6).
FIG 5 • Placement of intragastric bougie. A bougie is placed along the lesser curvature into the antrum to
guide formation of the sleeve. This illustration shows the use of an endoscope, which is easily
manipulated to match the contour of the lesser curvature.
The gastric sleeve formation is completed with subsequent fires of the linear stapler along the bougie,
thus resecting the greater curvature of the stomach. With each staple fire, continued care is made to
assure that equal amounts of anterior and posterior gastric wall are resected (FIG 7). It is often helpful to
have the assistant maintain lateral traction on the lateral aspect of the stomach and, at times, toward the
posterior aspect. The final staple line should veer off the gastroesophageal junction as this area is
particularly susceptible to leaks.1 In FIG 8, a laparoscopic and endoscopic view of the completed sleeve
is shown.
FIG 6 • A. Initial gastric transection around the incisura angularis. The initial staple fire begins at the
previously measured distal division of the gastrocolic ligament and is (B) carefully placed to ensure no
narrowing or angulation of the stomach at the incisura as well as to resect equal segments of anterior
and posterior gastric wall. The initial staple line is shown in (C).
Staple loads should be chosen as appropriate for the thickness of the tissue. The gastric wall is generally
thickest on the initial distal staple line at the antrum. The use of staple line reinforcement is controversial.
There is some evidence that staple line reinforcement may decrease the incidence of bleeding
complications; however, any impact on leak rates is less clear. Several absorbable and permanent staple
line buttressing materials are available. Some oversew an unreinforced staple line routinely, which should
be performed with the bougie in place to prevent narrowing of the gastric conduit if it is done. Others
prefer not to use reinforcements, or to routinely oversew, due to concerns of excessive material where
staple lines cross, the added expense, and unclear benefit or potential harms from those practices.
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FIG 7 • Transection of greater curvature of stomach. Subsequent gastric transection is performed parallel to
the lesser curvature, along the bougie, and aimed toward the angle of His. In these photographs, staple line
buttressing material is used. The placement of the stapler is examined anteriorly (A) and posteriorly (B) to
ensure equal alignment of the gastric walls.
FIG 8 • Laparoscopic (A) and endoscopic (B) view of completed sleeve gastrectomy.
PROVOCATIVE LEAK TEST

A provocative leak test can be performed after the sleeve is created, either with gas or liquid dye. Our
practice is to submerge the staple line in saline irrigation while insufflating the sleeve with carbon dioxide
(CO2) via the indwelling endoscope and clamping the distal stomach. A laparoscopic assessment for
evidence of leaks or bubbles is done, and simultaneously, an endoluminal examination is performed to
exclude intraluminal bleeding and to assess the gastric conduit for any narrowing or kinking. Alternatively,
insufflation or instillation with distention via a nasogastric or other device can be done with CO2, air, or
colored liquid; however, oxygen alone should not be used.
Hemostasis of the staple line and divided greater curvature vessels is ensured. Although some surgeons
choose to recreate the gastrocolic ligament by suturing the omentum to the staple line in an effort to
prevent torsion of the sleeve, we do not routinely do that. The gastrectomy specimen is removed, which
can usually be accomplished using a protective bag without enlarging any incisions. The bougie, liver
retractor, and trocars are removed under direct vision; pneumoperitoneum is released; and closure is
performed of the extraction site with a fascial closure device.
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PEARLS AND PITFALLS
▪ Secure positioning of the patients extremities with a footboard is imperative to allow steep reverse
Trendelenburg to optimize laparoscopic visualization.
▪ During division of the gastrocolic ligament and short gastrics, care should be taken to avoid injury to
the gastroepiploic vessels and spleen.
▪ It is important to assure that the proximal fundus is completely mobilized by dissecting up to the left
crus and taking the highest short gastric vessel.
▪ Freeing of lesser sac adhesions to the pancreas and posterior gastric stomach and release of the
angle of His from the left crus give additional mobility of the greater curve to allow precise placement of
the stapler for greater curvature resection.
▪ A 32- to 40-Fr bougie should be placed along the lesser curvature of the stomach to aid in sizing of the
gastric sleeve.
▪ Care should be taken to avoid narrowing the gastric conduit, particularly at the incisura angularis.
▪ Accurate placement of each stapler ensuring equal resection of the anterior and posterior gastric walls
is critical to avoid spiraling of the sleeve, which could result in postoperative obstruction.
POSTOPERATIVE CARE
Postoperative care is similar to other bariatric patients. Early postoperative ambulation, adequate
postoperative analgesia, and frequent pulmonary toilet are important to help avoid pulmonary and thrombotic
complications. Appropriate perioperative antibiotics and venous thromboembolic prophylaxis are continued.
We keep our patients NPO on the first postoperative evening, but allow oral intake of important medications.
The use of routine postoperative upper GI series is of debatable value. It is our practice to routinely obtain a
Gastrografin and barium swallow examination on postoperative day 1 (FIG 9). We find this study helpful not
only to exclude leak or obstruction but also to obtain a baseline study of each patient’s anatomy for future
reference.
Following the swallow study, the patient is started on a clear liquid diet and oral analgesics. We discharge our
patients on either postoperative day 1 or 2. We maintain our patients on a liquid diet for 9 to 14 days and then
introduce soft foods. Multivitamin supplementation is started on discharge, and we keep our patients on acid
suppression in the perioperative period.
FIG 9 • Postoperative barium study of a sleeve gastrectomy.
OUTCOMES
Early data shows that the LSG is a safe and effective bariatric and metabolic operation, with outcomes
positioned between the adjustable gastric band and Roux-en-Y gastric bypass (GBP).2 Weight loss and
improvements in comorbid conditions such as diabetes, sleep apnea, hyperlipidemia, and hypertension
with LSG are significantly better than the gastric band, but do not quite reach the levels seen after GBP.
Similarly, rates of perioperative complications for the sleeve gastrectomy lie between the band and the
bypass. Overall, the incidence of death, serious complication, readmission, and reoperation in the early
postoperative period are equivalent for the LSG and the bypass and higher than for the gastric band.
Most studies have also shown a trend toward decreased rates of specific complications for the LSG
compared to the bypass—for example, obstruction, stricture, and anastomotic ulcer.2,3 Although
promising, good quality data are still lacking on the long-term effectiveness and safety of the LSG.
COMPLICATIONS
The most frequent complications after LSG are bleeding, urinary tract infections, superficial site
infections, and deep venous thromboses (DVTs). They are similar to other bariatric operations in their
incidence, diagnosis, and treatment.
A few LSG-specific complications merit further discussion. Leaks occur overall at a similar incidence as
the GBP. Sleeve leaks can occur both early and late and are most often found at the proximal staple line
near the angle of His. Principles and treatment of LSG leaks are similar to other abdominal leaks,
including control of sepsis with wide drainage and antibiotics and nutritional optimization. Treatment of
leaks after sleeve gastrectomy can be particularly challenging, as the intact pylorus and gastric conduit
itself often create a relative distal obstruction and enteral access for nutritional supplementation is more
problematic. However, unique to management of LSG leaks is the use of covered stents, which can be
placed endoscopically and can be useful to control leaks in combination with intraabdominal drainage.
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Although extremely infrequent, obstruction after sleeve gastrectomy can occur, and unlike the GBP, they
are not due to internal hernia, as the intestinal spaces are not disturbed, but more commonly due to
narrowing or twisting of the gastric conduit. Again, upper endoscopy can be particularly helpful for
diagnosing this problem and treatment with endoscopic dilation.
Severe gastroesophageal reflux has also been described following LSG. Management should include
fluoroscopic and endoscopic imaging of the sleeve to assess and treat any defined obstruction.
Recalcitrant reflux may even require reoperation with sleeve conversion to Roux-en-Y GBP.
REFERENCES
1. Rosenthal RJ; International Sleeve Gastrectomy Expert Panel. International sleeve gastrectomy expert
panel consensus statement: best practice guidelines based on experience of >12,000 cases. Surg Obes
Relat Dis. 2012;8(1):8-19.
2. Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric
Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned
between the band and the bypass. Ann Surg. 2011;254(3):410-420.
3. Carlin AM, Zeni TM, English WJ, et al. The comparative effectiveness of sleeve gastrectomy, gastric
bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg.
2013;257(5):791-797.
Chapter 28
Laparoscopic Gastric Band
Darren S. Tishler
Pavlos K. Papasavas
DEFINITION
The laparoscopic adjustable gastric band (LAGB) is a Food and Drug Administration (FDA)-approved,
implantable medical device for the treatment of morbid obesity and obesity-related medical comorbidities.
The adjustable gastric band (AGB) consists of an adjustable saline-filled annular balloon, a segment of
tubing, and a subcutaneous access port (FIG 1). This simple hydraulic system is placed around the
upper portion of the stomach, just distal to the gastroesophageal (GE) junction, to create a small
(approximately 30 mL) stomach pouch. The subcutaneous port is placed on the abdominal wall fascia
and allows for the band stoma area to be adjusted by the addition or removal of saline solution using a
noncoring needle. The AGB restricts the amount the stomach can accommodate to varying degrees,
depending on the fluid volume in the band. The AGB helps to slow the progression of food from the small
upper pouch to the distal stomach as well as possibly stimulating the production of gastric peptides and
neuronal pathway signals related to satiety.
The AGB differs from other bariatric procedures in three main ways: It is adjustable, reversible, and
involves no cutting or stapling of the stomach.
The AGB is an exclusively restrictive procedure, unlike other malabsorptive procedures such as the
Roux-en-Y gastric bypass (RYGB) (see Chapter 26) and the duodenal switch.
Patients who undergo AGB are at a low risk for developing major nutritional and vitamin deficiencies.
Although medication pill size can be a factor, the AGB does not have any effect on the absorption of
medications and other nutritional supplements.
FIG 1 • AGB system.

No validated algorithm exists to prescribe the most appropriate bariatric procedure.
Although the AGB is indicated for patients with body mass index (BMI) of 30 to 40 kg/m2 with medical
comorbidities or BMI greater than 40 kg/m2 with or without medical comorbidities, best results are often
obtained in patients with lower BMI.
AGB typically produces best results in patients who are ambulatory and capable of performing regular aerobic
activity.
In patients who fail to achieve adequate weight loss with AGB, the two most common factors are lack of
exercise and depression. These issues, when present, need to be addressed both prior to surgery and during
the requisite aftercare.
Ideal patients for AGB have an understanding of the importance of regular follow-up visits for band
adjustments. Several studies have demonstrated an association between number of aftercare visits and
weight loss. Patients require, on average, six to eight visits in the first year to achieve optimal results with the
AGB procedure.1
Although patients with long-standing severe gastroesophageal reflux disease (GERD) symptoms may improve
immediately after the placement of an AGB, long-term tolerance of restrictive procedures can be a problem in
this subset of patients.
Allergies must be assessed, as some patients could rarely experience adverse reactions to the materials in the
band.
In patients with a history of autoimmune disease, gastric banding procedures are contraindicated at this time
by the FDA.2 However, several studies have demonstrated both safety and efficacy of gastric banding in this
patient population.3 Contraindications to adjustable gastric banding are listed in Table 1.
Table 1: Contraindications to Adjustable Gastric Band Placement
Absolute Contraindications Relative Contraindications
Uncontrolled psychiatric disease Cigarette smoking

Current substance or alcohol abuse Severe GERD
Current history of anorexia or bulimia Gastroparesis
Achalasia Esophageal dysmotility
Prior GE junction surgery (fundoplication, Heller myotomy) Autoimmune disease
Prior bariatric surgery
GE, gastroesophageal; GERD, gastroesophageal reflux disease.
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Barium upper gastrointestinal (UGI) fluoroscopic evaluation is obtained in all of our patients prior to
restrictive procedures to rule out the possibility of a hiatal hernia and as a screening tool for functional and
structural esophageal disorders.
Routine diagnostic endoscopy is not required in all patients prior to placement of the AGB. However, it can
be of use in patients with an abnormal UGI study to confirm findings of esophageal or upper gastric
abnormalities or other unusual anatomy (i.e., diverticulum, paraesophageal hernia, Schatzki’s ring).
Esophageal function testing is a useful adjunct in patients with a suspected esophageal motility disorder.
Patients with significant esophageal dysmotility or conditions such as achalasia and diffuse esophageal spasm
should not be considered for adjustable gastric banding due to the high risk of long-term band intolerance.
SURGICAL MANAGEMENT
LAGB should be performed at a multidisciplinary bariatric surgery program or center.
The surgeon must be comfortable with laparoscopic intracorporal suturing and procedures of the GE junction.
Familiarity and preferably comfort with other bariatric surgical procedures is required.
Informed consent for the procedure should include a comprehensive discussion of alternative bariatric surgical
procedures, need for long-term follow-up and adjustments, and discussion of risks (Table 2).
A preoperative very low calorie diet (VLCD) is used to deplete hepatic glycogen stores and reduce liver
volume to facilitate UGI exposure. Surgery is postponed for patients with rapid weight gain just prior to the
scheduled procedure.
Positioning
The patient is positioned supine with both arms extended. A footboard and thigh straps are used to secure the
patient to the operating table.
Reverse Trendelenburg position helps to expose the upper abdomen, and steep positioning is often needed
for patients with a large amount of omentum and upper abdominal fat.
The stomach is decompressed immediately after intubation with an orogastric tube. Deep muscle relaxation
aids the exposure of the GE junction.
The surgeon stands to the patient’s right with an assistant to the left.
During the setup for the procedure, the scrub assistant will prepare the band per the manufacturer
recommendations to flush any air from the system.
Prophylactic antibiotics are given immediately prior to incision. In addition, mechanical and pharmacologic
deep vein thrombosis (DVT) prophylaxis is used.
Table 2: Risks of Adjustable Gastric Banding
General/systemic Infection, bleeding, venous thromboembolism, death
Dehydration, inadequate weight loss, weight regain, nutritional deficiencies

Device related Device intolerance
Prolapse
Erosion
Dysphagia/reflux/vomiting/regurgitation
Port leakage/tubing disconnection
TECHNIQUES
ENTRY TO ABDOMEN AND EXPOSURE
Laparoscopic exposure to the abdomen is obtained using an optically guided trocar in the left paramedian
position approximately 3 to 5 cm below the costal margin. Either a 30-degree, 45-degree, or deflectable-
tip camera is used.
Additional trocars are placed with a 12- or 15-mm trocar to accommodate the AGB insertion into the
abdomen. Precise positioning of trocars ensures appropriate angle for the placement of the AGB around
the upper stomach (FIG 2).
A Nathanson or similar liver retractor is placed just above the GE junction to retract the left lobe of the
liver. Upward (anterior) traction on the liver retractor helps to visualize the phrenoesophageal ligament
and proximal gastric anatomy. A solid and strong mounting clamp for the retractor greatly enhances the
exposure. In some cases, an assistant pulling anteriorly on the retractor can facilitate exposure on a
patient with both hepatomegaly and a large amount of fat around the GE junction.
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FIG 2 • Positioning and trocar placement. Careful placement of the trocars facilitates proper placement and
orientation of the AGB.
DISSECTION
The hepatogastric ligament (pars flaccida) is opened using hook electrocautery or ultrasonic shears.
Care must be taken to not injure a replaced or accessory hepatic artery.
The anterior GE (Belsey’s) fat pad is either lifted from the proximal stomach or removed altogether. There
are often small branch vessels arising from the left gastric artery within this fat.
The angle of His (junction of greater curvature of stomach and esophagus) is minimally dissected to free
the stomach from the diaphragm. This can be performed either bluntly or with hook electrocautery.
Inferior traction on the fundus by the assistant facilitates this exposure (FIG 3).
FIG 3 • Dissection of angle of His.
If a small hiatal hernia is seen, it should be repaired anteriorly after reduction and gentle mediastinal
dissection. Larger hiatal hernias may require a traditional posterior repair.
A small incision is made with electrocautery low down on the right crux of the diaphragm, at the point
where a small band of fat crosses the crux (FIG 4). Care must be taken to identify the vena cava prior to
this dissection. Exposure of this region is facilitated by the assistant providing gentle lateral (leftward)
retraction of the lesser curvature of the stomach.
FIG 4 • Exposure of right crux of diaphragm. Note lateral retraction of lesser curvature of stomach.
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PLACEMENT OF ADJUSTABLE GASTRIC BAND
Either a long blunt grasper or specialized curved instrument is passed behind the upper portion of the
stomach from right to left at a 45-degree angle to the long axis of the body (FIG 5). There should be no
resistance to the passage of this instrument and it should be observed exiting exactly at the point where
the angle of His dissection was made. Care must be taken to not perforate the stomach or esophagus
posteriorly during this step of the procedure.
The band is grasped and brought behind the stomach using the grasper just placed behind the stomach.
The orientation of the band for placement (band first or tubing first) is determined based on which brand
of band is selected.
The AGB is buckled per manufacturer instructions (FIG 6). The band should sit loosely on the stomach
when buckled and be able to rotate easily. If a gastric tube was used to help identify the GE junction, it
should be removed at this time.
FIG 5 • A,B. Grasper placed behind upper stomach at 45-degree angle to grasp tubing and bring unbuckled
band behind stomach. C. Intraoperative view.
FIG 6 • Band is buckled after placement around upper stomach.
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GASTROGASTRIC PLICATION
A series of gastrogastric sutures are then placed from lateral (left) to medial (right) (FIG 7).
Nonabsorbable sutures can either be placed in an interrupted or running fashion. The entire lateral and
anterior portions of the band should be covered stopping at the buckle. Anywhere from two to four
sutures may be needed to complete this step of the procedure.
FIG 7 • A,B. Gastrogastric plication sutures. Stomach folded over and laterally and anteriorly. GE,
gastroesophageal.
Recently, some surgeons have begun to place additional anterior gastric plication sutures below the level
of the AGB to possibly (1) improve restriction and weight loss and (2) reduce the incidence of band
prolapse.
PLACEMENT OF SUBCUTANEOUS ACCESS PORT
Prior to removal of the trocars, the tubing from the band is exteriorized, trimmed, and connected to the
access port. Excessive tubing length should not be left in the patient’s abdomen to prevent the possibility
of the tubing causing a bowel obstruction. The port is affixed to the abdominal wall on the rectus muscle
with care that the port is not placed directly under the costal margin or in a position where it will be
aggravated by the patient’s clothing. Most surgeons place the port in either the right or left upper
quadrant.
The port can be affixed to the fascia using one of three techniques.
The port can be attached to a small disc of mesh and then placed in a small, tight subcutaneous
pocket directly on the fascia without any suturing.
The port can be attached using interrupted nonabsorbable sutures placed directly into the anterior
fascia.
A proprietary port applier can be used to affix the port directly to the fascia.
Care needs to be taken to ensure that the fascia is clear of fat for proper port adherence.
Scarpa’s fascia is closed over the port prior to subcuticular closure of the skin.
Band adjustment or “prefilling” is generally not required, as the band tends to be tight during the first few
postoperative days due to gastric edema.
ALTERNATIVE BAND PLACEMENT TECHNIQUES
Both single-incision and dual-incision techniques have been described for the placement of AGBs. The
authors of this chapter do not perform the procedure using these techniques. However, if such a
technique is desired, it requires the ability to
Place the band in the same position as in a multiport operation
Not jeopardize the exposure of the critical landmarks for the procedure
Allow for uncompromised suturing of the gastrogastric plication sutures.
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PEARLS AND PITFALLS
Vitamin ▪ Daily multivitamins, calcium; vitamin B12 generally not required

supplementation
Hiatal hernia ▪ Always look for and repair at time of surgery.4 A “dimple” at the hiatus warrants
repair further investigation.
Port mesh ▪ Port can be affixed to abdominal wall by sewing a small disc of polypropylene
fixation mesh to the port and placing the port on anterior abdominal wall fascia with minimal
dissection
Follow-up and ▪ Optimal adjustment critical for success

adjustments ▪ Frequent aftercare visits are needed for best results.
Upper GI ▪ Perform annually and when patient is having difficulty achieving optimal band fill
contrast volume
swallow study
Foods to avoid ▪ Dry crumbly foods: chips, crackers, cookies, cakes, pretzels
▪ Liquid calories: ice cream, alcoholic drinks, milk, soft drinks
POSTOPERATIVE CARE
Patients are typically discharged within 24 hours. Patients with low BMI, uncomplicated procedures, and no
evidence of obstructive sleep apnea can be safely discharged the day of surgery.
Venous thromboembolism (VTE) prophylaxis is continued until discharge in all patients and postdischarge in
high-risk patients.
A baseline water-soluble UGI swallow study is selectively obtained on postoperative day 1. This study should
demonstrate flow of contrast through the band with minimal restriction. The band itself should lie at
approximately 45 degrees to the vertical axis of the body (FIG 8). Failure of contrast to pass through the band
is usually due to postoperative edema and will resolve within 24 to 72 hours in most cases. Alternatively, a
plain upper abdominal x-ray can be obtained in patients already able to tolerate liquids. This baseline image is
important as a comparison at a later date if a prolapse is suspected (change in band orientation) (FIG 9).
Sips of water are started on the day of surgery. Sugar-free clear liquids are started on postoperative day 1.
Sugar-free full liquid diet is progressed to soft diet over the first 2 weeks after the procedure, and a general
bariatric diet is begun 3 to 4 weeks after surgery. Bread, rice, pasta, and fibrous meats are avoided initially.
Patients are cautioned about the signs and symptoms of dehydration prior to discharge from the hospital.
Intravenous (IV) fluid is continued until just prior to discharge to help minimize early dehydration.
Like other bariatric surgery procedures, good outcomes with adjustable gastric banding require adherence to
a regimented diet, daily aerobic exercise, and long-term support and follow-up. However, the AGB also
requires regular adjustments for optimal weight loss and comorbidity resolution.
FIG 8 • Abdominal radiograph demonstrating normal band orientation.
Patients are seen for a postoperative check 2 weeks after surgery. Wounds are inspected and diet
progression is reviewed.
Patients are evaluated for the following on each visit:
Presence of hunger between meals
Ability to feel satisfied after eating a small meal
Meal size
Weight loss since last visit
FIG 9 • A,B. Large prolapse of AGB. Note flattening of band orientation.
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Table 3: Band Adjustments

Remove fluid (too tight) Optimal fluid Filled (too tight)
Hunger Small meals Poor food choices

Large meals Optimal weight loss Regurgitation
Poor weight loss Satiety Discomfort while eating
Patient satisfaction Poor weight loss Night cough or GERD
GERD, gastroesophageal reflux disease.
Patients should lose between 0.5 and 2 lb per week with an optimally adjusted band. Large meals, hunger,
and poor weight loss are indications to tighten the band. Small meals, satiety, and optimal weight loss indicate
a well-adjusted band. Finally, maladaptive eating behaviors (cravings for dry crumbly foods, sweets, ice
cream, and soups), GERD, and nighttime coughing are signs that the band is too tight. See Table 3 for
guidelines.
Band Adjustments
Once determined that an adjustment is needed, the patient is placed in the supine position. Arms crossed
behind the head or across the chest can help tense the abdominal musculature to facilitate port access. The
port is located, and the area is cleaned with an alcohol swab. The patient is asked to perform an abdominal
“crunch” or partial sit-up to elevate the port.
A noncoring 20-gauge (Huber) needle is used for port access. The needle is placed on a syringe containing
sterile saline to prevent air from being introduced into the system.
The port is stabilized between the thumb and index finger with the nondominant hand (FIG 10). Care is taken
to not redirect the needle once placed under the skin, as this leads to a bending of the needle. Local
anesthetic is generally not necessary.
Once the port is accessed, a small amount of fluid is drawn back into the syringe to confirm entry into the port.
Although some surgeons remove all fluid from the port prior to an adjustment, this step is not routinely
necessary, as fluid can simply be either added or removed.
By quickly removing the needle, leakage from the self-sealing port is prevented.
Adjustments can be performed under fluoroscopy. Proponents of this technique note that optimal adjustment
can be obtained faster and overtightening of the band can be prevented.
Patients need to be able to swallow water with minimal or no restriction prior to leaving the office after
adjustment. A liquid diet for 1 to 3 days after the adjustment minimizes need for early readjustment. Patients
should return to the office if progressive dysphagia, pain, cough, or frequent vomiting occurs.
Each band type and size has its own filling protocol and capacity. It is unusual, however, for patients to reach
maximal capacity of the band.
Patient visits should be scheduled for every 4 to 6 weeks for the first year after surgery, with band adjustments
being performed as needed during these visits. Patients are instructed to return to the office immediately if
there are any signs or symptoms of a tight band (water brash, dysphagia, vomiting, maladaptive eating
behaviors, or dehydration).
Frequent visits for adjustment are continued long as the patient is losing weight. Once a desired and stable
weight is obtained, the frequency of visits can be decreased but should remain at a minimum of one to two
visits per year.
UGI fluoroscopic swallow is performed annually or any time a patient develops any symptoms suggestive of a
band prolapse such as progressive dysphagia, frequent vomiting, and/or requirements for frequent removal of
fluid with worsening symptoms.
OUTCOMES
Based on a meta-analysis, laparoscopic gastric banding results in an average percentage of excess
weight loss (%EWL) of 47.4% (40.7% to 54.2%) during the first 2 postoperative years.5
A long-term follow-up study has shown that %EWL is preserved at 47.1% 15 years following LAGB, with
a revision rate of 50.1% (79% during the perigastric era and 38.4% during the pars flaccida era) and an
explant rate of 5.6%.6
In a meta-analysis of 32,908 patients undergoing LAGB, type 2 diabetes mellitus resolved in 56.7% of
patients.7
In a prospective randomized study, 60 patients newly diagnosed with type 2 diabetes mellitus, aged
between 20 and 60 years and with a BMI between 30 and 40 kg/m2 were
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randomized to either follow a conventional diabetes management program or follow the same program
and also undergo LAGB. The conventional program included lifestyle modification and open access to a
general physician, dietitian, nurse, and diabetes educator. Remission of type 2 diabetes was achieved by
13% in the conventional-therapy group and by 73% in the surgical group.8
FIG 10 • Technique for accessing subcutaneous port. Port is stabilized by nondominant hand.
Hypertension, hyperlipidemia, and sleep apnea improve or resolve in 70.8%, 71%, and 68%,
respectively.5
There is controversy on the effect of LAGB on GERD. In one study, LAGB led to resolution of GERD in
80% and improvement in 11% of patients at 2 years postoperative.9 In another study, GERD symptoms
decreased postoperatively from 32.9% to 7.7%, but newly developed GERD symptoms were found in
15% of the patients and esophageal dysmotility increased from 3.5% to 12.6%.10
Significant improvement in health-related quality of life (HRQOL) is observed in the first year after
LAGB.11 Food tolerance and gastrointestinal quality of life 2 to 4 years postoperatively appears to be
lower with LAGB compared to RYGB or laparoscopic sleeve gastrectomy (LSG).12
COMPLICATIONS
Early device-related complications are rare.
Port infection in the first few weeks is usually related to the wound itself. However, an unrecognized
gastric perforation must be considered in the event the infection does not quickly resolve with antibiotics.
AGB patients must have long-term surveillance for prolapse (slippage). Prolapse may be a result of the
band being too tight, repeated vomiting, or frequent overeating. A patient with a prolapse presents with
progressive reflux, dysphagia, and poor weight loss, as well as usually requiring fluid to be removed from
the band over time to maintain ability to tolerate solid foods. Confirmation of prolapse is made with a
barium swallow. A flattening of the angle of the band toward the horizontal, vertical orientation of the
band, or en-face rotation of the band is highly suggestive of AGB prolapse. Early identification of
prolapse increases the chances that the band position can be revised.
Band erosions into the stomach are rare with the pars flaccida (hepatogastric ligament technique). One
should suspect erosion anytime there are signs and symptoms of a chronic port infection. Late port
infections, in our experience, are usually a sign of a more significant underlying problem with the band.
Tubing and/or port malfunction are usually a result of incorrect positioning of the port. The nonarmored
portion of the tubing can be punctured during band adjustments and is probably the most common cause
of a system leak. System leaks of saline and or inability to maintain volume early on after surgery are
most likely due to the band being punctured by a needle during initial placement. Rarely, the tubing may
become fractured from frequent repetitive motion. Tubing dislodgement has also been described. One
should suspect a system leak in a patient who suddenly reports the ability to eat much larger meals due
to a lack of restriction.
Some patients will develop AGB intolerance months to years after placement. Despite a normal
positioned band on UGI fluoroscopy, some patients are not able to tolerate even a small amount of
restriction from the band. GE reflux and regurgitation can be severe and prevent any meaningful long-
term weight loss.
REFERENCES
1. Fielding G, Ren C. Laparoscopic adjustable gastric band. Surg Clin N Am. 2005;85:129-140.
2. The LAP-BAND adjustable gastric banding system: summary of safety and effectiveness data. Food and
Drug Administration Web Site. http://www.accessdata.fda.gov/cdrh_docs/pdf/P000008b.pdf. Accessed
January 28, 2013.
3. Gagne DJ, Papasavas PK, Dovec E, et al. Effect of immunosuppression on patients undergoing bariatric
surgery. Surg Obes Relat Dis. 2009; 5(3):339-345.
4. Gulkarov I, Wetterau M, Ren C, et al. Hiatal hernia repair at the initial laparoscopic adjustable gastric band
operation reduces the need for reoperation. Surg Endosc. 2008;22:1035-1041.
5. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis.
JAMA. 2004;292(14):1724-1737.
6. O’Brien PE, MacDonald L, Anderson M, et al. Long-term outcomes after bariatric surgery: fifteen-year
follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg.
2013;257(1):87-94.
7. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic
review and meta-analysis. Am J Med. 2009;122(3):248-256.
8. Dixon JB, O’Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2
diabetes: a randomized controlled trial. JAMA. 2008;299(3):316-323.
9. Woodman G, Cywes R, Billy H, et al. Effect of adjustable gastric banding on changes in gastroesophageal
reflux disease (GERD) and quality of life. Curr Med Res Opin. 2012;28(4):581-589.
10. de Jong JR, Besselink MG, van Ramshorst B, et al. Effects of adjustable gastric banding on
gastroesophageal reflux and esophageal motility: a systematic review. Obes Rev. 201;11(4):297-305.
11. Pilone V, Mozzi E, Schettino AM, et al. Improvement in health-related quality of life in first year after
laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2012;8(3):260-268.
12. Overs SE, Freeman RA, Zarshenas N, et al. Food tolerance and gastrointestinal quality of life following
three bariatric procedures: adjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy.
Obes Surg. 2012;22(4):536-543.
Chapter 29
Laparoscopic Cholecystectomy
Georgios Rossidis
DEFINITION
Laparoscopic cholecystectomy describes a procedure involving the removal of the gallbladder using a
laparoscope, a fiberoptic instrument inserted into the abdomen.1
There are a number of indications for a laparoscopic cholecystectomy. The widespread use of
ultrasonography has led to an increasing detection of patients with asymptomatic gallstones and the
management of these patients is controversial because only 2% to 3% of these patients become
symptomatic per year.
The indications in asymptomatic patients are the following:
Patients who are immunocompromised or awaiting organ allotransplantation or have sickle cell disease
Presence of gallbladder polyps that are bigger than 10 mm or are increasing in size rapidly
Porcelain gallbladder
Gallstones bigger than 3 cm in diameter in areas with high prevalence of gallbladder cancer
The indications in symptomatic patients are the following:
Episodes of biliary colic in patients with identified gallstones
Acute cholecystitis
Patients with biliary dyskinesia diagnosed with cholecystokinin-HIDA cholescintigraphy
Patients with gallstone pancreatitis with no choledocholithiasis based on imaging and laboratory
values
Patients with choledocholithiasis. In most situations, cholecystectomy follows ERCP for extraction of
the common bile duct stones.

A good medical history is necessary to provide information about associated comorbidities that may affect the
patient’s tolerance to pneumoperitoneum or operative treatment in general.
Patients with cardiorespiratory disease may not tolerate the impact of CO2 pneumoperitoneum on cardiac
output or CO2 elimination.
Coagulopathic disorders or anticoagulants should be identified and managed.

Medical history can identify the patients who have a higher risk for choledocholithiasis (patients with jaundice,
gallstone pancreatitis, or cholangitis).
Physical examination of the abdomen reveals any surgical scars, hernias, or stomas that may alter the port
placement. Previous abdominal surgery does not preclude attempt at laparoscopic cholecystectomy. Adhesive
disease is a rare indication for conversion to an open procedure.

Ultrasonography is now the gold standard for the noninvasive diagnosis of cholelithiasis. This imaging test is
highly accurate (>96%), can be performed at the patient’s bedside, and does not require the use of ionizing
radiation. Gallstones must fulfill three major sonographic criteria. They must (1) show an echogenic focus, (2)
cast an acoustic shadow, and (3) seek gravitational dependence (FIG 1). Presence of a dilated common bile
duct during ultrasonography is suggestive of choledocholithiasis. In the case of acute cholecystitis, ultrasound
can demonstrate pericholecystic fluid, gallbladder wall thickening, and even a sonographic Murphy’s sign,
documenting tenderness specifically over the gallbladder.
In atypical cases, a hepatobiliary iminodiacetic acid (HIDA) cholescintigraphy scan may be used to
demonstrate obstruction of the cystic duct, which definitively diagnoses cholecystitis. Filling of the gallbladder
during a HIDA scan essentially eliminates the diagnosis of cholecystitis (FIG 2).
HIDA scan is the diagnostic tool of choice in biliary dyskinesia and is performed with the concurrent
administration of cholecystokinin. An ejection fraction of less than 20% is suggestive of the disease.
If there is suspicion of choledocholithiasis, as in patients with jaundice, pancreatitis, cholangitis, or dilated
common bile duct on ultrasonography, the biliary tree can be delineated and inspected for presence of
gallstones with the use of magnetic resonance cholangiopancreatography (MRCP) (FIG 3). MRCP is highly
sensitive (>90%) and almost has a 100% specificity. As a noninvasive test, MRCP provides accurate imaging
of the biliary tree, but in the setting of choledocholithiasis, it does not provide a therapeutic solution.
Endoscopic retrograde cholangiopancreatography (ERCP) can be used as a diagnostic and therapeutic
modality (FIG 4). In the presence of stones in the common bile duct during ERCP, a sphincterotomy is
performed to allow enlargement of the papilla and subsequent extraction of stones with a balloon or basket
(FIGS 5 and 6). With this approach, more than 80% of all stones can be removed successfully. Larger stones
may
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require additional removal techniques such as mechanical or intraductal lithotripsy. ERCP has a complication
rate of around 8%; complications are sedation-related, pancreatitis, bleeding, perforation, and infection.
FIG 1 • Ultrasound of the abdomen showing multiple gallstones in the lumen of the gallbladder. There is no
gallbladder thickening or pericholecystic fluid, thus acute cholecystitis is ruled out.
FIG 2 • HIDA cholescintigraphy scan. Filling of the gallbladder during a HIDA scan, as in this study, essentially
eliminates the diagnosis of cholecystitis.
FIG 3 • Magnetic resonance cholangiopancreatography (MRCP). Note the filling defect in the distal common
bile duct suggestive of choledocholithiasis. CBD, common bile duct; CHD, common hepatic duct; GB,
gallbladder; PD, pancreatic duct.
FIG 4 • Endoscopic retrograde cholangiopancreatography (ERCP). The solid arrow shows filling defect in the
distal common bile duct, suggestive of choledocholithiasis.
FIG 5 • ERCP on the same patient with sphincterotomy and balloon sweeping of all common bile duct stones.
The solid arrow shows the endoscopic balloon.
Preoperative laboratory studies should include liver function, renal function, electrolyte, and coagulation
studies. Abnormal liver function studies may reflect choledocholithiasis or primary hepatic dysfunction.
SURGICAL MANAGEMENT
In the preoperative area, the patient is asked if any conditions exist that were not present during the last clinic
visit and would factor in the operative decision making; for example, a recent myocardial infarction or other
cerebrovascular event.
The patient is asked to void just prior to transfer to the operating room so as to avoid placement of a Foley
catheter that is not indicated for an elective laparoscopic cholecystectomy.
The operative consent, imaging, and laboratory values are reviewed.
FIG 6 • Completed ERCP showing a patent common bile duct and absence of filling defects.
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FIG 7 • The patient is placed in a supine position with the left arm tagged and the right arm extended. The
primary surgeon stands to the left of the patient and the assistant to the right of the patient.
Positioning
The patient is placed in a supine position with the right arm extended and the left arm is secured along the
patient’s torso (FIG 7).
A footboard is placed at the patient’s feet, and the patient is strapped at the thighs and the legs to avoid a fall
from the bed during steep reverse Trendelenburg position (FIG 8).
Heel pads, sequential compression devices for deep venous thrombosis prophylaxis, and warming devices are
also placed.
An orogastric tube is inserted to decompress the stomach.
The primary surgeon stands at the patient’s left and the assistant surgeon at the patient’s right (FIG 7).
Two monitors are placed at the head of the bed, one on the right and one on the left, facing the surgeon and
the assistant.
The laparoscopic camera, light source, insufflation tubing, suction, and electrocautery are passed to a tower
at the feet of the patient.
FIG 8 • The patient is strapped at the thighs and legs and a footboard is placed to support the patient during
reverse Trendelenburg.
TECHNIQUES
ENTRY INTO THE PERITONEAL CAVITY AND ACHIEVING PNEUMOPERITONEUM
The base of the umbilicus is grasped with two penetrating towel clips and is elevated for easier access. A
5-mm incision is created at the base of the umbilicus with the use of a no. 11 blade. The base of the
umbilicus is chosen because it gives a better cosmetic result.
Through this incision, a Veress needle is introduced into the peritoneal cavity (FIG 9). A syringe with
saline is attached to the Veress needle. First, aspirate the syringe to rule out placement of the Veress
needle in the lumen of intestine or a vessel. Then infuse saline to determine if it will flow through the
needle without resistance. This finding signifies that the needle is in the peritoneal cavity and not in the
subcutaneous tissues. The insufflation tubing is attached to the Veress needle and pneumoperitoneum is
achieved with 15 mmHg of CO2.
Next, a 0-degree laparoscope is inserted in a 5-mm OptiView port, and the port is inserted in the
peritoneal cavity through the same incision under direct vision (FIG 10).
FIG 9 • Placement of the Veress needle.
Alternatively, if the patient has a midline scar and a history of multiple intraabdominal procedures, entry
into the peritoneal cavity is achieved through an incision in the left subcostal area just inferior to the rib in
the anterior axillary line.
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FIG 10 • With the laparoscope inserted in a 5-mm port, the surgeon places the first port under direct
vision. Notice that the surgeon watches the monitor as he advances the port.
PLACEMENT OF THE OTHER PORTS

Once the first port is in place, inspect the intestines immediately beneath the incision to rule out any
inadvertent injury. The 0-degree scope is replaced with a 30-degree scope that allows views through
different angles.
The patient is then placed in reverse Trendelenburg position. The gallbladder is typically easy to
visualize following this maneuver.
The next additional port to be placed is a 5-mm port in the patient’s right flank. The port is placed in the
anterior axillary line around two fingerbreadths below the costal margin. Through this port, the assistant
surgeon grasps the fundus of the gallbladder and retracts the gallbladder and the liver in an anterior and
cephalad direction toward the diaphragm. This facilitates visualization of the triangle of Calot. If the
gallbladder is very distended and inflamed, making it hard to be grasped, the gallbladder may be deflated
with an endoscopic needle.
If the anatomy of the liver precludes visualization of the triangle of Calot, an additional 5-mm port is
placed in the left anterior axillary line at the level of the costal margin and a liver retractor inserted.
With this exposure, precise placement of the working port is determined. This is typically a 12-mm port
that is placed in the epigastrium just below the xiphoid process and to the right of the falciform ligament.
Ideally, the port is situated above the triangle of Calot just inferior to the liver edge.
The third port placed is a 5-mm port in the midclavicular line allowing for adequate spacing between the
ports (FIG 11).
FIG 11 • Placement of the four ports.
The assistant surgeon holds the camera and the right flank port retracting the gallbladder, whereas the
primary surgeon works through the epigastric and midclavicular ports.
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EXPOSURE OF THE TRIANGLE OF CALOT
With the use of a blunt dissector through the epigastric port, any adhesions between the gallbladder and
the omentum or transverse mesocolon are divided, always taking such adhesions along the wall of the
gallbladder to minimize bleeding (FIG 12).
A grasping forceps, through the 5-mm midclavicular line port, is used to grasp the gallbladder at the
Hartman’s pouch and provide lateral traction (FIG 13). This maneuver retracts the gallbladder away from
vital structures and puts the cystic duct at a 90-degree angle to the common bile duct, minimizing the risk
of inadvertent injury to the hepatic or common bile ducts.
The peritoneum is then bluntly dissected off the gallbladder to expose the infundibulum-cystic duct
junction. This is done by stripping the peritoneum at the lateral edge of the gallbladder just below where
the infundibulum is grasped (FIG 14).
As the peritoneum is dissected from the gallbladder wall, the lymph node of Calot is also often identified.
The lymph node overlies the cystic artery and thus is a useful landmark. Peritoneal attachments around
the node of Calot can be taken with hook electrocautery in order to minimize bleeding.
FIG 12 • Omental adhesions are stripped off from the gallbladder.
FIG 13 • The infundibulum is grasped and retracted lateral to the patient’s right side. This is a very
important maneuver as it places the cystic duct at a 90-degree angle to the common bile duct and
minimizes confusion and potential injury to the common bile duct.
This initial dissection exposes the triangle of Calot, also known as the hepatocystic triangle, bounded by
the cystic duct, the common hepatic duct, and the edge of the liver. The content of the triangle is the
cystic artery (FIG 15).
FIG 14 • The peritoneum is dissected off the gallbladder and the structures are becoming visible, exposing
the triangle of Calot. Notice the dissection is carried high along the body of the gallbladder so that injury to
the hepatic or common bile duct is avoided. CA, cystic artery; CD, cystic duct.
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FIG 15 • Schematic drawing showing the triangle of Calot, its borders and the content of the triangle, and
the cystic artery. The interrupted lines represent the borders of the triangle. Notice the lymph node of Calot,
immediately above the cystic artery. It can act as landmark for identification of the cystic artery.
EXPOSURE OF THE REVERSE TRIANGLE

The reverse side of the hepatocystic triangle is bordered by the cystic duct, the inferior lateral border of
the gallbladder, and the right lobe of the liver.
In order to expose the reverse triangle, the infundibulum is retracted medially and superiorly and then
peritoneal attachments are taken bluntly or with the hook electrocautery (FIG 16). This enables one to
further identify the cystic duct and cystic artery, and maneuvering the infundibulum from medial to lateral,
exposure of both triangles is realized and the ability to circumferentially dissect the cystic duct and cystic
artery.
Importantly, division of the posterior triangle peritoneum early in the dissection can dramatically impact
exposure to the anterior triangle by facilitating retraction of the infundibulum away from other portal
structures.
FIG 16 • Exposure of the reverse triangle. The gallbladder (GB) is retracted medially and the reverse
triangle can be exposed by dissection of the peritoneum off the structures. CD, cystic duct.
THE CRITICAL VIEW

It is of paramount importance to obtain a critical view of the cystic duct and artery prior to clipping or
dividing any structures. This view is obtained when both the cystic duct and cystic artery are
circumferentially dissected and windows have been created between the two structures and medial to the
cystic artery (FIG 17). Ideally, the medial wall of the gallbladder is dissected up to the
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liver. This visualization minimizes the risk of dividing the hepatic or common bile duct or an aberrant
branch of the right hepatic duct. The dissection medial to the cystic artery reduces the risk of injuring a
meandering right hepatic artery that is also at risk for inadvertent injury.
Should this dissection and exposure be limited by inflammation or other factors such as an intrahepatic
gallbladder, a hypertrophied left lobe of the liver, or aberrant anatomy, a retrograde dissection of the
gallbladder as is classically done during the open procedure can be considered or the decision for
conversion to an open procedure should be made.
FIG 17 • The critical view. The two triangles show the windows that need to be formed between the cystic
duct and the cystic artery and medial to the cystic artery. The surgeon should be able to see the visceral
surface of the liver through these windows. CA, cystic artery; CD, cystic duct.
DIVISION OF THE CYSTIC DUCT AND CYSTIC ARTERY

Once the critical view is obtained, the two structures can safely be clipped and divided with laparoscopic
shears. A clip applier is introduced through the epigastric port, and the cystic artery and cystic duct are
clipped with two to three clips proximally and one clip distally (FIG 18). The posterior jaw of the clip
applier should be visualized across the structure to assure that the clip will traverse the entire lumen of
each structure. Once both structures are divided, the clipped stumps of the two structures are inspected
(FIG 19). An alternative approach for a large caliber cystic duct or friable tissues is the use of a
laparoscopic endoloop or stapling device to control the duct.
FIG 18 • Clipping of the cystic duct and cystic artery.
FIG 19 • Inspecting the clipped stumps of both structures.
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DISSECTION OF THE GALLBLADDER OFF THE GALLBLADDER FOSSA
Next, the gallbladder is dissected from attachments to the undersurface of the liver using hook and/or
spatula electrocautery. The infundibulum is grasped and elevated toward the anterior abdominal wall and
lateral to create tension and the body of the gallbladder is dissected off the gallbladder fossa (FIG 20). In
order to dissect the lateral side of the gallbladder, the infundibulum is retracted medially and superiorly
and again the hook electrocautery dissects the whole length of the lateral wall of the gallbladder (FIG
21). Prior to completely freeing the gallbladder, it can be used as a handle to lift the liver and inspect the
operative bed for bleeding. The gallbladder is then completely separated from the liver (FIG 22).
FIG 20 • Dissection of the gallbladder fossa with electrocautery.
FIG 21 • Dissection of the lateral wall of the gallbladder off the gallbladder fossa.
FIG 22 • The gallbladder is pulled away from the liver, and the tip of the fundus is divided from the liver to
complete the gallbladder dissection.
EXTRACTION OF THE GALLBLADDER

The gallbladder is now completely dissected off the liver. A 10-mm specimen bag is introduced through
the epigastric port and opened facing the camera. The gallbladder is placed in the specimen bag (FIG
23) and then extracted through the port site. If the gallbladder is too big or contains large stones, the port
incision may need to be extended to accommodate the bigger gallbladder.
The specimen is sent to pathology for histologic examination.
FIG 23 • The gallbladder is placed in an EndoCatch bag.
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CLOSURE
The epigastric port is closed at the fascial level with the use of a transfascial suture passer and 0 braided
absorbable suture (FIG 24).
The other ports are retrieved under direct vision to rule out hemorrhage at the port sites.
Once hemostasis is confirmed at the port sites, the peritoneum is deflated and the skin incisions are
closed with subcuticular 4-0 monofilament absorbable suture.
FIG 24 • The incision is reapproximated with a transfascial suture passer and 0 braided absorbable suture.
PEARLS AND PITFALLS

Placement of ▪ Many authors place the 12-mm port in the umbilicus. We advocate placement of
12-mm port the 12-mm port in the epigastrium because the umbilicus is the weakest point of
the abdominal wall and the risk of incisional hernia is higher. Furthermore, if a
hernia develops at the epigastric port, the risk of bowel incarceration is very low
because the port is very high and above the liver, minimizing the risk of
strangulation or incarceration.
Intraoperative ▪ A surgeon performing laparoscopic surgery should be facile and comfortable

cholangiogram performing an intraoperative cholangiogram. We do not advocate routine
performance of cholangiograms, but there should be a very low threshold for
performing a cholangiogram in cases of questionable anatomy or suspicion of
injury.
Dissection of ▪ Dissection of the peritoneum to identify the structures should be done as close
triangle of to the gallbladder as possible. This minimizes the risk of injury to the hepatic or
Calot common bile duct which lies deeper.
Two-handed ▪ In the above description, the primary surgeon uses two hands to retract the
skills gallbladder and dissect at the same time. In a teaching institution, or when a
laparoscopic novice is performing the cholecystectomy, two-hand laparoscopic
cholecystectomy is a very good starting procedure to obtain bimanual dexterity
before embarking on more complex laparoscopic cases.
Spilled stones ▪ Every effort should be made to avoid perforation of the gallbladder and spillage
of gallstones. If this happens, all gallstones should be retrieved to avoid
associated complications such as postoperative granulomas or abscesses.
POSTOPERATIVE CARE
The majority of laparoscopic cholecystectomies are performed as outpatient surgery and thus patients are
discharged home on the same day. If the procedure is performed in the setting of resolved pancreatitis or
choledocholithiasis on a patient who was already hospitalized, an overnight postoperative stay is the norm. A
diet can be initiated immediately.
COMPLICATIONS
The overall perioperative mortality varies between 0% and 0.3%.2,3
The overall incidence of bile duct injuries requiring corrective surgery varies between 0.1% and 0.3%.
Corrective surgery for bile duct injury carries its own risks including perioperative mortality (1% to 4%),
secondary biliary cirrhosis (11%), anastomotic stricture (9% to 20%), and cholangitis (5%).4,5
Other complications include the following:
Bile leak treated conservatively (0.1% to 0.2%), radiologically (0% to 0.1%) or endoscopically (0.05%
to 0.1%), or by operation (0% to 0.05%).
Peritonitis requiring reoperation, typically from a missed, inadvertent enterotomy (0.2%)
Postoperative bleeding requiring operation (0.1% to 0.5%)
Intraabdominal abscesses requiring operation (0.1%)
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REFERENCES
1. Keus F, Gooszen HG, van Laarhoven CJ. Open, small-incision, or laparoscopic cholecystectomy for
patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews.
Cochrane Database Syst Rev. 2010;(1):CD008318.
2. Duca SS, Bãlã OO, Al-Hajjar NN, et al. Laparoscopic cholecystectomy: incidents and complications. A
retrospective analysis of 9542 consecutive laparoscopic operations. HPB (Oxford). 2003;5(3): 152-158.
3. Giger UF, Michel JM, Opitz I, et al. Risk factors for perioperative complications in patients undergoing
laparoscopic cholecystectomy: analysis of 22,953 consecutive cases from the Swiss Association of
Laparoscopic and Thoracoscopic Surgery database. J Am Coll Surg. 2006;203(5):723-728.
4. Sicklick JK, Camp MS, Lillemoe KD, et al. Surgical management of bile duct injuries sustained during
laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005;241(5):786-785.
5. Schmidt SC, Settmacher U, Langrehr JM, et al. Management and outcome of patients with combined bile
duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery. 2004;135(6):613-618.
Chapter 30
Open Cholecystectomy
Sean P. Montgomery
Preston B. Rich
DEFINITION
Removal of the gallbladder for benign disease using an open technique when the laparoscopic technique
is not prudent.
Acute cholecystitis
Symptomatic biliary colic
Acalculous cholecystitis
Diseases that can present similarly and are not treatable by simple cholecystectomy include peptic ulcer
disease, hepatitis, pancreatitis, cholangitis, gallbladder cancer, colitis, irritable bowel syndrome, and
atypical appendicitis.

Biliary colic (symptomatic cholelithiasis) is typically a right upper quadrant (RUQ) or epigastric postprandial
pain. Symptoms classically start 30 to 90 minutes after eating and association with high-fat meals may be
described. Nausea and bloating are common. The pain typically will resolve within 6 hours. Pain lasting more
than 6 hours and/or fever is suggestive of acute cholecystitis.
On physical examination, tenderness will usually be present in the RUQ. The presence of a Murphy’s sign
(inspiratory arrest with RUQ palpation) is suggestive of acute cholecystitis.

A fasting RUQ ultrasound is the “gold standard” for the diagnosis of gallstones and is frequently the only
imaging necessary to diagnose acute cholecystitis. Gallstones are identified as mobile echogenic foci with
posterior shadowing (FIG 1). Cholecystitis is suggested by gallbladder wall thickening (>3 mm),
pericholecystic fluid, or inspiratory arrest elicited by placement of the ultrasound probe directly over the
gallbladder (a sonographic Murphy’s sign). The sensitivity and specificity of ultrasound for calculous
cholecystitis are around 82%.1 In critically ill patients with acalculous cholecystitis, the specificity drops
significantly.
The other common imaging study used to diagnose gallbladder pathology is a nuclear medicine test called
either hepatobiliary scintigraphy or a hepatobiliary iminodiacetic acid (HIDA) scan (commonly referred to as a
HIDA scan.) In this test, a radiolabeled substrate is intravenously administered, taken up by the liver, and
excreted into the biliary tree (FIG 2). If the substrate fails to fill the gallbladder within 1 hour, the sensitivity is
96% for acute cholecystitis.1 A HIDA scan will also provide information about obstruction of the common bile
duct, as substrate will be seen accumulating in the duodenum if the duct is not obstructed. In the setting of
hepatic failure or cholestasis, this study is not useful, as the liver often will not take up enough substrate to
allow an adequate study. Gallstones are not revealed with this study, but rather, the presence or absence of
cholecystitis is determined by assessing patency of the cystic duct regardless of the etiology. HIDA
scintigraphy is generally performed if the clinical findings and ultrasound are inconclusive for calculous
cholecystitis or in critically ill patients with suspected acalculous cholecystitis.2
SURGICAL MANAGEMENT
The vast majority of patients will be appropriate candidates for a laparoscopic cholecystectomy. Conversion
from laparoscopy due to variable anatomy or severe inflammation is the most common indication for the open
procedure. Rare patients in whom a primary open cholecystectomy should be considered are the following:
Septic patients on vasoactive agents for hemodynamic support that have failed percutaneous drainage
Patients with complicated anterior abdominal walls and/or severe adhesions. Specifically, if there are large
pieces
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of prosthetic mesh in the umbilical and epigastric areas and/or prior RUQ surgery, laparoscopic completion
of a cholecystectomy can be challenging.
FIG 1 • Gallbladder ultrasound. Figure A demonstrates the normal ultrasound appearance of the
gallbladder. In Figure B, the presence of gallstones, thickening of the gallbladder wall, and gallbladder wall
edema are suggestive of acute cholecystitis.
FIG 2 • HIDA scintigraphy. In Figure A, tracer promptly fills the gallbladder and duodenum, demonstrating
normal gallbladder physiology and a nonobstructed biliary system. In Figure B, nonfilling of the gallbladder
at 1 hour following substrate injection is consistent with acute cholecystitis.
The need for concomitant open common bile duct exploration
Positioning
The patient is positioned supine. Arms can be tucked by the side or extended out at right angles to the bed. An
oral or nasal tube for gastric decompression is placed.
TECHNIQUES
INCISION
The gallbladder is most easily accessed through an oblique RUQ incision (FIG 3). The incision should be
placed two fingerbreadths below the right costal margin to facilitate fascial closure. In patients with
significant hepatomegaly, the incision may be moved inferiorly to two fingerbreadths below the palpable
liver edge, but this should rarely be necessary. The incision is carried down to the fascia.
FIG 3 • Incision. An oblique RUQ incision is created two fingerbreadths below the costal margin (Kocher’s
incision). The right rectus abdominis muscle is divided before entering the abdominal cavity.
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OPENING OF THE ABDOMINAL WALL
The anterior rectus fascia should be incised with electrocautery. A Kelly or other large clamp is placed
under the lateral border of the rectus muscle, retracting it anteriorly, to facilitate division of the muscle
with electrocautery. The superior epigastric vessels can be encountered, typically about halfway across
the rectus. The vessels can be ligated or cauterized, or they can be reflected medially and preserved with
the medial half of the rectus.
PLACEMENT OF RETRACTORS
This step is the key to a successful operation. Safely keeping the bowel out of the operative field and
delivering the gallbladder to the center of the wound will make the remainder of the case straightforward
with proper exposure. A Bookwalter fixed retractor or other tablemounted retractor should be used (FIG
4). In cases of dense adhesions to the gallbladder, start with body wall retractors placed inferiorly and
superiorly. In cases of minimal adhesions or after some initial adhesiolysis, use moist laparotomy pads to
push the transverse colon and duodenum inferior and medial, respectively, away from the gallbladder.
Malleable or long right-angle retractors for the retractor should be placed inferomedially and
inferolaterally to hold these lap pads away from the gallbladder. A deep body wall retractor may be
required inferiorly to adequately open the space between the duodenum and gallbladder.
Superomedially, a flat deep retractor, such as a Harrington (or Sweetheart) or medium right-angle should
be placed against the liver to pull it to the superior aspect of the wound. A superolateral body wall
retractor can be progressively exchanged for deeper retractors as the gallbladder is progressively
dissected from the gallbladder bed to elevate the liver and separate it from the gallbladder. A Kelly or
large clamp is then placed on the infundibulum of the gallbladder to facilitate moving it within the space
created.
FIG 4 • Placement of retractors. Correct application of a fixed retracting device (Bookwalter) is the key to a
successful and safe open cholecystectomy. Inferiorly, moist laparotomy pads are carefully placed behind
deep retractors to exclude the duodenum, colon, and small bowel from the operative field. Superiorly,
additional retractors are placed to retain the liver. As the gallbladder is dissected free from its bed, the more
lateral superior retractor can be progressively exchanged for deeper retractors placed over the dissected
bed to improve visualization.
INCISION OF THE VISCERAL PERITONEUM

The peritoneum is incised just off the liver edge at the most anterior point of the gallbladder (FIGS 5 and
6). A tonsil or other fine-tipped dissector is used to enter the plane between the peritoneum and the
gallbladder. Electrocautery is then used to open the peritoneum. This is repeated for the other side of the
gallbladder.
FIG 5 • Incision of the peritoneum and dissection of the gallbladder from the gallbladder fossa. The
infundibulum is grasped with a large clamp (Kelly) to facilitate mobilization. The peritoneum (serosa of the
gallbladder) is incised 3 to 5 mm from the interface with the substance of the liver and the areolar tissue
between the gallbladder and the liver is divided with electrocautery. The gallbladder is dissected in a top-
down fashion toward the porta hepatis.
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FIG 6 • Ligation of the cystic duct and cystic artery. After the gallbladder has been dissected free from its
bed, a combination of blunt and sharp dissection is used to isolate the cystic duct and cystic artery.
Dissection should be directed from the gallbladder toward the portal structures to avoid injury. Both
structures are divided separately between ligatures. Care should be taken to not apply electrocautery when
in proximity to the colon, duodenum, or portal structures.
RETROGRADE DISSECTION OF THE GALLBLADDER OFF OF THE GALLBLADDER FOSSA
Electrocautery is then used to dissect the gallbladder free from the liver. This is performed in a top-down
fashion, starting anteriorly and continuing until the gallbladder is suspended from its pedicle.
LIGATION OF THE CYSTIC DUCT AND ARTERY
After the gallbladder has been dissected free from its bed, a combination of sharp and blunt dissection is
performed around the pedicle until the artery and duct are dissected free (FIGS 7,8 and 9). Tracing the
cystic duct until its intersection with the common bile duct is not necessary if the duct is confirmed to be
headed directly out of the gallbladder. Because the most common indication for an open cholecystectomy
is the presence of severe inflammation, unnecessary dissection in the porta hepatis can be unsafe and
should be avoided if possible. Simple
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ligation of the cystic duct and artery are accomplished with separate ties. The gallbladder is then excised
free. If the gallbladder or cystic duct appears necrotic, a drain should be placed to control a bile leak
should one occur.
FIG 7 • Operative photograph of a “top-down” dissection of the gallbladder from the undersurface of the
liver. The peritoneum has been incised over the triangle of Calot, exposing adipose tissue around the
infundibulum of the gallbladder and the key portal structures.
FIG 8 • Isolation of the cystic artery. Inferior and lateral retraction facilitates identification of the cystic artery
as shown.
FIG 9 • Isolation of the cystic duct. Once the cystic artery has been ligated and divided, the cystic duct is
circumferentially dissected.
ALTERNATIVE: SUBTOTAL CHOLECYSTECTOMY

Open cholecystectomy is usually reserved for cases with severe inflammation. In some patients, the
inflammation may be so severe that dissection around the neck of the gallbladder to identify the cystic
duct becomes unsafe. If the cystic duct cannot be safely identified and dissected free due to adhesions, a
subtotal cholecystectomy may be performed. In this case, the gallbladder neck is dissected to the region
where inflammation prohibits further dissection. The gallbladder is then transected at that point and the
internal opening of the cystic duct is ligated with suture (FIG 10). If a significant portion of the gallbladder
wall remains, the remainder of the gallbladder fulgurated and then the edges of the wall are sewn closed
with a running monofilament suture. In these cases, a drain should be left, as the incidence of bile leak
after subtotal cholecystectomy can be in excess of 20%.3 It is for this reason that a complete
cholecystectomy is performed whenever the cystic duct can be safely identified.
If significant bleeding from the liver is encountered, such as in unsuspected portal hypertension, the back
wall of the gallbladder can be left adherent to the liver.4,5 Fulguration of any viable mucosa is advised.
FIG 10 • Subtotal cholecystectomy. In cases where severe inflammation is encountered, dissection to the
cystic duct may be unsafe. In such case, the infundibulum of the gallbladder can be amputated at the
junction where dissection must be stopped and the cystic duct opening closed with suture ligature. When a
cuff of gallbladder remains, it is fulgurated with electrocautery and closed with a running absorbable
monofilament suture.
CLOSURE
The posterior and anterior fascia should be closed in separate layers. The skin is closed with staples due
to the clean-contaminated nature of the procedure.
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PEARLS AND PITFALLS
Electrocautery ▪ To avoid injury, electrocautery should be avoided when dissecting near the
duodenum, colon, biliary structures, or porta hepatis.
Visualization ▪ If the colon or duodenum is crowding the operative space, consider a deeper
blade for the retractor that is “toed in” slightly on laparotomy pads.
Common bile ▪ If the inflammation is so severe that it is difficult to dissect the cystic duct at the
duct injury neck of the gallbladder, consider a subtotal cholecystectomy. In this
circumstance, leave a drain.
Bleeding ▪ During surgery for acute cholecystitis, inflammatory bleeding is often
encountered from the gallbladder fossa during top-down dissection. When
present, this can usually be best controlled with a laparotomy sponge and
pressure applied directly to the raw surface following separation of the
gallbladder from its liver bed. Often, a deeper retractor blade can be placed
between the gallbladder and its bed to maintain pressure while also improving
visualization.
POSTOPERATIVE CARE
Ileus is unusual after open cholecystectomy, so diet can be rapidly advanced. Narcotic requirements will be
higher than for laparoscopic cholecystectomy and a 2- to 3-day hospital stay may be necessary for adequate
pain control.6 If a cystic duct leak occurs, it will often not be clinically apparent for several days after the
original operation (an average of 2.3 days).7 Therefore, if drains were placed due to a high-risk cystic duct
stump, they should be left for several days before being removed.
OUTCOMES
Long-term outcomes after cholecystectomy are excellent. Short-term morbidities include cystic duct leak,
the incidence of which averages about 0.4% for elective patients and threefold higher for emergent
cholecystectomies. After subtotal cholecystectomy, issues from the remnant gallbladder are rare.4,5
COMPLICATIONS
Cystic duct leak
Common bile duct injury (<1/1,000).
Wound infection
Hemorrhage from the liver
REFERENCES
1. Kiewiet JJ, Leeuwenburgh MM, Bipat S, et al. A systematic review and meta-analysis of diagnostic
performance of imaging in acute cholecystitis. Radiology. 2012;264(3):708-720.
2. Puc MM, Tran HS, Wry PW, et al. Ultrasound is not a useful screening tool for acute acalculous
cholecystitis in critically ill trauma patients. Am Surg. 2002;68(1):65-69.
3. Davis B, Castaneda G, Lopez J. Subtotal cholecystectomy versus total cholecystectomy in complicated

cholecystitis. Am Surg. 2012;78(7): 814-817.
4. Bornman PC, Terblanche J. Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension
and cholecystitis. Surgery. 1985;98(1):1-6.
5. Cottier DJ, McKay C, Anderson JR. Subtotal cholecystectomy. Br J Surg. 1991;78(11):1326-1328.
6. Kelley JE, Burrus RG, Burns RP, et al. Safety, efficacy, cost, and morbidity of laparoscopic versus open
cholecystectomy: a prospective analysis of 228 consecutive patients. Am Surg. 1993;59(1):23-27.
7. Eisenstein S, Greenstein AJ, Kim U, et al. Cystic duct stump leaks: after the learning curve. Arch Surg.
2008;143(12):1178-1183.
Chapter 31
Intraoperative Cholangiogram
Chasen A. Croft
Dawood G. Dalaly
DEFINITION
Intraoperative cholangiography (IOC) is the use of radiography with contrast media injected directly into the
biliary tree to determine biliary anatomy, assess the biliary tree for obstructive processes, and to evaluate for
potential injury to the biliary tract.

Many surgeons routinely perform cholangiography as a part of every cholecystectomy. Others selectively use
cholangiography based on the results of preoperative testing or intraoperative findings. A preoperative common
bile duct (CBD) diameter greater than 6 mm, obstructive jaundice (direct bilirubin >4.0 g/dL), pancreatitis, and
small stones in the gallbladder have all been forwarded as indications for IOC. Intraoperative indications would
include palpating stones in the CBD, unclear biliary anatomy, or to evaluate for inadvertent injury to the biliary
tree.1

Prior to proceeding with cholecystectomy with IOC, patients should have an ultrasound evaluation of their biliary
tree to assess for cholelithiasis, cholecystitis, and to determine the diameter of the extrahepatic CBD. Note that
abdominal ultrasound is not a sensitive indicator of choledocholithiasis as CBD gallstones are often located in the
distal CBD within the intrapancreatic portion and are thus obscured by air in the overlying stomach and/or are
beyond the depth of penetration of ultrasound.
FIG 1 • A. The patient is positioned supine with the left arm tucked. A footboard is placed. The C-arm fluoroscopy
unit is positioned to the patient's left, with the monitor readily visible to the operating surgeon who is on the
patient's right. B. The patient must be positioned with respect to the pedestal of the operating table so that there is
adequate room for the C-arm. (continued)
In the absence of cholangitis, but presence of ultrasound or laboratory findings suggestive of choledocholithiasis,
one forwarded option is to preoperatively evaluate the biliary tree with magnetic resonance
cholangiopancreatography (MRCP) to determine the cause of biliary tree obstruction. Should biliary obstruction be
present, preoperative endoscopic retrograde cholangiopancreatography (ERCP) is then performed to clear the
duct of stones prior to cholecystectomy or identify more ominous etiologies of the biliary obstruction.
Alternatively, others have advocated directly proceeding to cholecystectomy with IOC in this clinical setting,
arguing that current modalities lack accuracy in identifying clinically significant choledocholithiasis and
performance of an IOC often clears the duct of small stones. As such, these surgeons argue that the presurgical
probability that an ERCP is necessary is low and this approach is more cost-effective by avoiding unnecessary
ERCP.
SURGICAL MANAGEMENT Positioning

The patient should be placed in the supine position on the operating room table. The left arm is preferentially
tucked against the torso to provide room for C-arm fluoroscopy. The table should be positioned with respect to the
supporting pedestal so as to allow the fluoroscopy C-arm to slide underneath the operating table unobstructed
(FIG 1).
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FIG 1 • (continued) C. Photograph demonstrating a clear path beneath the abdomen of the patient for the C-arm.
The C-arm fluoroscopy unit should be positioned to the patient's right with the screen monitor clearly visible to the
operating surgeon.
The bed should have a footboard placed and the patient should be well secured to the operating table, as reverse
Trendelenburg position is required during the procedure.
Radiation Safety
The surgeon must be knowledgeable in the use of fluoroscopy. This should include successful completion of
institutional training including certification for use of fluoroscopy in the operating theater.
All operating room personnel should don appropriate protective garments prior to scrubbing and gowning.
TECHNIQUES
CHOLANGIOCATHETER PLACEMENT
Cystic duct approach
The gallbladder infundibulum should be mobilized and dissection of Calot's triangle should identify the
cystic duct and artery entering the infundibulum.
Once the cystic duct is circumferentially dissected, a clip should be placed across the cystic duct as
proximal as possible to the infundibulum (FIG 2).
A ductotomy should be made along the cystic duct, leaving adequate length for subsequent double clip
ligation. Care must be taken to avoid fully transecting the duct with this maneuver. An intact posterior-
cephalad cystic duct wall is essential to maintain exposure and facilitate placement of the cholangiogram
catheter (FIG 3). Note that it is typical for the ductotomy to enlarge with the necessary lateral retraction to
provide exposure or with manipulation with the cholangiogram catheter. Furthermore, the skeletonized
cystic duct typically lacks intrinsic strength and can tear easily with aggressive retraction once a ductotomy
has been made.
FIG 2 • After circumferential dissection of the cystic duct, a clip is applied at the junction with the
infundibulum.
Two techniques for placement of the cholangiocatheter for laparoscopic IOC have been described:
The first technique employs a 5-Fr cholangiocatheter inserted through an introducer sheath (FIG 4).
This sheath, available as a component
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of commercially available cholangiogram catheter kits, is inserted through a separate incision along the
right subcostal margin. Placement of this incision should be guided by location of the ductotomy. Ideally,
the catheter enters the abdomen lateral and caudad to the cystic duct (FIG 5).
FIG 3 • A. A ductotomy is sharply incised. B. The ductotomy should just be large enough to admit a
small-caliber catheter. Note the majority of the cystic duct remains intact.
The catheter is then gently guided into the cystic duct with atraumatic technique and secured with a
partially occluding clip placed just distal to the ductotomy.
An alternative technique is to use an Olsen-Reddick clamp (FIG 6). This device has a channel through
the center of the clamp to accommodate a 5-Fr cholangiocatheter. The clamp is advanced though a
laterally placed trocar. Once intraabdominal, the jaws of the clamp are opened and the
cholangiocatheter is inserted through the center channel until the catheter tip extends beyond the jaws
of the clamp. The catheter is then directed into the cystic duct. Once in place, the jaws of the clamp are
closed around the cystic duct and cholangiocatheter, preventing leakage of contrast through the
ductotomy (see FIG 2).
FIG 4 • The cholangiogram catheter is inserted into the cystic duct. The catheter depicted has an
expandable cuff that can be appreciated within the cystic duct.
This method remove the use of clips along the cystic duct during IOC.
Infundibular approach
This approach is less technically demanding than direct cannulation of the cystic duct. It is also of value
should identification of the cystic duct be difficult secondary to inflammation or scarring of the porta hepatis;
however, in this clinical setting, the cystic duct may be occluded, precluding the approach.
FIG 5 • Cannulation of the cystic duct using a flexible 5-Fr cholangiogram catheter. A clip is placed across
the cystic duct just proximal to infundibulum of the gallbladder and a second, nonoccluding clip is placed
across the cystic duct and catheter to prevent retrograde leakage of contrast material.
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FIG 6 • An Olsen-Reddick clamp can be used to stabilize and expose the cystic duct. The clamp has a
channel for passage of the cholangiogram catheter.
FIG 7 • A Kumar clamp is used when performing an IOC by injecting the infundibulum of the gallbladder.
This is the least technically demanding approach to IOC but not an option in the setting of acute
cholecystitis.
The peritoneum should be incised and the infundibulum dissected free from the hepatic bed. Once the
infundibulum is mobilized, a Kumar clamp should be inserted through a laterally placed subcostal trocar.
This clamp has long, atraumatic jaws, which completely occlude the infundibulum, and a side channel for
the introduction of a needle-tipped cholangiocatheter. The clamp is applied along the lower body of the
gallbladder, just above Hartmann's pouch (FIG 7).
Advance the Kumar catheter through the side channel and visualize the needle as Hartmann's pouch is
punctured.
Once the catheter is placed, aspiration of bile contents ensures adequate biliary access.
Fundus approach
If neither cystic duct nor infundibular approaches are feasible, a cholangiocatheter can be inserted directly
through the fundus of the gallbladder. This technique is similar to that of the cystic duct approach. During
IOC, a larger volume of contrast must be used as the entire gallbladder must fill prior to visualizing the
cystic duct.
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FIG 8 • A 25-gauge butterfly needle can be directly inserted into the CBD. When performed laparoscopically,
one of the flanges of the needle can be removed to facilitate passage through the trocar.
Needle cholangiogram approach

In the clinical situation of acute cholecystitis where inflammation is extensive and the primary indication for
cholangiography is defining the anatomy of the biliary tree, the CBD can be directly cannulated with a
small-gauge butterfly needle (FIG 8). Once complete, the puncture site should be closed with an
interrupted 4-0 absorbable monofilament suture.
Open technique
During open hepatobiliary surgery, IOC may be performed by inserting a cholangiocatheter in a similar
fashion using any of the aforementioned laparoscopic techniques.
CHOLANGIOGRAM
Prior to insertion, the cholangiogram catheter should be flushed with saline to avoid injection of air bubbles
that can easily be misinterpreted as CBD stones.
Once the cholangiogram catheter has been successfully placed, the catheter should be gently flushed with
saline to ensure no leakage of contrast will occur during cholangiography.
FIG 9 • Operative photograph of appropriate C-arm positioning.
The fluoroscopy C-arm should be moved into position, taking care to maintain sterility (FIG 9).
The accessory laparoscopic instruments and camera should be removed.
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FIG 10 • Normal cholangiogram. Note visualization of the entire biliary tree including the intrahepatic ducts
(arrow) (A). Passage of contrast into the duodenum without filling defects is also demonstrated (arrow) (B).
A test cholangiogram should be performed to verify adequate positioning of the fluoroscopic C-arm.
After position is verified, the IOC is performed. Ten to 25 mL of low osmolar, radiopaque contrast is usually
required for visualization of the entire biliary tree. The authors typically dilute the water-soluble contrast 1:1 in
normal saline. An IOC is not adequate until the cystic duct, CBD, left and right hepatic ducts, and passage of
contrast into the duodenum are all visualized. This may be facilitated by altering patient positioning, using
Trendelenburg, reverse Trendelenburg, and lateral rotation of the patient (see FIG 6).
FIG 11 • Visualization of a CBD stone by IOC. A filling defect is noted in the distal CBD; there is lack of flow of
contrast material into the duodenum despite adequate pressure (black arrows). Incidental filling of the
pancreatic duct can also be appreciated in this example (white arrow).
Examples of distal obstruction remove from malignancy, inflammation, or calculi are shown in FIGS 10,11 and
12.
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FIG 12 • A. Biliary obstruction due to malignancy. B. Note the irregular border of the malignant “shelf” (arrow).
PEARLS AND PITFALLS
Patient ▪ Routine versus selective application of IOC is a subject of controversy.

selection
Surgical ▪ Positioning of the patient with respect to the pedestal of the operating table is
management essential for access of the C-arm fluoroscopy unit.
▪ The semicircular valves of the cystic duct can impede the advancement of the
cholangiogram catheter. Care must be taken to not cause a laceration while
advancing the catheter into the duct.
Operative ▪ Intraoperative cholangiogram during cholecystectomy should be used whenever

decision anatomy is confusing.
making
▪ If the cystic duct cannot be adequately mobilized, either the infundibular or fundus
approaches are acceptable alternatives for placement of the cholangiocatheter.
Cholangiogram ▪ Flush the catheter prior to insertion to avoid the introduction of air into the CBD. The
interpretation bubbles that form cannot be easily differentiated from stones.
▪ If the entire biliary tree cannot initially be visualized during IOC, the patient should be
repositioned to ensure flow of contrast is not being inhibited by hydrostatic pressure.
If, after repositioning, the biliary tree cannot be seen in its entirety, one should
suspect an obstructive process or inadvertent ductal injury.
▪ If distal obstruction is identified, ligate the cystic duct rather than clip it to reduce the
risk of postoperative bile leak. Leave a drain.
POSTOPERATIVE CARE
Postoperative care does not differ from that described for cholecystectomy.
OUTCOMES
The selective application of IOC versus routine IOC remains a subject of controversy; differences in outcomes
between the two approaches have not been well demonstrated.2,3
IOC with CBD exploration versus postoperative endoscopic retrograde cholangiography has been shown to
be more cost-effective than routine preoperative assessment of CBD stones.4
COMPLICATIONS
Laceration of the cystic duct or CBD
Bile leak
Radiation injury to the skin
REFERENCES
1. Metcalfe MS, Ong T, Bruening MH, et al. Is laparoscopic intraoperative cholangiogram a matter of routine? Am
J Surg. 2004;187(4):475-481.
2. Massarweh NN, Flum DR. Role of intraoperative cholangiography in avoiding bile duct injury. J Am Coll Surg.
2007;204(4):656-664.
3. MacFadyen BV. Intraoperative cholangiography: past, present, and future. Surg Endosc. 2006;20(suppl
2):S436-S440.
4. Urbach DR, Khajanchee YS, Jobe BA, et al. Cost-effective management of common bile duct stones: a
decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative
cholangiography, and laparoscopic bile duct exploration. Surg Endosc. 2001;15(1):4-13.
Chapter 32
Splenectomy (Open and Laparoscopic Techniques)
Vanessa Cranford
Janeen R. Jordan
Frederick A. Moore
DEFINITION
Splenectomy is defined as the surgical removal of the spleen.
DIFFERENTIAL DIAGNOSIS/INDICATIONS
Traumatic rupture
Autoimmune disorders
Red blood cell disorders
Genetic disorders
Lymphomas/leukemias/myeloproliferative disorders
Vascular disorders
Idiopathic/iatrogenic
Miscellaneous (abscesses, tumors, cysts)

A thorough history should be performed prior to surgery, including a detailed past medical history, all signs
and symptoms of disordered bleeding and liver failure, as well as a history of abdominal pain or constitutional
symptoms. A list of medications, allergies, and personal and family histories of bleeding, clotting disorders, and
cancers should be noted.
A complete physical exam of the patient should be done and all patients should be examined for signs of
portal hypertension or liver failure as well as the presence or absence of splenomegaly.
Patients presenting with splenic trauma have variable clinical presentations determined by the severity of
injury, ranging from mild abdominal pain with hemodynamic stability to peritonitis and hemorrhagic shock with
complete cardiovascular collapse. This hemodynamic instability can be immediate upon presentation or days
later in the case of a delayed rupture.
Hematologic conditions such as leukemia present with a patient history of purpura, epistaxis, petechiae,
gingival bleeding, hematuria, gastrointestinal bleeding, myalgia, or fatigue. Although now a rare indication for
splenectomy, patients with lymphomas and myeloproliferative disorders present with diffuse lymphadenopathy,
constitutional symptoms, pancytopenia, abdominal pain, splenomegaly, or early satiety.
Patients with hemoglobinopathies and hereditary disorders present with jaundice, abdominal pain, or
splenomegaly. Alternatively, they may be asymptomatic and incidentally identified due to an abnormal
laboratory value obtained for a different indication.
Patients with hereditary spherocytosis (HS) benefit from splenectomy. Sequestration of the defective red blood
cells (RBCs) results in splenomegaly in 75% of affected patients.1 Splenectomy eliminates or improves anemia
in patients with moderate HS and eliminates the need for regular transfusions in patients with the severe form
of the disease.2,3 These patients often receive splenectomies in childhood to alleviate symptoms and long-
term sequela of the disease including skeletal abnormalities and repeated need for blood transfusion. In mild
HS, the purpose of splenectomy is to prevent the production of bilirubin gallstones (a common complication
that has an increased prevalence with age). In these cases, splenectomy is combined with a cholecystectomy.
Splenectomy for hematologic disorders such as idiopathic thrombocytopenia (ITP) is a result of failed medical
management to control thrombocytopenia or abdominal pain associated with splenomegaly. Most of these
patients will be referred to a treating hematologist. Medical management is the first-line treatment for ITP and
most patients initially respond to glucocorticoids. However, in one series, only 39% of prednisone-treated
patients achieve complete remission, and only one-half of these patients have sustained remission beyond 6
months of cessation of maintenance therapy.4 Intravenous immunoglobulin (IVIG) can also be used as firstline
treatment and can increase the platelet count in over 75% of patients within 5 days of treatment.5 However, it
is not a long-term cure. It is reserved for those patients with life-threatening bleeding and intracranial
hemorrhage and those preparing for splenectomy or other surgical procedures. Otherwise, splenectomy is
reserved for patients with symptomatic thrombocytopenia following glucocorticoid administration for at least 8
weeks and having a platelet count persistently less than 30,000/μL. Splenectomy is also indicated in patients
who recur after cessation of therapy.
Splenectomies may be performed via open or laparoscopic technique. The approach is determined by the
disease process and clinical stability of the patient. Absolute and relative contraindications for laparoscopic
splenectomy are listed in Table 1.

All patients with a known or suspected hematologic, autoimmune, or myeloproliferative disorder should have a
blood smear or bone marrow analysis as needed and a hematologist fully involved in the patient's evaluation
and treatment plan.
Computed tomography (CT) scan is the ideal imaging modality for splenic disorders and is a crucial part of
planning
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for the operating room (OR). CT has the capability for determining the size of the spleen, the anatomy and size
of the splenic vascular supply, the relationship of the spleen to surrounding organs, and potential locations of
accessory spleens in the abdomen (FIG 1). For stable trauma patients, it can accurately identify the extent of
splenic injury (FIG 2).
Table 1: Absolute and Relative Contraindication of Laparoscopic Splenectomy
Absolute Relative
Severe cardiopulmonary disease Splenomegaly
Cirrhosis with portal hypertension Short gastric varices with coagulopathy

Pregnancy Previous abdominal surgery
FIG 1 • CT image demonstrating splenomegaly. The volume of the spleen approaches that of the liver. SA,
splenic artery; SV, splenic vein.
Ultrasound is a noninvasive modality for the examination of splenomegaly and portal hypertension. In the
setting of a trauma, focused abdominal sonography for trauma (FAST) has become an accepted screening
tool to diagnose intraperitoneal blood (FIG 3).
Magnetic resonance imaging (MRI) of the spleen is an excellent method for evaluating focal lesions as well as
aid in the detection and differential diagnosis of peri- and intrasplenic tumors.6
SURGICAL MANAGEMENT
Certain patients with autoimmune disorders will be treated with prolonged courses of glucocorticoids. It is
important to consider administering appropriate stress-dose steroids intraoperatively, with rapid tapering
postoperatively.
FIG 2 • CT of splenic injury. White arrow points to one of the lacerations.

FIG 3 • Positive FAST showing intraperitoneal fluid. White arrow indicates intraabdominal fluid. This would be
the appearance of blood in a traumatic injury.
Blood products should be ordered and available intraoperatively. If the need for transfusion arises, it should be
given after ligation of the splenic artery, provided the splenectomy is performed for hematologic disorders.
For all elective cases, vaccinations against the encapsulated organisms (Hemophilus influenza B,
Streptococcus pneumoniae, and Neisseria meningitidis) should be administered prior to surgery. For
emergent cases, vaccinations should also be administered. Timing of vaccination is debated, but 2 to 4 weeks
postoperatively is recommended, although for trauma patients, just prior to discharge is acceptable due to a
high incidence of patients not returning for postinjury clinic appointments. This is to prevent the incidence of
overwhelming postsplenectomy infection (OPSI). It is the most feared complication of splenectomy. OPSI is the
development of a fulminant, rapidly fatal bacterial infection following the removal of the spleen. The current
incidence of OPSI in the first 2 years postsplenectomy is estimated to be 0.9% for adults and 5% for children.7
Current guidelines for vaccination to prevent OPSI are listed in Table 2.
All patients should be given a prophylactic dose of antibiotics to cover skin flora within 60 minutes of making
the skin incision in the OR. Nasal or oral gastric tubes should be inserted once the patient is under anesthesia
to decompress the stomach and aid in visualization. This will often be left in postoperatively for 24 to 48 hours
to prevent gastric distention and subsequent disruption of the ligated short gastric vessels.
Table 2: Guidelines for Overwhelming Postsplenectomy Infection Prophylaxis
Haemophilus influenzae B, pneumococcus, and meningococcus 2 weeks preoperatively (elective

cases) or at discharge or 2 weeks postoperatively (nonelective cases)
If patient received immunosuppression therapy, vaccinate 3 months after treatment.
Booster vaccinations for pneumococcus +/− meningococcus every 5 years
H. influenza AB titers can be followed to assess the need for booster dose.
Consider monitoring antibody titers of all three pathogens in immunocompromised patients.
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Laparoscopic splenectomy is the operation of choice for most elective splenectomies. However, other options
include hand-assisted or open approaches. Indications for conversion from laparoscopy to an open procedure
include intolerability or inability to insufflate the peritoneum, uncontrollable coagulopathy or hemorrhage,
massive splenomegaly that is unable to be placed in the extraction bag, or need for another procedure.
In cases of massive splenomegaly or portal hypertension, preoperative embolization of the splenic artery by
interventional radiology will decrease the amount of blood loss and may aid in the technical aspects of the
procedure. Embolization of the splenic artery causes decreased perfusion and thereby results in involution of
the spleen, making mobilization of the spleen technically easier.
POSITIONING
Patients undergoing laparoscopic splenectomy can be positioned supine or in the right lateral decubitus
position. In the latter position, the beanbag or kidney rest is placed to maximize exposure between the costal
margin and iliac crest. The table may also be flexed to assist in widening this space. Ensure that all pressure
points are properly padded and the shoulders, extremities, and spine are in comfortable, neutral positions (FIG
4).
For open splenectomies, most patients are placed in a supine position, with both arms extended, and a midline
laparotomy incision is made. Indeed, in the case of an exploratory laparotomy in the setting of a trauma, this is
the recommended approach as the surgeon will need to evaluate the entire abdomen for other injuries. An
additional option in isolated nontraumatic open cases is to make a left subcostal incision.
FIG 4 • Patient positioning in the right lateral decubitus position.
TECHNIQUES
OPEN SPLENECTOMY
Incision
Prior to incision, ensure adequate monitoring and intravenous access is obtained in preparation for
potential bleeding. An arterial line is not mandatory but is recommended. A nasogastric (NG) tube should
be placed for optimal gastric decompression, which will be imperative for visualization of the spleen.
After endotracheal intubation and standard prepping and draping of the patient, a midline laparotomy
incision is used to enter the peritoneal cavity (FIG 5). If this is an isolated splenectomy with no concern
for other injuries, a supraumbilical incision can be made initially with extension inferiorly as needed for
exposure. If the operation is done in the setting of an exploratory laparotomy with concern for other
intraabdominal injuries, a generous incision from xiphoid to pubis should be made. Quickly evacuate all
fluid and particulate matter (if present) and place a retractor to aid in visualization. This step is imperative.
Without good exposure from retraction and adequate visualization, the propensity for bleeding will
increase, making the operation much more technically difficult.
Mobilization
The spleen resides high and posterior in the upper left abdomen. In order to remove the spleen, all
peritoneal and visceral attachments must be removed. These include the splenorenal attachments to the
kidney; the splenophrenic attachments to the diaphragm; the splenocolic
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attachments to the splenic flexure of the colon; and the gastrosplenic ligament, which contains the short
gastric vessels (FIG 6).
FIG 5 • Various incisions for an open splenectomy.

FIG 6 • Attachments of the spleen in the left upper quadrant.
FIG 7 • Direction of force applied to the spleen and line of division of the splenic attachments.
Splenic mobilization is accomplished using traction and countertraction. The operating surgeon places a
splayed, nondominant hand (usually with the aid of a lap sponge for better grip) and applies dorsal and
medial traction on the spleen. This will help clearly define the splenorenal and splenophrenic ligaments.
Be sure to first mobilize all attachments of the spleen to the anterior abdominal wall or you will find this
maneuver cannot be done.
Downward dorsal and medial traction is important as a tendency for a lifting out of the left upper quadrant
often occurs. This can result in capsular tearing, with unnecessary bleeding or hemorrhage.
Division of the ligaments is initiated with the splenocolic ligament. Mobilization of the splenic flexure
displaces the colon away from the spleen (FIG 7). This is best done sharply or by using electrocautery.
Once this is done, continue laterally toward the splenorenal ligaments, which when divided, separate the
spleen from Gerota's fascia of the kidney. Finally, continue superiorly to the splenophrenic ligaments.
Again, the importance of traction and countertraction cannot be overemphasized. The first assistant
provides countertraction with tissue forceps to divide the ligaments, whereas the surgeon continues to
maintain midline traction on the spleen.
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FIG 8 • Quick blunt mobilization and posterior packing with laparotomy pads in a traumatic injury.
Even in the setting of trauma and hemorrhage, mobilization of the spleen medially is the key to gaining
vascular control. The steps are the same, simply done in a quicker fashion. In many traumatic splenic
injuries, the dissection may be done for you by the trauma and resultant hematoma, and much of the
remaining dissection can be done bluntly. If facing an exsanguinating spleen in a sea of blood, it may be
difficult to see the attachments; however, you will be able to palpate them. Digital traction and blunt
mobilization is employed, then laparotomy pads are sequentially placed posteriorly (FIG 8). This bluntly
dissects the attachments of the spleen for you and aids medial and anterior mobilization. Generally, 5 to
10 laparotomy pads are used for this maneuver.
Division of the ligaments should be made 1 to 2 cm from the spleen to avoid injury to both the spleen and
other organs. As the spleen is mobilized anteriorly, deeper layers of connective tissue are brought into
view and can be easily divided either bluntly or sharply.
Once free from the retroperitoneal attachments, digital control of the hilar vessels can be accomplished
and will stop any ongoing hemorrhage and improve visualization.
As dissection continues lateral to medial, the left adrenal gland will come into view and should remain
untouched. The tail of the pancreas and the splenic vein will also come into view. This visualization is
crucial and paramount to preservation of the pancreas without disruption (FIG 9).
FIG 9 • Appropriate plane of dissection to mobilize the spleen and pancreas medially.
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Ligation of Vessels and Excision
With the spleen fully mobilized midline, one can turn attention to the vascular supply. Gentle traction can
be placed on the gastrosplenic ligament which will allow exposure of the short gastric vessels (FIG 10).
Traction will also allow visualization of the stomach wall, of which injury should be avoided. The short
gastric vessels are then divided using either bipolar electrocautery, ultrasonic shears, or sutures as
desired (FIG 11).
The splenic artery is seen on the superior border of the pancreas and is visualized entering the hilum of
the spleen. The artery and vein are individually isolated or ligated en bloc, using suture ligature (such as
0-silk), LigaSure (Valleylab, Boulder, Colorado, CA), or vascular load stapler. The spleen is now free and
can be passed off for pathologic examination.
The tail of the pancreas will often extend into the splenic hilum. In 75% of patients, it lies within 1 cm of
the hilum, and of these, 30% actually touch it.8 Care must be taken to ensure a pancreatic injury is
avoided when dividing and ligating the splenic vessels (FIG 12).
Once the spleen is removed and hemostasis is obtained, if electrocautery was used for division, the short
gastric vessels are oversewn along the greater curvature of the stomach. Careful attention should be
made to the apical vessels; this is the most frequent site of missed, surgical bleeding requiring
reoperation.
If the splenectomy was undertaken for hematologic disorders, close inspection for accessory spleens
must be undertaken or the operation has a high chance for failure to cure. Accessory spleens are
identified in up to 30% of patients. Common locations for accessory spleens are the splenic hilum, the
splenorenal ligament, the greater omentum, the retroperitoneal area surrounding the tail of the pancreas,
the splenocolic ligament, and the small bowel mesentery. These areas must be examined after
splenectomy, and if splenic tissue is found, it must be excised as well.
FIG 10 • Mobilization of the spleen medially and exposure of the gastrosplenic ligament, containing the short
gastric vessels (arrow).
FIG 11 • Division of the short gastric vessels.
FIG 12 • The tail of the pancreas abuts the splenic hilum. White arrow indicates the splenic vein.
Closure
Once the spleen is removed, attention must be made to ensuring hemostasis is achieved. All laparotomy
pads are removed and careful examination of the splenic bed must be undertaken. Oozing from the
splenic bed can usually be controlled with selected cauterization, argon beam, or hemostatic agents.
Once hemostasis is achieved and assessment for accessory spleens is completed, irrigation of the
abdominal cavity may be necessary and the abdomen is closed in the usual fashion. There is no reason
to place a closed suction drain
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in the splenic bed, unless injury of the tail of the pancreas is known or suspected.
If the splenectomy occurred in the setting of a damage control laparotomy and multiple injuries are
treated, the abdomen is often left open. This allows for a second-look laparotomy and treatment of
impending abdominal compartment syndrome. In this situation, it is appropriate to obtain hemostasis as
able, then leave laparotomy pads in the left upper quadrant and reevaluate after correction of
coagulopathy and sufficient resuscitation.
LAPAROSCOPIC SPLENECTOMY
Incision
The position of the operating surgeon and placement of the port sites can be seen in FIG 13. Once
pneumoperitoneum is established, the operation is begun with a thorough exploration of the abdominal
cavity, looking for accessory spleens, in locations stated earlier. If found, all accessory spleens need to
be excised.
Mobilization
There are two main approaches for mobilization of the spleen, the supine (anterior) approach and the
lateral decubitus approach. As the lateral approach is the one most commonly used when performing
laparoscopic splenectomies, it will be the operation described in the following text.
Following placements of proper monitors, vascular access, antibiotic administration, and endotracheal
intubation, the patient is placed in the right lateral decubitus position, with beanbag support and proper
padding and positioning of the head, shoulders, neck, and extremities.
Dissection begins similar to an open procedure, with mobilization of the splenic flexure of the colon from
the spleen. This is done using sharp dissection under direct visualization and can be done using hook
electrocautery or an ultrasonic dissector. It is important to note that this division of the splenocolic
ligament should be done without disturbing the spleen itself, decreasing the risk of a capsular tear (FIG
14). As with an open procedure, the technique of traction and countertraction is also employed with the
laparoscopic technique.
FIG 13 • Arrangement and port site placement for a laparoscopic splenectomy. Note that patient is drawn
supine to clearly show port site placement.
Dissection is approached in an inferior to superior counterclockwise direction. The superior

splenophrenic attachments are left intact, however, to help facilitate exposure for dissection of the splenic
hilum.
Small accessory vessels can be seen with attachments to the greater omentum. These vessels can be
individually divided using electrocautery.
With the complete release of the splenocolic ligament and posterior dissection up to the splenophrenic
ligament, dissection of the hilum itself can now begin.
Ligation of Vessels and Excision
Similar to the open procedure, the lesser sac is entered and progression moves in a cephalad direction,
exposing the anterior surface of the hilum. The posterior aspect of the hilum should already be cleared.
This allows the surgeon to have quick access for any unexpected bleeding should it arise before isolating
the vessels themselves.
FIG 14 • Laparoscopic division of the splenocolic ligament.
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The short gastric vessels and main vascular pedicle are visualized. The short gastric vessels are divided
using an ultrasonic or bipolar electrocautery dissector along the greater curvature of the stomach. With
this released, the hilum of the spleen is easily accessible.
Once the splenic artery and vein are dissected free using a combination of blunt dissection and hook
electrocautery, the vessels are ligated in a similar fashion to the open approach, using suture ligature or
(more commonly) an endoscopic vascular stapler (FIG 15). Ligating and dividing the artery and vein
individually to prevent a future arteriovenous fistula was once standard practice; however, resection of
the vessels en masse with an endoscopic vascular stapler is acceptable.
As with the open procedure, close attention must be given to the tail of the pancreas when dividing the
hilar vessels to avoid injury.
With the spleen completely devascularized, it is now suspended by the small cuff of splenophrenic
attachments. These attachments can be transected at this time, or, if necessary, used to assist placing
the spleen in the extraction bag. Introduction of an extraction bag is done using one of the port sites
(usually the left lateral port). Once the bag is deployed in the peritoneal cavity, the spleen is placed
inside. The remaining attachments are then divided (if not done previously), the drawstring of the bag
closed, and the open end of the bag brought out through a large trocar site (usually the hand port or the
umbilical or epigastric sites). The extraction site occasionally will need to be lengthened to facilitate
removal of the spleen.
FIG 15 • Laparoscopic ligation of the splenic artery and vein.
The spleen often requires finger fraction or morcellation with ring forceps and removed piecemeal (FIG
16). As the spleen is rarely excised in the setting of malignancy, this is an accepted practice. Although a
rare occurrence, there have been case reports of splenic implants in the surgical wound and
contamination should be avoided.
The abdomen is then examined for hemostasis, pneumoperitoneum is stopped, and the port sites are
closed by usual means. We recommend fascial closure for all incisions measuring greater than 1 cm to
avoid future hernias.
Drainage of the splenic bed is performed selectively, as stated earlier.
FIG 16 • Extraction and morcellation of the spleen.

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PEARLS AND PITFALLS
Imaging and other ▪ Involvement of a hematologist is essential for proper diagnosis and
diagnostic modalities preoperative medical management.
▪ For elective splenectomies, CT of the abdomen is pivotal in the

preoperative planning.
Preoperative planning ▪ All elective splenectomy patients need vaccinations 2 weeks

preoperatively.
▪ Consider prophylactic embolization for splenomegaly or portal

hypertension.
▪ Have blood products with a current type and screen, type and
crossmatch readily available intraoperatively.
Technique—open ▪ Quick mobilization to the midline is a key maneuver in a hemorrhaging

splenectomy spleen.
▪ Keep dorsal and medial traction when mobilizing to avoid capsular

tears.
▪ Work lateral to medial.
▪ Leave a 1- to 2-cm cuff of peritoneum to prevent damage to

surrounding organs or further injury to the spleen.
▪ Ligate the splenic artery and vein, with close attention not to injure the
pancreatic tail.
Technique— ▪ Positioning the patient with maximal exposure between the iliac crest
laparoscopic and costal margin is key.
splenectomy
▪ Examine the entire abdomen for accessory spleens.
▪ Let gravity help you in the dissection.
Technique—closure ▪ No need for a drain unless there is a known or suspected pancreatic

injury, infection, or bleeding.
POSTOPERATIVE CARE
Most patients who undergo laparoscopic splenectomy have a swift recovery and short hospital stay. In one
review, hospital stay ranged from 1.5 to 6.4 days.9 Most patients are able to return to work in a week.
Patients who undergo open splenectomy have a longer hospital stay, longer return to a full diet, and increased
need for narcotics.10,11 This is not a surprising finding, however, given that most patients undergoing open
splenectomies either have a contraindication for laparoscopic procedures or have surgery under emergent
conditions (i.e., in the setting of a trauma).
OUTCOMES
The hematologic and long-term cure rates are the most important factors when patients undergo elective
laparoscopic splenectomies. For some disorders (i.e., the hemoglobinopathies), cure is not possible, and
the goal of splenectomy is to alleviate the symptoms of the disease. For other diseases, splenectomy
offers the relief of pain and early satiety that can accompany splenomegaly.
Patients undergoing splenectomy for ITP generally have excellent outcomes. It has the highest rate of
complete and durable remission; in fact, two-thirds of patients treated with splenectomy for ITP achieve a
complete remission (defined as a normal platelet count with no further glucocorticoid requirements). An
additional 20% will have a partial response, with a platelet count greater than 50,000 μL, with or without
continuation of steroids. Younger patients have a more favorable response.12 Also, favorable response to
splenectomy is also found in patients with a postoperative platelet count greater than 150,000 by
postoperative day 3.
Patients undergoing splenectomy for HS have reasonable outcomes. Coupling the splenectomy with a
cholecystectomy obviates the need for a cholecystectomy later in life if pigmented stones are present.
For severe HS, splenectomy eliminates the need for regular blood transfusions; however, an anemia will
still persist. Growth failure or skeletal changes from the high degree of erythropoiesis needed to
compensate for the hemolytic anemia is reversed for children after the spleen is removed.13
COMPLICATIONS
Bleeding 4% to 16% (most common)
Thromboembolic events/thrombosis 2% to 4%
Pancreatic injury
Seroma
Hematoma
Incisional hernia
Wound dehiscence
OPSI
REFERENCES
1. Mackinney AA Jr. Hereditary spherocytosis; clinical family studies. Arch Intern Med. 1965;116:257-265.
2. Schilling RF. Risks and benefits of splenectomy versus no splenectomy for hereditary spherocytosis—a
personal view. Br J Haematol. 2009;145:728-732.
3. Agre P, Asimos A, Casella JF, et al. Inheritance pattern and clinical response to splenectomy as a
reflection of erythrocyte spectrin deficiency in hereditary spherocytosis. N Engl J Med. 1986;315:1579-1583.
4. Stasi R, Stipa E, Masi M, et al. Long-term observation of 208 adults with chronic idiopathic
thrombocytopenia purpura. Am J Med. 2003;98:436-442.
5. Godeau B, Chevret S, Varet B, et al. Intravenous immunoglobulin or high dose methylprednisolone, with or
without oral prednisone, for adults with untreated severe autoimmune thrombocytopenic purpura: a
randomized, multicenter trial. Lancet. 2002;359:23-29.
6. Dujardin M, Vandebroucke F, Boulet C, et al. Indications for body MRI Part I. Upper abdomen and renal
imaging. Eur J Radiol. 2008;65(2):214-221.
7. Mourtzoukou EG, Pappas G, Peppas G, et al. Vaccination of asplenic or hyposplenic adults. Br J Surg.
2008;95:273-280.
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8. Beauchamp RD, Holzman MD, Fabian TC, et al. The spleen. In: Townsend CM, ed. Sabiston Textbook of
Surgery: The Biological Basis of Modern Surgical Practice. 18th ed. Philadelphia, PA: Saunders/Elsevier;
1965:1624-1652.
9. Katkhouda N, Mavor E. Laparoscopic splenectomy. Surg Clin North Am. 2000;80:1285-1297.
10. Curran TJ, Foley MI, Swanstrom LL, et al. Laparoscopy improves outcomes for pediatric splenectomy. J
Pediatr Surg. 1998;33:1498-1500.
11. Tanoue K, Okita K, Akahoshi T, et al. Laparoscopic splenectomy for hematologic diseases. Surgery.
2002;131:S318-S323.
12. Kojouri K, Vesely SK, Terrell DR, et al. Splenectomy for adult patients with idiopathic thrombocytopenic
purpura: a systemic review to assess long-term platelet count responses, prediction of response, and
surgical complications. Blood. 2004;104:2623-2634.
13. Taghizadeh M, Muscarella P II. The spleen: splenectomy for hematologic disorders. In: Cameron JL,
Cameron AM, eds. Current Surgical Therapy. 10th ed. Philadelphia, PA: Saunders/Elsevier; 2011:473-479.
Chapter 33
Inguinal Hernia: Open Approaches
Michael D. Paul
Kamal M.F. Itani
DEFINITION
Inguinal hernia is one of the most commonly encountered clinical problems for the general surgeon.
An inguinal hernia is an opening in the myofascial plain of the oblique and transversalis muscles that can
allow herniation of intraabdominal or extraperitoneal organs.
There are three potential spaces for an inguinal hernia: (1) an indirect hernia occurs lateral to the inferior
epigastric vessels and through the opening that accommodates the cord structures in men and the round
ligament in women, (2) a direct hernia occurs through Hesselbach’s triangle, and (3) a femoral hernia
occurs through the femoral canal medial to the femoral vein.
Patients present with complaints of either a bulge in the groin or groin pain.
The differential diagnosis for a groin bulge includes inguinal lymphadenopathy, hydrocele, varicocele, a
testicular mass, a cord lipoma, or an iliac or femoral aneurysm.
The differential diagnosis for groin pain includes testicular pathology, ilioinguinal strain, or an athlete’s
hernia.

The presence of an inguinal hernia can almost always be confirmed on physical examination. Both groins and
testicles should be assessed for masses. A reducible mass is best felt with the patient standing and providing
intermittent Valsalva such as a cough. A femoral hernia will be felt below the inguinal ligament, adjacent to the
femoral vessels.

If the diagnosis cannot be definitely made with physical examination, ultrasound or computed tomography (CT)
scan can be used to assess the integrity of the abdominal wall.
SURGICAL MANAGEMENT
The bulk of surgical treatment is discussed in the “Techniques” section. Here, consider indications and other
more general concerns, such as the following:
The role of routine antibiotic prophylaxis for elective inguinal hernia remains controversial. There is a body of
literature indicating no statistically significant advantage to the use of antibiotic prophylaxis in the performance
of routine inguinal hernia repair with or without the use of mesh. Nevertheless, many surgeons argue that
antibiotic prophylaxis with a first-generation cephalosporin to cover skin flora is both inexpensive and safe and
that such practice should not be considered inappropriate. In the acute setting of a small bowel obstruction
secondary to an incarcerated hernia, appropriate perioperative antibiotics should be given within 60 minutes of
the initial skin incision.
Patients should be asked to void preoperatively. In most elective cases, a Foley catheter is not necessary.
Deep vein thrombosis (DVT) prophylaxis with pneumatic compression devices starting prior to surgery and
continuing in the recovery phase is now standard of care.
Anesthesia options for inguinal herniorrhaphy include general, spinal, and local anesthesia with or without
intravenous sedation. Emergent cases of small bowel obstruction secondary to an incarcerated inguinal or
femoral hernias will require general anesthesia.
Positioning
The patient is positioned supine with arms out on arm boards.
TECHNIQUES
The approach to the inguinal canal is the same for all anterior groin hernia repairs.
Gentle palpation of the inguinal area allows the identification of the spermatic cord. An oblique incision or
incision along a skin crease or hairline centered around the cord structures is then made (FIG 1).
Using electrocautery, the soft tissue is dissected to the superficial epigastric vessels, which are ligated.
The dissection is then carried down through Camper’s fascia and the more fibrous Scarpa’s fascia. The
next layer is the transparent innominate fascia and the external oblique aponeurosis. Palpation along the
external oblique aponeurosis moving laterally and inferiorly should exclude a femoral hernia.
The external ring is identified and is covered with the external spermatic fascia, which is continuous with
the innominate fascia. The external oblique aponeurosis is opened with a scissor, starting medial at the
external ring and moving superior/lateral parallel to the inguinal ligament (FIG 2). Elevating the fascia and
using a scissor protects the ilioinguinal nerve from sharp or thermal injury. The ilioinguinal nerve lies just
below the aponeurosis of the external oblique and anterior to the cord. If injury to the nerve occurs, it is
best divided and excised proximally, allowing the nerve to retract into the muscle or preperitoneal space.
The medial and lateral external oblique flaps are then dissected free. Insertion of Weitlaner retractors
below
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the flaps greatly facilitates exposure of the spermatic cord. The iliohypogastric nerve can be identified
running between the internal and external oblique superior and medial to the spermatic cord. It exits the
external oblique medial and superior to the external ring (FIG 3).
FIG 1 • Incision for repair of an inguinal hernia is centered over the palpable spermatic cord along a
hairline crease (AB, lower line). Alternatively, incision is done parallel to the inguinal ligament (AB, upper
line towards C representing the anterior superior iliac spine).
The spermatic cord is mobilized and isolated in the inguinal canal at the pubic tubercle but not medial to it
(FIG 4). This will reduce the chance of damaging the posterior inguinal canal and any collateral
circulation to the testes. A Penrose drain is placed around the cord structures and can be used to provide
traction during dissection of the cord.
The spermatic cord is explored for evidence of an indirect hernia. The cremaster muscle fibers are not
divided but are split parallel to the cord. The genital branch of the genitofemoral nerve lies posterior in
the cord and is best preserved by splitting the cremasteric muscles. Inspection on the anterior medial
aspect of the cord will identify an indirect hernia (FIG 5).
FIG 2 • The external oblique is opened from the superficial ring toward the deep ring while avoiding injury
to the ilioinguinal nerve.
FIG 3 • Location of the ilioinguinal and genitofemoral iliohypogastric nerves.
The indirect hernia sac is then dissected from the cord structures using sharp and blunt dissection. The
sac is dissected down to the internal inguinal ring and freed from surrounding structures. Care must be
taken to avoid damage to the vas deferens, which is closely associated with the sac proximally. The
hernia sac is then reduced through the internal ring. The sac can also be transected and ligated. If
ligated, the sac should be opened to assure that there is not a sliding component to the hernia.
FIG 4 • The isolation of the spermatic cord is done above the pubic tubercle to prevent injury to the
inguinal floor.
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FIG 5 • In very large inguinal hernias, it may be necessary to isolate the hernia sac prior to mobilization of
the cord. Here, the cremasteric muscle fibers are split in order to access the indirect sac.
In female patients, the round ligament can be completely transected, allowing for closure of the internal
ring during repair.
A cord “lipoma” is not a lipoma (suggesting growth of adipose tissue) but is rather extra or preperitoneal
fat. It is usually associated with an indirect hernia but could also be present without an associated sac.
Cord lipomas should be dissected free and resected as they can act as a lead point for a hernia sac (FIG
6).
A sliding hernia is an indirect hernia that has part of its sac made up of retroperitoneal viscus. This could
be bladder, cecum, or sigmoid colon. The safest method of managing a sliding hernia is a safe dissection
of the indirect sac and simple reduction back to the preperitoneal space. The danger with high ligation of
an indirect hernia sac, without proper inspection of the sac, is injury to the bowel within a sliding hernia.
Following inspection of the spermatic cord and reduction of any indirect sac and excision of any
preperitoneal fat, attention is turned to the posterior inguinal canal.
Gentle retraction of the spermatic cord will facilitate exposure. Any defects or weakness of the floor
should be assessed. In large direct hernias, a purse-string suture around the defect or imbrications of the
floor with figure-of-eight sutures will reduce the direct bulge, allowing one to work unencumbered by it.
FIG 6 • Cord lipomas, which can act as leads to a sac, should be resected in order to reduce the incidence
of recurrent inguinal hernias. The hernia sac lies anteromedial to the cord and is separated from a large
cord lipoma.
BASSINI REPAIR
The Bassini repair is rarely performed today but remains the foundation for all hernia repairs. It is a
primary tissue repair that consists of suturing of the transversus abdominis muscle, internal oblique
muscle, and transversalis fascia medially to the inguinal ligament laterally.1,2 It is an option to consider in
cases where contamination is likely and the use of mesh becomes contraindicated.
Technique
Bassini’s original description of the procedure included resection of the cremasteric fibers. Although still
advocated by some, it is not routinely done.
After elevation and lateral retraction of the spermatic cord, the inguinal canal is carefully inspected for
defects and weaknesses.
The muscular and aponeurotic arch formed by the lower fibers of the transversus abdominis muscle and
the internal oblique muscle is used to identify the medial edge of the repair.3 In his repair, Bassini opened
the transversalis fascia,1 but most surgeons today would often omit this step and place the sutures
between the aponeurotic arch and the deeper transversalis fascia to the inguinal ligament. If the anatomic
layers are not clear, as in recurrent hernia surgery, opening the floor and clearly defining the anatomy will
ensure the incorporation of the three anatomic layers medially: the internal oblique muscle, the
transversus abdominis muscle, and the transversalis fascia.
If the decision is made to open the inguinal canal floor, it is done by incising the transversalis fascia from
the pubic tubercle to the internal inguinal ring. Care should be taken not to injure the inferior epigastric
vessels, which are directly posterior to the transversalis fascia. Once the transversalis fascia is opened
and the undersurface of the fascial flaps is exposed, one can easily identify the three anatomic layers
described earlier and more carefully inspect the femoral canal.
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FIG 7 • If the transversalis fascia is opened in a Bassini repair, the iliopubic tract may be incorporated into
the lateral stitch.
Once the muscular aponeurotic arch and the inguinal ligament are properly exposed and a femoral hernia
is ruled out, single interrupted permanent polypropylene sutures are used to perform the repair. The first
stitch is the most medial and should include the lateral edge of the rectus sheath if possible. It is placed
from the rectus sheath and aponeurotic arch to the fascia overlying the pubic tubercle and not the
inguinal ligament. This is an important technical point in order to reduce recurrence at the pubic tubercle,
a common site.
Subsequent sutures should be placed from the muscular aponeurotic arch, incorporating all three layers,
to the inguinal ligament. Medially, each suture is taken 2 cm from the edge of the arch. Laterally, the
suture should incorporate few fibers of inguinal ligament, thus avoiding the underlying femoral vessels.
Different fibers should be incorporated with each suture to avoid tearing the inguinal ligament. Upon
reaching the internal inguinal ring, the ring is tightened, allowing the tip of a forceps to pass through the
ring and avoiding strangulation of the cord structures.
If the transversalis fascia has been opened, the iliopubic tract will be identified. The medial stitch should
first incorporate the iliopubic tract and then the inguinal ligament (FIG 7).
The spermatic cord is returned to its normal anatomic position, lying superior to the newly reconstructed
inguinal floor, and closure of the superficial layers is performed in the standard fashion (FIG 8).
In order to decrease tissue tension after the repair is completed, a relaxing incision can be made
vertically for few centimeters on the anterior rectus sheath parallel to the repair line. This will allow
relaxation of the aponeurotic arch toward the inguinal ligament.
FIG 8 • The Bassini repair is carried lateral until the internal ring is re-created.
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SHOULDICE REPAIR
After Bassini, the Shouldice repair is the most popular inguinal hernia tissue repair.4 It continues to be
used as the primary inguinal hernia repair in the Shouldice clinic and by others who trained at the
Shouldice clinic.5 It can also be used in situations where mesh is contraindicated such as in
contaminated cases.
Technique
Like the Bassini repair, the Shouldice repair starts with a resection of the cremasteric muscle as an
important step of the repair. Although some still advocate this step, we do not think that this adds to the
durability of repair and it potentially exposes the genital branch of the genitofemoral nerve to injury.
The transversalis fascia is opened from the medial aspect of the internal ring to the fascial thickening of
Cooper’s ligament. This should be done with caution as the inferior epigastric vessels will be
encountered just below the transversalis fascia. The opening of the transversalis fascia allows
identification of all three layers of the posterior wall (transversalis abdominis muscle, internal oblique
muscle, and transversalis fascia). Flaps of transversalis fascia are developed medially and laterally by
carefully sweeping the underlying preperitoneal fat (FIG 9).
Dissection of the lateral flap should be carried to Cooper’s ligament to identify any femoral hernias and
clearly expose the iliopubic tract. Although not done at our institution, incision of the superficial thigh
fascia (cribriform fascia) to assess the femoral canal and to improve mobility of the external oblique has
been reported and practiced at the Shouldice Hospital in Ontario.
Originally performed with stainless steel wire, this repair is now performed with 2-0 Prolene sutures. A
four-layer repair is performed using two continuous sutures. The first layer begins medially, anchoring the
suture from the transversalis fascia to the fascia overlying the periosteum of the pubic tubercle. Leaving a
portion of suture long enough to tie to, the stitch is run laterally, approximating the posterior rectus sheath
to the iliopubic tract. When the rectus sheath can no longer be brought to the iliopubic tract without
tension, the stitch is transitioned to the posterior transversalis fascia and is run superior and lateral until
the internal ring is re-created (FIG 10).
FIG 9 • In a Shouldice repair, the transversalis fascia is opened. It is necessary to protect the inferior
epigastric vessels from injury.
FIG 10 • The first row in a Shouldice repair incorporates the aponeurotic arch by taking posterior bites
through the transversalis fascia and approximating the arch to the ileopubic tract.
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FIG 11 • Starting at the internal ring, the third suture layer of a Shouldice repair incorporates the internal
oblique and the underlying transversus abdominis medially, which are approximated to the undersurface
of external oblique just above and parallel to the inguinal ligament laterally.
FIG 12 • In the Shouldice repair, the fourth layer reapproximates the internal oblique to the undersurface
of the external oblique, thus effectively reenforcing the third layer.
The suture is then reversed, and a second layer is started using the same Prolene suture. The second
layer approximates the three layers, including the free edge of the medial transversalis fascia, the internal
oblique, and the transversus abdominis to the inguinal ligament. The second suture line is brought over
the anchoring stitch, reinforcing the medial aspect of the repair, and tied to the anchoring stitch of the first
suture line. This effectively imbricates the first layer.
The third and fourth layers are also run continuously. Starting at the internal ring, the first stitch is blindly
placed in the internal oblique and transversus abdominis and approximated to the posterior external
oblique aponeurosis, just above the inguinal ligament. This is run medially, creating a ridge just superior
and parallel to the inguinal ligament (FIG 11).
The fourth layer is run back to the internal ring, buttressing the third layer, again taking the transversus
abdominis and internal oblique, and approximating them to undersurface of the external oblique. The
suture is tied to its tail (FIG 12).
THE MCVAY REPAIR OR COOPER’S LIGAMENT REPAIR
The Cooper’s ligament repair is a primary tissue repair that was described and advocated by Dr. McVay
in 1958. Following 300 cadaver dissections, he noted that the internal oblique and external oblique do not
attach to the inguinal ligament. Rather, they attach to the pubic bone at the location of Cooper’s ligament
attachment.6 He concluded that repair of the inguinal defect would be anatomically correct if the three
layers (internal oblique aponeurosis, transversus abdominis, and transversalis fascia) were sutured to
Cooper’s ligament and then transitioned to the inguinal ligament following closure of the femoral
myopectineal defect.
The repair provides closure of the femoral, indirect, and direct spaces and, as such, can be used to
repair any hernia defect that may occur in the groin.7 However, and due to the tension created by this
repair, the risk of injury to the femoral vessels, and the risk of recurrence at the suture transition from
Cooper’s ligament to inguinal ligament, this repair is now mostly reserved for femoral hernias. The
postoperative morbidity and mortality increase significantly in patients undergoing emergent repair,
highlighting the importance of repairing femoral hernias in an elective setting.
Technique
Following examination of the spermatic cord, the posterior wall of the inguinal canal is opened from the
deep inguinal ring to the pubic tubercle. Care should be taken to avoid injury to the inferior epigastric
vessels that lie just posterior to the transversalis fascia near the deep ring.8
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FIG 13 • When addressing a femoral hernia, the sac is opened and its contents inspected prior to
reduction of the sac.
FIG 14 • In a McVay repair, the transversus abdominis, internal oblique aponeurosis, and transversalis
fascia are approximated to Cooper’s ligament.
This provides exposure to the preperitoneal space (space of Bogros), femoral vein, and femoral canal.
The femoral hernia sac is found medial to the femoral vein and is reduced.
If an incarcerated or strangulated femoral hernia cannot be reduced with traction from the preperitoneal
space and pressure from below the femoral ring on the anterior thigh, the medial lacunar ligament can be
incised to enlarge the femoral ring. If still unable to reduce the hernia, the inguinal ligament can be
divided and then repaired following reduction of the hernia (FIG 13).
Incising the posterior wall of the inguinal canal exposes the three aponeurotic layers: the internal oblique
muscle and aponeurosis, the transversus abdominis muscle and aponeurosis, and the transversalis
fascia. Starting medially, simple interrupted sutures are used to approximate the internal oblique
aponeurosis, transversus abdominis muscle and aponeurosis, and the transversalis fascia to Cooper’s
ligament (FIG 14).
A transition stitch is placed, incorporating the triple layer, Cooper’s ligament, the femoral sheath at its
medial aspect, and the inguinal ligament. If the femoral sheath cannot be identified, it may be omitted.
The femoral sheath is intimately associated with the femoral vein. If bleeding occurs following a stitch in
the femoral sheath, it should be immediately removed and direct pressure applied. It should not be tied as
this would result in tearing of the femoral vein. If the stitch is placed too lateral on Cooper’s ligament, the
femoral vein can be compressed leading to thrombosis (FIG 15).
The remainder of the inguinal floor is repaired by approximating the triple layer to the inguinal ligament
and continuing, lateral, to the level of the internal ring (FIG 16).
FIG 15 • The transition stitch of a McVay repair incorporates Cooper’s ligament, the medial femoral
sheath, and the inguinal ligament. If bleeding occurs, the stitch is immediately removed and pressure
should be held.
This repair creates tension. The distance to Cooper’s ligament from the aponeurotic arch of the
transversus and internal oblique can be up to 8 cm. To release this tension, a relaxing incision is
required. This involves
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first exposing the rectus sheath behind the external oblique aponeurosis. Sparing the external oblique
component, the rectus sheath is then incised vertically from the tubercle extending cephalad for
approximately 6 cm along its lateral edge. The relaxing incision should be performed before the sutures
are tied (FIG 17).
FIG 16 • The final step of a McVay repair is the approximation of the aponeurotic arch to the inguinal
ligament beyond the transition stitch in order to re-create the internal ring.
FIG 17 • A relaxing incision performed on the rectus fascia will relax the repair and should be performed
prior to tying the sutures.
The external oblique and skin are closed as described previously.

Alternatively, a mesh can be used to perform a McVay repair. This is outlined in the “Lichtenstein Repair”
section. Laterally, the mesh is sutured to Cooper’s ligament up to the point where the femoral vein exits at
which point the suture is transitioned to the inguinal ligament.
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LICHTENSTEIN REPAIR
The use of prosthesis in inguinal herniorrhaphy is a dynamic field with frequent introduction of new
devices, prosthesis, and modifications in technique. Although we cannot include all of them, a thorough
understanding of the mechanics and anatomy will provide the foundation that newtechnology can build
on. The Lichtenstein hernia repair uses prosthetic material to bridge the muscular aponeurotic defect in
the inguinal region, creating an onlay mesh repair. It is an operation that is straightforward and is
considered to be a “tension-free” repair.9,10
Technique
After the spermatic cord has been evaluated for an indirect hernia, attention is then focused on the
inguinal floor.
Any protrusion of a direct hernia can be imbricated to flatten the posterior wall.
A sheet of at least 3 in × 6 in mesh, preferably consisting of soft polypropylene, is fashioned so that the
mesh overlaps the rectus by 1 to 2 cm and reaches the inguinal ligament. The mesh should extend
underneath the external oblique past the deep inguinal ring. A slit is made on the proximal end of the
mesh to accommodate the spermatic cord. This creates two tails of mesh. In females, if the round
ligament is ligated, obviously, no slit is required (FIG 18).
The mesh is first placed underneath the spermatic cord. With the medial aspect of the mesh overlying 2
to 3 cm on the pubic tubercle, a Prolene suture is used to anchor the mesh. The suture should include
the fascia overlying the tubercle but not the periosteum. Overlapping the pubic tubercle with mesh is
important as this is a frequent site of recurrence (FIG 19).
The first stitch is run continuously from the patch to the inguinal ligament every 1 cm. This stitch is
continued until it runs past the deep inguinal ring.
The medial sutures are interrupted, attaching the patch to the rectus sheath, and eventually will include
the internal oblique muscle or aponeurosis. These sutures should be spaced every 2 to 3 cm and are
placed to prevent migration of the mesh. The mesh should wrinkle rather than lay flat in order to
accommodate shrinking of the mesh and prevent tension.
The tails are then sutured together around the spermatic cord and to the inguinal ligament, creating a
new internal ring. The medial tail should lie anterior to the lateral tail. The tails are then tucked superiorly
underneath the external oblique aponeurosis, extending at least 3 cm past the internal ring.
FIG 18 • Mesh consisting of soft polypropylene fashioned from a 3 in × 6 in piece of mesh for a
Lichtenstein repair.
FIG 19 • In a Lichtenstein repair, the mesh is used to bridge the aponeurotic arch medially and the
inguinal ligament laterally.
The spermatic cord is then placed in its anatomic position lying on top of the mesh and the external
oblique is closed over the cord recreating the external inguinal ring.
PROLENE HERNIA SYSTEM AND PLUG SYSTEM
First introduced in 1998, the Prolene Hernia System (PHS) is an evolution of both the Lichtenstein repair
and the preperitoneal approach for inguinal hernia repair. Whereas the Lichtenstein approach uses solely
an onlay mesh and the preperitoneal approach uses solely an underlay approach, the PHS uses both
(FIG 20). It was designed to completely cover the myopectineal orifice, treating indirect, direct, and
femoral defects.11,12 Direct and indirect hernias may be approached differently and are presented
separately.
Technique
Indirect hernia approach
After examination of the spermatic cord and complete reduction of the indirect sac, the floor of the
inguinal canal is examined. If the posterior wall of the inguinal
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canal looks intact, the preperitoneal space is entered through the deep inguinal ring.
The preperitoneal space is accessed through the internal ring. The preperitoneal fat and peritoneum are
separated from the transversalis fascia. This is facilitated by introducing a Raytech sponge through the
internal ring and doing this dissection bluntly with care not to injure the inferior epigastric vessels. The
borders of dissection should be inferior to the pubic tubercle, below Cooper’s ligament, and lateral to past
the deep inguinal ring. This creates a space where the posterior leaflet of the mesh will cover all defects
within the myopectineal orifice.
FIG 20 • PHS mesh comes in three different sizes: small, medium, and extended. The extended mesh is
shown in this photograph.
Direct hernia approach

If the direct hernia is easily reduced, the method described earlier for developing the preperitoneal plane
can be used. Alternatively, the preperitoneal space can be accessed directly through transversalis fascia.
The transversalis fascia is entered, and the epigastric vessels are identified. A Raytech sponge may be
used to create a space that extends below the pubic tubercle and inferior to Cooper’s ligament. Because
the dissection of the preperitoneal space was started more medially than the indirect method, it is
important to ensure adequate dissection of the lateral defect. The space should be extended past the
deep ring, ensuring adequate coverage of the lateral myopectineal orifice.
Insertion of Prolene hernia system mesh
The PHS mesh consists of two leaflets connected in the middle (FIG 20). Proper preparation of the mesh
is integral for proper deployment. The circular posterior leaflet is designed to sit in the preperitoneal
space and the oblong oriented leaflet is designed to lie on top of transversalis fascia with the short end
toward the pubic tubercle. Insertion of the posterior leaflet starts with folding the oblong portion of the
mesh and holding it with a ring forceps close to the connector. This will allow easier insertion of the
posterior leaflet of the mesh through either the internal ring or the opening made into transversalis fascia
by pushing the mesh with the ring forceps (FIG 21).
The mesh is then fully inserted through the internal ring, or the direct defect, creating an umbrella shape
of the circular mesh. When gently pulling the anterior leaflet mesh out of the defect, the posterior leaflet
should expand above the preperitoneal fat and peritoneum. This could be assisted by gently pushing the
edges of the posterior mesh with the back of a forceps. It is important to ensure that this mesh expands to
below the pubic tubercle, below Cooper’s ligament, and lateral to cover the internal ring (FIG 22).
FIG 21 • In a PHS repair, the posterior leaflet of the mesh sits below transversalis fascia above the
peritoneum and reduced sac and covers the femoral defect. The anterior leaflet of the mesh lies above
transversalis fascia and is sutured to the inguinal ligament laterally and rectus fascia medially.
FIG 22 • Insertion of the posterior leaflet of the PHS mesh.
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FIG 23 • The PHS mesh with the posterior leaflet in place.
The connector between the anterior and posterior leaflets is allowed to sit in the internal ring or within the
opening made into transversalis fascia. This opening can be tightened around the connector with one or
two interrupted 2-0 Prolene sutures (FIG 23).
The anterior leaflet of the mesh is then treated as a Lichtenstein repair. A 2-cm overlap is allowed
between the anterior leaflet of the mesh and the pubic tubercle. The anchoring suture to the fascia
overlying the pubic tubercle is run between the lateral edge of the anterior leaflet and the inguinal
ligament up to the level of the internal ring. The suture is then tied to itself. Medially, the mesh is
anchored with few interrupted sutures to the rectus fascia.
A slit is made in the lateral border of the anterior leaflet to accommodate the spermatic cord. The edges
of the slit are then approximated to each other around the cord and to the inguinal ligament. The proximal
portion of the anterior mesh is tucked flat underneath the external oblique aponeurosis proximally.
The external oblique aponeurosis is closed in the standard fashion.
Closure
The spermatic cord is placed in its normal anatomic position on the re-created floor of the inguinal canal.
The external oblique aponeurosis is then closed with a continuous absorbable suture starting proximally
and moving distally, thus re-creating the external inguinal ring. The ilioinguinal and iliohypogastric nerves
should be protected during this step to avoid injury and entrapment (FIG 24).
FIG 24 • The external oblique is reapproximated, avoiding the ilioinguinal or iliohypogastric nerve.
Several interrupted absorbable sutures are placed to reapproximate Scarpa’s fascia and the
subcutaneous tissue layers (FIG 25).
The skin is closed with a running absorbable subcuticular suture and an occlusive dressing is placed.
Following the removal of the sterile drapes, the testicles at the site of repair should be examined. If
retracted, gentle traction on the scrotum will reduce the testicle back to its anatomic position. If left in the
inguinal canal, it may permanently scar in that location.
FIG 25 • Scarpa’s fascia is reapproximated.
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PEARLS AND PITFALLS
Unable to ▪ If unable to locate a direct or indirect hernia defect, then open the inguinal floor
locate the medial to the inferior epigastric vessels to examine the femoral canal.
hernia defect
Primary ▪ If the tissue quality is poor, use a mesh prosthesis to allow for a tension-free repair.
repair on ▪ If mesh is contraindicated, a relaxing incision in the anterior rectus fascia should be
tension performed.
▪ Avoid use of mesh in contaminated operative fields.
Meticulous ▪ Patients undergoing hernia repair are often on antiplatelet or anticoagulants for
hemostasis cardiac disease. Meticulous hemostasis is important to prevent postoperative
hematoma and wound complications.
POSTOPERATIVE CARE
Most patients are discharged on the day of repair. Patients should void prior to leaving the recovery area.
OUTCOMES
Elective repair of inguinal hernia is associated with low recurrence rates. Tension-free mesh repairs have
the lowest rates of recurrence in adult populations. The overall recurrence rate is 3% to 5% for mesh
repairs and 10% to 15% for suture repairs.13
COMPLICATIONS
The rate of complications after inguinal herniorrhaphy has been reported between 15% and 50%.14
When evaluating patient-centered outcomes, the overall rate of complications is consistently above 30%.
The knowledge of complications, experience with handling them, and anticipation of adverse events can
reduce their occurrence and guide informed consent.
The most frequent complication is the development of a seroma. This has been reported to be between
2.4% and 13.6%. The introduction of bacteria by aspiration of a seroma has been widely reported. In the
presence of mesh, any attempt at aspiration should be reserved to patients with suspected infection for
diagnostic purposes. A seroma should spontaneously resolve over 6 to 8 weeks. Careful ligation of
vessels, limiting dissection of soft tissue, and closure of dead spaces can reduce seroma formation.
The risk of hematoma is reported between 5.5% and 6.5%. Meticulous hemostasis and knowledge of the
vascular anatomy of the groin can reduce occurrence. Small hematomas may be treated conservatively;
however, large hematomas inducing significant pain or creating tension will usually require evacuation.
The risk of hemorrhage requiring transfusion is very rare. Intraoperative injury to major vessels is most
likely to occur when suturing to Cooper’s or the inguinal ligament. The femoral artery and vein are
bordered by Cooper’s ligament posteriorly and the inguinal ligament anteriorly. Superficial bites under
direct vision should reduce the chance of injury. If an injury does occur, immediate removal of the suture,
without tying the suture, and holding direct pressure usually prevent excessive bleeding. If the injury is
not recognized, or the suture is tied resulting in a tear of the femoral vein, the inguinal ligament should be
divided and a vascular repair should be initiated.
The reported rate of surgical site infection in clean, nonemergent, inguinal hernia repairs ranges from
0.5% to 3%. This rate of infection is higher for recurrent and emergent hernia operations. Guiding
principles of surgical infection prevention are applicable. In case of infection, early opening of the wound
and appropriate antibiotic therapy for cellulitis and systemic symptoms will treat the majority of superficial
infections. Deep surgical site infections, which are likely associated with foreign material such as suture
or mesh, require fastidious wound care and drainage. Although usually not required in the early stages of
therapy with early recognition and proper wound care, the mesh may ultimately need to be removed or
debrided.
Urinary retention is reported to occur in 0.2% to 2.42% of the cases. Urinary retention is lowest in
patients having regional anesthesia compared to general anesthesia. For those patients with retention,
bladder catheterization is required. Bladder injury should be rare. In the case of an iatrogenic injury
during a sliding hernia, a twolayer repair of the bladder with absorbable suture will suffice.
Ischemic orchitis occurs in less than 1% of the cases. It may progress to testicular atrophy, but its clinical
course is difficult to predict. Ischemic orchitis is most often caused by thrombosis of the testicular vein
within the spermatic cord but can also be from arterial injury. A Doppler ultrasound can evaluate blood
supply to the testicles. Reducing cord dissection, preventing overly tight internal ring reconstruction, and
transecting large distal hernia sacs and leaving them in situ can reduce this risk.
Injury to the vas deferens should be rare. When an injury is recognized, and surgical repair is indicated,
microsurgical repair with an operating microscope gives superior outcomes. However, repair may also be
performed over a 0 Prolene suture, which is brought through the vas at a point distal to the
reanastomosis. The Prolene is then brought through the skin and removed on day 3. If unable to repair
an injured vas, ligation with permanent suture, and preventing further dissection of the vas, may allow
reconstruction in the future. When the vas is injured by rough handling or becomes entrapped by mesh,
painful ejaculation or dysejaculation can develop from the resulting partially obstructed lumen.
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Chronic or severe pain following inguinal herniorraphy is reported in 10% to 14% of the cases. It remains
a perplexing and challenging problem. It is associated with preoperative chronic pain and with recurrent
inguinal hernia repair.15 The identification and protection of the ilioinguinal, genitofemoral, and
iliohypogastric nerves are important in preventing nerve entrapment injuries. If a nerve is injured, it should
be transected and ligated proximally, allowing it to retract into the muscle or preperitoneal space.
Operative treatment with planned resection of the three nerves can improve or resolve the pain.
However, a multidisciplinary pain team approach is imperative for optimal patient outcomes.
REFERENCES
1. Bassini E. Sulla cura radicale del ernia. Arch Soc Ital Chir. 1887;4:380.
2. Catterina A. Bassini’s Operation for the Radical Cure of Inguinal Hernia. London, United Kingdom: Lewis;
1934.
3. Fruchaud H. Anatomie Chirurgicale Des Hernies Del’aine. Bendavid R, Cunningham P, trans. Paris,
France: Gaston Doin & Cie; 1956.
4. Shouldice EB. The Shouldice repair for groin hernias. Surg Clin N Am. 2003;83:1163-1187.
5. Glassow F. The Shouldice hospital technique. Int Surg. 1986;71(3): 148-153.
6. McVay CB, Anson BJ. A fundamental error in current methods of inguinal herniorrhaphy. Surg Gynecol
Obstet. 1942;74:746-750.
7. Barbier J, Carretier MD, Richer JP. Cooper ligament repair: an update. World J Surg. 1989;13:499-505.
8. Rutledge RH. The Cooper’s ligament repair. In: Fitzgibbons RJ Jr, Greenburg AG, eds. Nyhus and
Condon’s Hernia. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:139-148.
9. Lichtenstein IL, Shulman AG, Amid PK, et al. The tension-free hernioplasty. Am J Surg. 1989;157:188-193.
10. Shulman AG, Amid PK, Lichtenstein IL. The Lichtenstein open “tensionfree” mesh repair of inguinal
hernias. Surg Today. 1995;25:619-625.
11. Gilbert A, Graham M, Voigt W. A bilayer patch device for inguinal hernia repair. Hernia. 1999;3:161-166.
12. Awad SS, Yallampalli S, Srour AM, et al. Improved outcomes with the Prolene Hernia System mesh
compared with the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair. Am J Surg.
2007;193:697-701.
13. Bendavid R. Complications of groin hernia surgery. In: Bendavid R, ed. Abdominal Wall Hernias. New
York, NY: Springer-Verlag. 2001;693-700.
14. Matthews RD, Anthony T, Kim LT, et al. Factors associated with postoperative complications and hernia
recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study
Group. Am J Surg. 2007;194:611-617.
15. Grant AM; EU Hernia Trialists Collaboration. Open mesh versus nonmesh repair of groin hernia: meta-
analysis of randomized trials based on individual patient data [corrected]. Hernia. 2002;6:130-136.
Chapter 34
Inguinal Hernia: Laparoscopic Approaches
Benjamin K. Poulose
Michael D. Holzman
Rebeccah B. Baucom
DEFINITION
Inguinal hernias can be divided into indirect, direct, and femoral based on location.
Inguinal hernia repair is one of the most common procedures performed by general surgeons in the
United States, with 750,000 to 800,000 cases annually.
Inguinal hernia will affect nearly 25% of men and less than 2% of women over their lifetime.
The majority of femoral hernias occur in women (around 70%), but indirect inguinal hernias are still the
most common type of hernia in women.
Indirect inguinal hernias result from a patent processus vaginalis and are responsible for most pediatric
inguinal hernias.
ANATOMY
The myopectineal orifice includes both the inguinal and femoral regions. The inguinal ligament divides the
myopectineal orifice into the inguinal region superiorly and the femoral region inferiorly.
The boundaries of the inguinal canal are as follows: anteriorly, the aponeurosis of the external oblique and the
internal oblique muscle laterally; posteriorly, the transversalis fascia and the transversus abdominis muscle;
superiorly, the arch formed by the internal oblique muscle; inferiorly, the inguinal ligament; medially, the
aponeurosis of the external oblique and its insertion on the pubic symphysis (FIG 1).
An indirect hernia passes with the spermatic cord (or round ligament, in women) through the inguinal canal via
the internal and external rings.
A direct hernia passes through the posterior wall of the canal (i.e., the transversalis fascia and transversus
abdominis), medial to the inferior epigastric vessels, above the inguinal ligament. This region is considered
Hesselbach’s triangle.
Femoral hernias pass through the femoral canal, medial to the femoral vessels, inferior to the inguinal
ligament.
The nerves at risk for traction injury in most anterior inguinal hernia repairs include the ilioinguinal nerve,
iliohypogastric nerve, and the genital and femoral branches of the genitofemoral nerve.
PATHOGENESIS
Indirect hernias occur as a result of a patent processus vaginalis and are congenital. The hernia involves a
peritoneal sac passing through the inguinal canal alongside the spermatic cord or round ligament.
FIG 1 • Anatomy of the inguinal canal, intraabdominal view.
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Direct hernias tend to occur secondary to increased intraabdominal pressure. Predisposing factors include
chronic cough, constipation, straining and difficulty with urination, obesity, and ascites.
NATURAL HISTORY
The natural history of untreated inguinal hernias is not fully known, although many believe that progression is
inevitable. Traditionally, repair of all inguinal hernias has been recommended to prevent progression, hernia
symptoms, and strangulation.
Watchful waiting is a reasonable strategy especially in men with minimal symptoms, as the rate of acute hernia
incarceration with bowel obstruction, strangulation of intraabdominal contents, or both is less than 2 per 1,000
patient-years.1

Most patients present with a groin bulge as their primary complaint. Over time, this tends to increase and may
be associated with pain or discomfort in the groin, thigh, or testicle.
Some are asymptomatic and detected on physical exam by a primary care physician.
Significant pain at initial presentation, particularly if not accompanied by an obvious bulge, may not be due to
hernia. Often, these patients will have chronic pain even after groin exploration.
Patients who develop progressive symptoms with increasing hernia size tend to have the best outcomes after
surgical repair with significant improvement in pain.
Physical examination is the best way to diagnose inguinal hernias, and both sides should be evaluated for the
presence of a hernia. The patient should be examined supine and upright, with a finger palpating the external
ring while the patient performs a Valsalva maneuver. A bulge detected below the inguinal ligament in the
medial thigh suggests a femoral hernia.
Adjunctive imaging studies are rarely required for diagnosis of inguinal hernia.
Ultrasound may be helpful but is dependent largely on the skill of the sonographer. Valsalva maneuvers
should be employed, and the exam should be performed with the patient supine and upright.
Some inguinal hernias can be seen on computed tomography (CT), although small studies suggest that the
sensitivity and specificity are only 85% and 65% to 85%, respectively. Therefore, if a hernia is not visualized
on CT, the diagnosis is not ruled out.
The role of magnetic resonance imaging (MRI) with and without Valsalva is unclear but may be available at
some centers. MRI is most useful in differentiating sports-related injuries from true inguinal hernias.
The differential diagnosis for a groin bulge includes hernia, lymphadenopathy, hydrocele, abscess,
hematoma, femoral artery aneurysm, or undescended testicle.
NONOPERATIVE MANAGEMENT
Patients with minimally symptomatic hernias may be candidates for nonoperative management or watchful
waiting.1 This approach entails follow-up after 6 months and annually by a care provider, along with
instructions regarding the signs and symptoms of acute incarceration or strangulation.
Delay of repair for 6 months has been shown not to have an adverse effect on surgical outcomes.2
Patients who experience significant pain with activity, those who have prostatism or constipation, and those
with overall good health status are likely to benefit most from surgical repair.3
After 2 years, about 25% of patients who are minimally symptomatic will develop worsening symptoms and
request surgical repair.1
SURGICAL MANAGEMENT
Techniques for the laparoscopic management of inguinal hernia include the transabdominal properitoneal
approach (TAPP) and the totally extraperitoneal (TEP) technique.
Laparoscopic repair is especially useful for recurrent or bilateral inguinal hernias.
A recent meta-analysis comparing open and laparoscopic repairs (TAPP and TEP) for primary unilateral
hernias demonstrated that both laparoscopic approaches resulted in less chronic groin pain and numbness
compared to open repair. TAPP and open repairs had a lower risk of recurrence compared to TEP. TAPP was
associated with a higher risk of perioperative complications compared to open repair.4
General anesthesia is usually required for laparoscopic repairs, whereas open repairs can be performed with
the use of local anesthesia.
Immediately prior to surgery, the patient should be instructed to void or a Foley catheter should be placed.
Most patients can adequately void preoperatively, precluding the need for a urinary catheter, which may
increase the risk of urinary retention as well as infection.
For recurrent hernias, it is imperative that the surgeon review previous operative reports. In general, the
approach used to repair a recurrence should use fresh surgical planes to facilitate the repair. For a previous
open repair that has recurred, a laparoscopic approach is usually favored. If a mesh plug has been used, a
TAPP approach may be significantly easier than TEP due to the high chance of peritoneal violation and need
to debulk the plug.
For a previous laparoscopic repair that has recurred, an open approach may be easier to perform. Given the
variety of laparoscopic inguinal hernia techniques used, many have found that repeat laparoscopic repair of a
recurrence is possible in experienced hands.
Caution should be taken in patients with previous prostatectomy or entrance into the space of Retzius, which
can make laparoscopic repair much more challenging. In these cases, serious consideration should be given
to an anterior
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approach. As with repairing laparoscopic inguinal hernia repair recurrences, a laparoscopic approach can be
attempted, if deemed advantageous, by an experienced laparoscopic hernia surgeon.
Positioning
The patient is positioned supine with arms tucked and legs secured in order to prevent slippage with changes
in table position during the procedure.
The surgeon stands on the contralateral side from the hernia being repaired.
TECHNIQUES
LAPAROSCOPIC TRANSABDOMINAL PROPERITONEAL INGUINAL HERNIA REPAIR
Establishment of Pneumoperitoneum and Port Placement
The first trocar is placed at the level of the umbilicus, typically beginning in the umbilicus and extending
the incision inferiorly. Pneumoperitoneum can be established either with a Veress needle or by placing a
12-mm Hasson port.
Two 5-mm ports are then placed lateral to the rectus sheath approximately 1 to 2 cm above the level of
the umbilicus (FIG 2). A 5-mm 30-degree laparoscopic is used and is placed in the port ipsilateral to the
hernia. The surgeon uses the umbilical port and port contralateral to the hernia.
The patient is placed in the Trendelenburg position displacing the pelvic viscera cephalad.
Peritoneal Incision
The inferior epigastric vessels are identified on the side of the hernia. During a TAPP, if there is a high
suspicion for inguinal hernia by history and physical examination, dissection commences on the
symptomatic side even if no obvious hernia is seen from the intraperitoneal view. Note that chronically
incarcerated properitoneal fat may occupy the hernia defect precluding clear visualization of the defect
itself.
The peritoneum is incised with Metzenbaum scissors beginning lateral to the inferior epigastric vessels
(FIG 3). This dissection can typically be done without the use of electrosurgery. The correct plane of
dissection in the TAPP repair is the true properitoneal plane. It is extremely easy to inadvertently dissect
the retrorectus plane with this approach (FIG 3). Should this occur, dissection can proceed (similar to the
TEP approach) but dissection into the retrorectus space without the benefit of balloon tamponade can
incur increased blood loss. Dissection during TAPP should proceed between the peritoneum and
transversalis fascia. The peritoneal flap is mobilized high up on the lower abdominal wall, extending
laterally to the anterior superior iliac spine and medially to the ipsilateral medial umbilical fold.
Care should be taken to avoid injury to the inferior epigastric vessels which lie posterior to the rectus
muscles in the retrorectus plane. Maintaining a plane of dissection in the true properitoneal space
minimizes the risk of injury to these vessels.
FIG 2 • Port placement. A. For TAPP, ports are placed at the umbilicus and lateral to the linea semilunaris
at the level of the umbilicus. B. TEP ports are placed in the midline at the umbilicus, 2 cm above the
symphysis pubis, and the final in between the first two, at least 4 cm cranial to the second port.
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Dissection of the Properitoneal Plane
Beginning laterally, retract the peritoneum medially, and dissect the properitoneal plane, leaving the fat
against the abdominal wall to preserve small nerves and vessels.
The inferior epigastric vessels are again identified and the properitoneal plane is developed medial to
these vessels toward Cooper’s ligament. During the initial learning curve of this procedure, the
overwhelming tendency is to dissect too far medially and posteriorly into the region of the bladder.
Confirmation of the trajectory of dissection toward Cooper’s ligament can be obtained by a brief
intraperitoneal view. Once Cooper’s ligament has been identified, it is exposed for about 2 cm
anticipating fixation at its superior aspect (FIG 4). A direct sac usually obscures Cooper’s ligament until
the sac is reduced entirely into the true pelvis.
After Cooper’s ligament has been identified, a dissection lateral to the inferior epigastric vessels is
commenced attempting to dissect the properitoneal fatty tissue anteriorly while maintaining integrity of the
peritoneum. This dissection is taken to the level of the iliopubic tract.
FIG 3 • Creation of the peritoneal flap during TAPP. Beginning lateral to the epigastric vessels, the
peritoneum is incised and the properitoneal space dissected, creating a flap. The retrorectus space, seen at
the top of this figure, may be inadvertently entered, resulting in increased bleeding.
FIG 4 • Cooper’s ligament. Dissection proceeds medially toward Cooper’s ligament. Once identified,
approximately 2 cm of the superior aspect of Cooper’s ligament is cleared for mesh fixation.
Reduction of the Hernia

At this point, attention is turned to an indirect hernia sac if present, and it is dissected away from the cord
structures. The peritoneum is now separated from the transversalis fascia overlying the inferior epigastric
vessels. As the indirect hernia sac is approached, gentle but persistent cephalad traction is applied to
reduce the hernia sac. Typically, if it can be done safely, the entire sac is reduced into the true pelvis. As
the sac is reduced, the medial vas deferens and lateral testicular vessels are identified. In women, the
round ligament is identified. The sac is dissected away from these structures. In women, the round
ligament can often be separated from the peritoneum.
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Should this not be possible, efforts are made to divide the peritoneum along the axis of the round
ligament, reapproximating the peritoneum after an adequate dissection has been performed. Division of
the round ligament should be avoided if possible to minimize risk of pain from transection of the genital
branch of the genitofemoral nerve. However, if transection is necessary to perform an adequate hernia
repair, the round ligament can be divided between clips or ligatures.
Once the hernia is reduced, the peritoneum is separated from the iliac vessels, vas, and testicular
vessels posteriorly toward the umbilicus (FIG 5). This ensures a generous exposure of the entire
myopectineal orifice. In addition, separation of the cord structures from the peritoneum ensures the ability
to place a solid piece of mesh across the myopectineal orifice without the need for keyhole creation (FIG
6). Should a keyhole configuration be employed, the dissection proceeds caudally to the vas and
testicular vessels, beginning at the level of the internal ring. Care should be taken to dissect well
posteriorly to allow mesh overlap
FIG 5 • Dissection of peritoneum off posterior structures. Once the hernia is reduced, the peritoneum is
separated from the cord structures and iliac vessels to allow adequate exposure of the myopectineal orifice.
This allows room for generous mesh overlap and is a key step in preventing hernia recurrence.
FIG 6 • Completed dissection. The hernia has been reduced and dissection completed prior to mesh
placement. Note the direct hernia defect; Cooper’s ligament, which has been cleared superiorly; and the
cord structures.
Mesh Placement and Fixation

An appropriately sized (usually 14 cm [transverse axis] × 12 cm [craniocaudal axis]), lightweight,
macroporous mesh should be chosen which will cover the hernia defect as well as the entire
myopectineal orifice.
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The mesh is then grasped medially and inserted into the 12-mm port, aiming toward Cooper’s ligament. A
Maryland dissector can be used to position the lateral and superior aspect of the mesh.
Prior to fixation, precise placement of the mesh over the entire myopectineal orifice is ensured. Care is
taken to ensure at least 3 cm of overlap over any hernia defect.
Minimal fixation is used to prevent migration of the mesh (FIG 7). For indirect hernias, two tacks are
placed just above Cooper’s ligament, one high medially over the posterior aspect of the rectus sheath,
and one high laterally well above the iliopubic tract. For direct defects, some additional fixation is usually
necessary to avoid early migration and recurrence. In general, no tacks should be placed below Cooper’s
ligament or below the iliopubic tract. Counterpressure should be used to feel the tip of the tacking device
on all tacks except those placed adjacent to Cooper’s ligament. There is little data to support any one
type of fixation (absorbable vs. permanent). Initial results suggest that avoiding mechanical fixation with
the use of sealants or glues may be feasible, especially with a TEP approach; however more conclusive
information is needed.5,6
FIG 7 • Mesh fixation. The mesh can be either a solid piece or one with a keyhole and should be taut.
Fixation tacks are used sparingly: two above Cooper’s ligament one in the posterior rectus sheath, and one
laterally, well above the iliopubic tract.
FIG 8 • Peritoneal flap closure for TAPP. The peritoneal flap is closed with sequential tacks.
Closing the Peritoneal Flap and Incisions

The peritoneal flap can usually be closed with tack fixation, taking care to avoid injury to the inferior
epigastric vessels (FIG 8). All attempts are made to minimize
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exposure of dissected tissue and mesh to the peritoneal cavity. During flap closure, care is taken to
ensure that the posterior aspect of the mesh does not buckle or twist, which can act as a lead point for
recurrence.
After desufflation, trocars are removed under direct visualization. The 12-mm port site is closed with 0
Vicryl, and skin is approximated with 4-0 Monocryl sutures.
TOTALLY EXTRAPERITONEAL INGUINAL HERNIA REPAIR
Establishment of the Operative (Properitoneal) Space and Port Placement
A 1- to 2-cm longitudinal skin incision is made inferior to the umbilicus and the subcutaneous tissues are
divided. The anterior rectus sheath is identified just lateral to linea alba on the ipsilateral side of the
hernia. The anterior rectus sheath is then divided using electrosurgery. The rectus muscle is retracted
laterally and the retrorectus space is entered. An endoscopic balloon dissector is advanced immediately
beneath the rectus muscle and advanced to the pubic symphysis (FIG 9). A 10-mm 0-degree laparoscope
is placed into the lumen of the balloon and it is fully inflated and held in position for 2 minutes to achieve
hemostasis. The balloon is removed and either a Hasson cannula (with stay sutures) or a balloontipped
cannula is inserted into the extraperitoneal space. Usually, action of the balloon dissector dissects both
the retrorectus space and the properitoneal space. This space is insufflated to a pressure of 12 mmHg
and a 10-mm 30-degree laparoscope is used for visualization. The patient is placed in Trendelenburg
position. Two 5-mm operating ports are inserted under direct visualization in the lower midline. The
lowest is placed 2 cm above the pubic symphysis. The second port is placed at least 4 cm cranial from
the first port (FIG 2). Use of a finder needle with local anesthetic can assist in placement of these ports.
Dissection of the Properitoneal Plane, Reduction of the Hernia, Mesh Placement, and Fixation
These steps proceed similarly to that described for the TAPP approach discussed previously.
Desufflation
After adequate hemostasis has been assured and mesh placement deemed appropriate, the 5-mm
operating ports are removed and the insufflation removed. The peritoneum should be visualized closing
the dissected space. Care should be taken to ensure that the mesh remains flat against the abdominal
wall without folding, buckling, or twisting. The Hasson or balloon-tipped cannula is then removed and the
anterior rectus sheath closed.
FIG 9 • Endoscopic balloon dissector, TEP. The balloon dissector is inserted into the retrorectus space,
advanced toward the pubic symphysis, and fully insufflated for 2 minutes to allow adequate hemostasis.
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PEARLS AND PITFALLS
TEP—entrance ▪ Entrance into the properitoneal space during TEP should be performed at least
into properitoneal 5-mm below the umbilicus as the peritoneum and transversalis fascia are fused
space to the umbilical stalk, preventing easy mobilization. Typically, the retrorectus
space is first entered, with the balloon dissector expanding this plane. The
dissector usually also expands the properitoneal plane. In some instances, the
transversalis fascia may remain intact, requiring laparoscopic mobilization into
the true properitoneal space.
TAPP— ▪ Care is taken to enter the plane between the peritoneum and the transversalis
properitoneal fascia. If the transversalis fascia is inadvertently entered, attempts should be
dissection made to get back into the properitoneal plane. If this cannot be done, the
dissection can proceed in the retrorectus space anterior to the transversalis
fascia. This is usually a less hemostatic plane; care should be taken to avoid
excessive bleeding.
TEP—avoidance ▪ Maintaining integrity of the peritoneum and avoidance of pneumoperitoneum

of facilitates exposure with the TEP approach. Tears in the peritoneum should be
pneumoperitoneum repaired with either clips, absorbable loop ligatures, or sutures. A Veress needle
can be placed into the peritoneal cavity in the upper abdomen to vent the
pneumoperitoneum and reestablish visualization in the extraperitoneal space.
Inability to control the peritoneal gas leak may necessitate conversion to a TAPP
approach.
TAPP/TEP— ▪ Dissection of Cooper’s ligament often exposes aberrant obturator vessels and
avoidance of injury the corona mortis venous plexus. Great care should be taken to avoid injury to
to aberrant these structures as hemostasis can be challenging. Additionally, these structures
obturator vessels should be taken into consideration when mesh fixation is used adjacent to
and corona mortis Cooper’s ligament.
venous plexus
TAPP/TEP—large ▪ With large direct sacs, identification of Cooper’s ligament can often be
direct hernia sac challenging. When a sizable direct hernia is encountered, the sac is reduced
early in the dissection to identify Cooper’s ligament.
TAPP—large ▪ Reduction of a large indirect hernia sac is one of the most challenging
indirect hernia sac maneuvers in laparoscopic inguinal hernia repair. Often, medial and lateral
retraction of the sac can help facilitate dissection of the sac away from the cord
structures and inferior epigastric vessels. Manual reduction (externally with
fingers) can sometimes help dissect the entire sac back into the true pelvis. If
complete reduction is unable to be achieved, transection of the sac can be
performed. The testicular vessels and vas are clearly identified and separated
from the tenacious sac. Laparoscopic clips are used to clip the proximal aspect
of the sac and the sac is divided, allowing the open distal aspect of the sac to
“parachute” back into the inguinal canal. The sac can then be mobilized in the
standard fashion to facilitate mesh placement.
POSTOPERATIVE CARE
In addition to the typical postoperative monitoring for hydration and adequate analgesia, it is important that the
patient be monitored for urinary retention in the immediate postoperative period and a Foley catheter inserted,
if needed.
Diet can be advanced quickly within 12 hours postoperatively. Ambulation can resume once appropriately
recovered from anesthesia. Patients are typically ready for discharge on the day of surgery.
Constipation and straining should be avoided postoperatively. Light activity can be resumed within 1 day of
surgery. Patients should be advised to avoid strenuous activity for at least 3 to 4 weeks postoperatively.
OUTCOMES
Recurrence after TAPP appears to be equivalent to open repair, and TEP has a slightly higher risk of
recurrence.4
Overall, TEP and TAPP have been associated with less chronic pain than open repair.4
COMPLICATIONS
Complications after inguinal hernia repair (whether open or laparoscopic) include surgical site infection,
seroma or hematoma, mesh infection (all < 1%), hernia recurrence (2% to 5% for primary inguinal hernia;
around 10% for recurrent hernia), and chronic groin pain (around 0.5%).
Men with bilateral hernias should be counseled regarding the slightly increased risk of decreased fertility
associated with bilateral laparoscopic inguinal hernia repairs.7
TAPP has been associated with an increased risk of intraabdominal and vascular injury, although this
risk is low (< 1 %).
Laparoscopic repair (TAPP and TEP) carries the risk of port site hernias (approximately 0.1% to 2%).
REFERENCES
1. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in
minimally symptomatic men: a randomized clinical trial. JAMA. 2006;295(3):285-292.
2. Thompson JS, Gibbs JO, Reda DJ, et al. Does delaying repair of an asymptomatic hernia have a penalty?
Am J Surg. 2008;195(1):89-93.
3. Sarosi GA, Wei Y, Gibbs JO, et al. A clinician’s guide to patient selection for watchful waiting management
of inguinal hernia. Ann Surg. 2011;253(3):605-610.
4. O’Reilly EA, Burke JP, O’Connell PR. A meta-analysis of surgical morbidity and recurrence after
laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012;255(5):846-853.
5. Shah NS, Bandara AI, Sheen AJ. Clinical outcome and quality of life in 100 consecutive laparoscopic
totally extra-peritoneal (TEP) groin hernia repairs using fibrin glue (Tisseel™): a United Kingdom experience.
Hernia. 2012; 16(6):647-653.
6. Kaul A, Hutfless S, Le H, et al. Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair
of inguinal hernia: a systematic review and meta-analysis. Surg Endosc. 2012;26(5):1269-1278.
7. Peeters E, Spiessens C, Oyen R, et al. Laparoscopic inguinal hernia repair in men with lightweight
meshes may significantly impair sperm motility: a randomized controlled trial. Ann Surg. 2010;252(2):240-
246.
Chapter 35
Incisional Hernia: Open Approaches
Mark D. Sawyer
Michael G. Sarr
DEFINITION
An incisional hernia is a defect in the musculoaponeurotic layer of the abdominal wall occurring at the site
of a prior incision. The sine qua non of any hernia is the presence of a fascial defect. Typically, a hernia
is a protrusion of intraperitoneal abdominal contents through the defect, usually contained within a “sac”
of peritoneum and covered with skin and perhaps subcutaneous fat. In certain circumstances such as the
sequelae of an open abdomen, there may not be a true peritoneal sac nor a cutaneous cover.
There are certain circumstances in which a pseudohernia can mimic a true hernia. Flank incisions can
denervate the lateral abdominal wall, causing flaccidity and an outward bulge appearing to be a “hernia,”
even though the musculoaponeurotic layers are intact. Diastasis of the rectus muscles will also lead to a
bulge especially on straining, but in both these circumstances, there is no actual defect in this
musculoaponeurotic layer.
Incisional hernias are classified as incarcerated when the contents of the hernia sac cannot be reduced
back into the confines of the peritoneal cavity and strangulated when incarceration leads to vascular
compromise and ischemia of the incarcerated contents. Strangulated contents may be salvageable if
reduction can be accomplished prior to irreversible ischemia and necrosis.
Incisional herniorrhaphies are designed to obliterate the musculoaponeurotic defect and restore
continuity to the abdominal wall. This process may be accomplished in a number of ways but fall into
three basic categories: (1) A primary repair with reapposition of the separated musculoaponeurotic edges
is the simplest type of repair; (2) synthetic and biologic prostheses to restore abdominal wall continuity
without primary apposition of the musculoaponeurotic layers, covering the defect in a bridging fashion
with a “patch.” Generally, repairs in this fashion are performed as an underlay or overlay with a
substantial amount of overlap beyond the musculoaponeurotic edge (usually ≥5 cm) because sewing the
prosthesis directly to the edges leads to an unacceptably high rate of hernia recurrence; and (3) a
component separation technique, which are extensive, anterior or posterior lateral relaxing incisions to
allow for greater tissue mobility, medialization of the rectus muscles, and decreased tension. The
component separation is often reinforced using synthetic or biologic prostheses as underlays or overlays.
The differential diagnosis of incisional hernias involves anything else that could cause a mass effect of
the abdominal wall.
Pseudohernias arising from flank incisions and diastasis recti may be mistaken for true hernias.
Diastasis recti is usually seen in the absence of a previous midline incision. Flank pseudohernias may
require imaging such as computed tomography (CT) of the abdomen to demonstrate that the
musculoaponeurotic layers of the abdominal wall are intact.
Neoplastic masses, such as desmoid tumors or other soft tissue tumors, such as lipomas and
sarcomas, can potentially be mistaken for hernias, especially an incarcerated hernia, because they do
not change with straining or coughing and obviously cannot be reduced.
Infections causing fluid collections, such as an abscess or seroma formation after prior herniorrhaphy
or abdominoplasty, can cause bulging that could be mistaken for a hernia and can occur or become
evident weeks to years after the herniorrhaphy.

The most common symptom is discomfort or pain directly over the site of the hernia, especially when standing
or otherwise increasing intraabdominal pressure; referred pain like a radiculopathy is rare. Patients will
complain of a bulge, loss of abdominal wall support (often with back pain), or a feeling that they are “falling
out” if the hernia is large. Patients often find the hernia cosmetically unacceptable. Localized borborygmi may
also be evident to the patient, as may visible peristalsis.
Hernias may cause varying degrees of intestinal obstruction— acute, chronic, or intermittent. Predisposing
factors include chronic or acute incarceration and a small hernia neck, especially with a relatively large
protrusion of intraabdominal content relative to the neck size. Intermittent, partial small intestinal obstruction
may manifest as cramping, abdominal pain, or emesis, and patients may have learned to massage the hernias
to provide relief. Acute or chronically incarcerated hernias may cause more severe obstructive symptoms,
including acute, complete small intestinal obstruction or chronic, partial obstruction. Although much less
common, large bowel obstruction may occur and manifest as constipation or acutely as obstipation.
Examination of the patient with an incisional hernia should be performed in both the supine and erect
positions. This approach may provide valuable information to the examiner—reducibility, the extent to which
the hernia protrudes, and to what extent the abdominal domain has been lost. The two most prevalent findings
on physical exam are the presence of a bulge over or lateral to the prior incision and a palpable fascial defect.
If the hernia reduces spontaneously in the supine position, the examination can be aided by having the patient
perform a Valsalva maneuver, standing, or both. Usually, the hernia can be elicited merely by having the
patient lift his or her head off the examination table. Subtle and smaller hernias can be difficult to detect and
may manifest during examination as a gentle,
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slowly developing bulge under the examiner’s fingers; in the obese patient, small hernias may be difficult or
impossible to appreciate.
The edges of the hernia defect should be determined circumferentially by palpation with the patient supine
and relaxed. The dimensions are important in determining whether musculoaponeurotic apposition will be
possible at the time of repair. Beware the possibility of a “Swiss cheese” hernia, that is, small multiple defects
along the fascial incision, especially when the fascia had been closed previously with interrupted sutures;
smaller defects may not be palpable.
As noted previously, an incarcerated hernia must raise other possibilities in the differential diagnosis, such as
seromas, abscesses, and both benign and malignant abdominal wall masses.
The examiner should palpate carefully over any prior port site after a laparoscopic procedure for a subtle
defect or “mass.”
Intramural hernias, where at least the most superficial musculoaponeurotic layer remains intact, can occur
after lateral celiotomies where the abdominal wall has several layers. Spigelian hernias can present as
intramural hernias. Intramural hernias are rare and can be difficult to diagnose and often impossible to feel. A
Valsalva maneuver during CT or even ultrasonography may be diagnostic when physical exam and even a
passive CT cannot demonstrate the hernia.
For very large hernias that remain evident with the patient supine, an estimation should be made as to the
extent to which the herniated contents have lost domain; that is, there is no longer adequate room within the
abdominal cavity to accommodate the extruded contents after attempted reduction back into the coelomic
cavity. CT of the abdomen is also particularly helpful in this regard. Loss of domain can preclude fascial
apposition, even with concomitant component separation or relaxing incisions. Substantial loss of domain will
cause undue tension in repairs, respiratory compromise, and an increased risk of recurrence after repair.
Severe loss of domain precludes repair.

The best imaging technique for incisional hernia is CT. CT provides excellent and actionable information
regarding the size and configuration of the hernia defect, can provide a visual estimate of loss of domain and
other potential pathologies in the differential diagnosis, and will aid in planning of the operation. In large,
complex hernias, the information can assist with decisions regarding the procedure of choice as well as the
potential for adjunctive measures such as tissue (skin surface area) expanders. For flank hernias, CT can rule
out a pseudohernia and is important to define the status of the oblique muscles cranial and caudal to the
defect, as well as the paraspinal muscles, which will need to serve as fixation points for the hernia prosthesis.
Routinely obtaining a CT to define the hernia defect, position, and size is controversial. For straightforward
incisional hernias easily felt and defined at examination, CT has little benefit. For large, complex, or recurrent
hernias, especially after prior repairs, CT can provide a wealth of information to define size and conformation,
position of any prior prosthetics, issues of abdominal domain, unappreciated additional defects, and the status
of the abdominal musculature such as loss or atrophy of specific muscle layers—critical information when
planning a concomitant component separation.
Magnetic resonance imaging (MRI) is acceptable but provides no more information than CT while being more
expensive, time consuming, and difficult for the patient (and for many physicians as MRI is more difficult to
interpret). Ultrasonography can be helpful, especially with the diagnosis of intramural hernias but is not
generally useful and provides far less information than CT.
SURGICAL MANAGEMENT
Timing of Operation
Although most incisional herniorrhaphies are elective operations, acutely incarcerated hernias are surgical
emergencies, particularly when strangulation is suspected. Signs of strangulation may include: nausea and
vomiting; peritonitis; acutely inflamed, indurated skin overlying the hernia; new onset of constant severe hernia
pain; and the signs and symptoms of local or systemic sepsis.
As a general rule, elective incisional herniorrhaphy should be delayed until optimum conditions for repair have
been achieved; this approach will decrease recurrence rate. Timing of repair, however, is relative to the
patient and the hernia; for example, a small-necked hernia considered at high risk for incarceration would
prompt an earlier repair especially if symptomatic, whereas a patient with multiple, potentially remediable risk
factors for recurrence, such as obesity, poorly controlled diabetes, tobacco use, malnutrition, constipation, or
chronic cough, would argue for a delayed approach until these issues are addressed. More immediate
concerns that should delay repair for the shorter term would include, open wounds on the abdominal wall,
cellulitis, panniculitis, or cutaneous candidiasis; distant infections such as pneumonia or urinary tract infection;
and uncontrolled, potentially reversible medical conditions such as diabetes, congestive heart failure, and
chronic obstructive pulmonary disease (COPD). A nonmature (“nonpinchable”) split thickness skin graft
overlying the hernia is a relative indication for delay, as is waiting to receive recoverable operative notes from
prior abdominal operations prior to operation.
Open versus Laparoscopic Repairs

The topic of open versus laparoscopic repairs is controversial. Each has advantages and disadvantages, and
the data regarding hernia recurrence, pain, and postoperative complications are roughly comparable. There
are factors that may predispose toward one or the other approach in a particular patient; a surgeon routinely
performing hernia repairs should be conversant with both. A recent Cochrane review examined 10 randomized
controlled trials with a total of 880 patients comparing laparoscopic versus open ventral hernia repairs. They
did not note any difference in recurrence rates or postoperative pain intensity. Laparoscopic repairs carried a
greater risk of enterotomy and incurred greater inhospital costs, but they were associated with a decreased
risk of wound and mesh infection and shortened hospital stay.
Factors favoring open repair: Theoretically, returning the abdominal musculature to its normal position of
continuity could be expected to restore optimal anatomic and physiologic functionality of the mechanics of the
abdominal wall, although
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this remains unproven. Apposition of the musculature in its anatomic position is more easily accomplished in
an open procedure. Although fascial apposition can be accomplished laparoscopically, as can a limited
component separation, these are performed more efficiently and completely in an open procedure, and more
complex component separations including the rectus sheath rollover technique can be accomplished. The
fascial apposition performed laparoscopically usually leaves a cosmetically undesirable ridge of skin and
subcutaneous fat above the repair. Dense adhesions, especially those resulting from an open wound and
subsequent split thickness skin grafting, make a laparoscopic repair difficult or impossible.
Several factors can affect the recurrence rate of incisional hernia repair. With a recurrence rate of 10% to 30%
or greater, attention to the factors that adversely affect recurrence rate in the preoperative phase is warranted.
Weight loss: If patients are substantially overweight, certainly if they meet medical criteria for severe
obesity, an attempt at weight loss prior to repair is warranted. If the patients are not able to lose weight
successfully after a reasonable period of time, however, it may be reasonable to proceed with repair.
Tobacco use: Experts in abdominal wall reconstruction are in general intolerant of tobacco use prior to
hernia repair, certainly within 6 weeks prior to the repair and especially if a components separation is
planned. The adverse effects of tobacco use on wound healing are well documented in the medical
literature. It is worthwhile noting that nicotine substitutes such as gum would be expected to cause the same
vasoconstriction and tissue ischemia as inhaled and oral tobacco products.
Abdominal wall strain: Voluntary and involuntary abdominal wall contractions can place an immense strain
on a fresh abdominal wall reconstruction—coughing, constipation, emesis, and straining to urinate all place
stresses on the abdominal wall that could have an adverse effect on herniorrhaphy. Any remediable causes
of these problems should be addressed prior to operation.
Routine screening: It is worthwhile to make certain that patients are up-to-date with routine medical
maintenance and screening such as colonoscopy so that other necessary intraabdominal conditions can be
treated concomitantly, beforehand, or sequentially with the herniorrhaphy as appropriate.
Routine health maintenance: A general preoperative clearance is useful to make certain the patient is
medically optimized for operation. Common diseases, such as hypertension, diabetes, COPD, and coronary
artery disease, should be evaluated and optimized prior to operation to minimize perioperative risk.
Incisional hernia repair is usually a clean case. Because enterotomies can occur and repairs usually entail
the placement of either a synthetic or biologic prosthesis, perioperative prophylactic antibiotics are
indicated. Bowel preparation is not indicated. A preoperative shower with chlorhexidine gluconate
(Hibiclens®) is prescribed at the preference of the surgeon. Adhesive drapes, such as Ioban™ (3M Corp,
Minneapolis, MN) and Steri-Drape™ (3M Corp), are used frequently for the theoretic purpose of “isolating
skin bacteria” from the wound and any prosthesis used, but strong evidentiary studies to support their use
are lacking.
Many hernia cases will require advance notice to ensure that necessary materials and equipment are
available.
Planned fixation of the prosthesis to the pubis or anterior iliac spine may require the use of a bone drill or
bone anchors.
Specialized, procedure-specific equipment such as a Reverdin needle
Biologic prosthetics (fetal bovine, porcine, or human dermis and others) are expensive and may be
stocked in limited supply. Be certain that the prosthesis required in size, thickness, and type is in stock
and available the day of operation, as well as alternatives should the originally planned material not be
usable as planned.
Positioning
Most incisional hernias can be repaired with the patient supine; the drapes should extend at least 10 to 15 cm
above and below the extent of the previous incision. There may be unappreciated defects discovered at the
time of operation along the entire extent of the previous incision.
For flank hernias, adequate exposure is paramount. Depending on the incision, a vertically placed bump under
the spine providing lateral position may give sufficient access, whereas for more lateral incisional hernias, a
complete lateral position may be necessary. See the following “Techniques” section.
Varieties of Repair
The optimal repair of an open incisional hernia is a controversial topic. We will present our choices for what
we consider the acceptable and optimal repairs, as well as general considerations that are valid regardless of
the other technical details. For most purposes, we consider fascial apposition with a prosthesis underlay in the
retrorectus or preperitoneal position to be the best repair for most open incisional hernias.
Choice of Mesh
In general, the synthetic (alloplastic) meshes are preferable when there is no contamination precluding their
use, whereas biologic prostheses are preferable when microbial contamination is present. There are
innumerable choices for both synthetic and biologic prostheses and little to support the superiority of one
particular type over another within their respective classes. It is useful to categorize broadly the various
products by functional use. The most important distinction is synthetic versus biologic. The biologic prosthetics
are in general more resistant to bacterial colonization and infection and may be chosen in a contaminated
field, but they may remodel and weaken over time, especially when used in a bridging fashion. The synthetics
are stronger than the biologic meshes and do not remodel, although a varied extent of shrinkage does occur,
depending on the prosthetic material. The synthetics may be further subdivided into barrier and nonbarrier
meshes. Barrier meshes are designed to allow them to be apposed to the abdominal viscera are in theory
minimize adhesions to the side facing intracorporeally. Nonbarrier synthetics should only be used in a
protected space, such as the preperitoneal or retrorectus spaces.
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Procedure Categorization
Open
Fascial apposition alone
Fascial apposition with prosthesis underlay
Protected space mesh placement (preperitoneal and retrorectus)
Intraperitoneal mesh placement
Fascial apposition with prosthesis overlay
Components separation
Laparoscopic
Prosthesis underlay
Suture fixation with tacks
Tack fixation alone
Fascial apposition
Components separation
TECHNIQUES
WIDE ONLAY TECHNIQUE OF INCISIONAL HERNIORRHAPHY
The concept behind this wide onlay repair is that the procedure can remain fully extraperitoneal, and the
meshed prosthesis provides a large surface area for transgrowth through the mesh and thus a wide
tissue fixation.
Placement of Incision
The entire prior skin incision is excised along with any underlying fibrosis back to healthy epidermis and
subcutaneous fat in attempt to minimize infection (FIG 1A).
Dissection proceeds directly down to the hernia sac, being careful not to enter the sac. If the incision is
longer than the hernia defect, only the skin and subcutaneous tissues that are chronically scarred with
concerns for healing need be excised. This type of repair can be accomplished totally extraperitoneally.
The lateral aspect of the hernia sac is mobilized medially back to the fascial defect. This maneuver may
be accomplished purely by blunt dissection, but if the interface of sac and subcutaneous tissue is
scarred, sharp dissection may be required (FIG 1B).
Creation of Space for Prosthesis
The skin and subcutaneous tissue flaps are mobilized for at least 5 to 7 cm lateral to the edge of the
hernia defect. This plane is created just anterior to the abdominal wall fascia (anterior rectus fascia and
possibly out to the external oblique fascia or aponeurosis more laterally) to allow a wide, lateral overlap of
the prosthesis. A 5- to 7-cm skin and subcutaneous flap is mobilized off the midline fascia past the cranial
and caudal extents of the hernia defect (FIG 1C).
Reapproximation of Fascia Edges
A decision needs to be made whether and how the fascial edges of the defect can be reapproximated
(FIG 2A) or only bridged or “patched” by the prosthesis
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(FIG 2B) (see Chapter 37). If the fascial edges are to be sutured together, some dissection under the
fascial edges may be necessary to place the fascial sutures safely. Most surgeons believe that
reapproximation of the fascial edges reinforced by a prosthesis provides a superior outcome compared to
a bridge or patch of a persistent fascial defect. If the defect is wide and would require a more complicated
abdominal wall reconstruction, the advantages and disadvantages should be considered. In this situation,
the skin flaps can be dissected further laterally beyond the lateral border of the rectus muscle; then the
external oblique fascia and muscle can be transected being careful not to disrupt the internal oblique
muscle/fascia—a form of anterior components separation—this maneuver allows the rectus muscle to be
“medialized” and the medial edges of the fascia to be sewn together (FIG 2C) (see Chapter 37, for more
in-depth description). This maneuver allows 4 to 6 cm of medialization of the rectus muscles on both
sides. Another option to “approximate” the fascial edges of the defect is a rectus rollover technique (FIG
2C). With this technique, the anterior rectus fascia is incised just medial to its lateral border, mobilized off
the underlying rectus muscle, and “rolled” medially. These edges of the rolled anterior rectus fascia can
be sutured together in the midline. Note that the rectus muscles are not medialized with this technique.
FIG 1 • Incision and mobilization of hernia sac. A. The incision is centered over the hernia excising the prior
incision; all subcutaneous scars should be excised back to healthy, vascularized subcutaneous tissue. B.
The hernia sac is mobilized laterally to the medial edge of the hernia defect; try to not violate the hernia sac.
(continued)
FIG 1 • (continued) C. The anterior surface of the abdominal wall musculature is mobilized circumferentially
at least 5 to 10 cm from the edges of the hernia defect to provide a wide surface area to allow transgrowth
through the onlay meshed prosthesis for a stable tissue incorporation/fixation.
FIG 2 • Closure of hernia defect prior to placement of meshed prosthesis. A. Primary reapproximation—
when possible, the medial edges of the defect are reapproximated with a running suture closure. B. Anterior
components separation—when the defect cannot be approximated primarily, the external oblique
muscle/aponeurosis can be incised 1 to 2 cm lateral to the lateral border of the rectus muscle to allow
medialization of the rectus muscle for primary closure of the defect. (continued)
FIG 2 • (continued) C. Rectus rollover—another alternative to the anterior lateral “release” or “relaxing”
incision in B figure is to incise the anterior rectus fascia and mobilize the fascia medially to allow it to
“rollover” medially for primary fascial closure—note, this technique does not fully medialize the rectus
muscles but does allow fascial approximation over the hernia defect (see insert).
Placement of Prosthetic Mesh

A large sheet of prosthetic mesh is then sized to cover the anterior abdominal wall hernia defect and to
extend a further 5 to 7 cm from the hernia defect (so-called “wide onlay”) on all sides of the defect. The
lateral edges of the prosthesis are sewn to the anterior abdominal wall fascia circumferentially with #0 or
no. 1 suture material (e.g., 0 or no. 1 polydioxanone) (FIG 3). The use of absorbable versus permanent
sutures is controversial. Proponents of permanent sutures believe that permanent sutures minimize the
possibility of late migration or dislodgement of the prosthesis, whereas those surgeons favoring the
longer lasting absorbable suture (such as polydioxanone) believe that permanent sutures can lead to
suture granulomas and ultimately contamination and infection of the prosthesis. Although there is no
good evidence supporting either argument, we prefer the absorbable suture provided there will be a large
surface area for mesh transgrowth.
In progressively smaller concentric circles, one or two additional suture fixation of the prosthesis to the
underlying anterior abdominal wall can also be placed (FIG 3A). If the repair is a bridge repair, these
concentric circles should not extend medial to the edges of the fascial defect because the underlying
hernia sac and viscera can be injured. A porous synthetic prosthetic and not a solid prosthetic (ePTFE) is
used to achieve the goal to provide a
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wide surface area for transgrowth through the mesh for tissue fixation.
If an anterior components separation is performed, the prosthesis extends laterally to the lateral
transected edge of the external oblique aponeurosis (a very wide onlay repair) or just 5 to 7 cm lateral to
the medial edge of the hernia defect which is usually to the lateral edge of the rectus muscle.
If a rectus rollover is performed, the prosthesis should extend 5 cm lateral to the site of incision in the
anterior rectus fascia to provide solid points of fascial fixation of the prosthesis.
For situations where there is bacterial contamination (clean-contaminated cases) or active infection,
albeit treated, a synthetic mesh is contraindicated, and a bioprosthesis would be a better choice.
FIG 3 • Implantation of meshed prosthesis. A. The prosthesis is sutured to the anterior surface of the
fascia of the anterior abdominal wall. Several concentric circles of suture fixation can be performed. B.
Pleating of subcutaneous space—in an attempt to obliterate dead space, the posterior aspect of the
lateral skin/subcutaneous flap created to allow a wide onlay repair can be sewn to the anterior abdominal
wall fascia. Prior to closing the skin, several closed suction drains are placed in this subcutaneous space
and brought out cranially (skin is cleaner cranially than caudally) lateral to the lateral edge of the
mobilized skin/subcutaneous flaps (not shown).
Wound Closure
Most surgeons place one or two closed suction drains in the large subcutaneous space to prevent a
seroma. When the drains should be removed is controversial; for a bioprosthesis, drains are mandatory
to prevent a seroma.
Prior to closing the skin, a pleating technique may be used, whereby the posterior adipose surface of the
skin/subcutaneous flaps can be sewn to the anterior surface of the prosthesis in attempt to minimize the
“dead space” and the possibility of seroma (FIG 3B).
RECTRORECTUS SUBLAY REPAIR: MODIFIED RIVES-STOPPA REPAIR
Many believe that this repair has the best results of all current incisional herniorrhaphies. Whether it is
better than a wide, intraperitoneal sublay (IPOM) can be debated, but there are no studies comparing the
two repairs. This modified Rives-Stoppa repair is based on the principle of wide surface area of a
meshed synthetic prosthesis placed in a very vascular field—the retrorectus space (to allow a stable,
reliable anterior and posterior transgrowth for mesh fixation). Importantly, the prosthesis is neither in the
less vascular subcutaneous space where the risk of infection and seroma is greater nor is the prosthesis
direct in contact with the intraperitoneal viscera. Moreover, in most patients, the repair can be
accomplished extraperitoneally.
As with other repairs, the incision should be made directly over the hernia defect with resection of the
skin incision and the underlying, poorly vascularized scar tissue. The skin incision preferably should not
extend all the way up to the xiphoid or all the way down to the pubis but rather stay 5 to 8 cm away from
xiphoid and pubis.
Mobilization of Retrorectus Space
As described in the first technique (wide onlay technique of incisional herniorrhaphy), the
subcutaneous hernia sac is mobilized back to the hernia defect for the entire circumference of the defect.
The hernia sac, though, is neither incised nor opened unless a concomitant, “clean” intraperitoneal
procedure is planned—for example, adhesiolysis, insertion of an adjustable gastric band, and so forth. It
could
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be argued that clean-contaminated procedures, such as an elective cholecystectomy or hysterectomy do
not pose a clinically significant bacterial contamination load despite being clean-contaminated
procedures, but considering the morbidity and requirement for at least one additional procedure in the
event of mesh infection, the authors tend to refrain from performing even these minimally contaminating
procedures concomitantly in most circumstances. Certainly, other “clean-contaminated” procedures such
as gastrectomy, small or large bowel resections, appendectomy, biliary drainage procedures, or most
bariatric operations other than a band would be considered by most to be an indication to use a
bioprosthesis rather than a permanent synthetic mesh.
FIG 4 • Dissection of retrorectus space. A. An anterior rectus fasciotomy is made at the medial edge of
the rectus muscle (at lateral edge of the hernia defect) allowing access to the avascular retrorectus
space. B. Lateral dissection is facilitated by retracting the medial edge of the anterior rectus fascia
anteriorly and the medial edge of the posterior rectus fascia medially and posteriorly. Much of this
dissection can be blunt.
Next, the medial edge of the anterior rectus fascia is incised at the lateral edges of the hernia defect,
thereby exposing the vertical fibers of the underlying rectus muscle (FIG 4A). The rectus muscle is
dissected and retracted anterolaterally to expose the firm, white surface of the posterior rectus fascia
(FIG 4B).
There are minimal, if any, adhesions between the posterior surface of the rectus muscle and the anterior
surface of the posterior rectus fascia, except medially where the transfascial sutures from the originally
fascial closure had been placed. The benefit of this retrorectus space is that it is virtually avascular to
dissect and very easily mobilized.
Care must be taken to preserve the inferior epigastric vessels (artery and vein) cranially near the xiphoid
where they will course from medially near the xiphoid to the midrectus muscle anterior to the posterior
rectus fascia before entering the rectus muscle. Caudally, the deep inferior epigastric vessels arise from
the external iliac vessels medial to the internal inguinal ring and course cranially in the preperitoneal
space caudal to the semicircular line and then on the anterior surface of the posterior rectus fascia before
entering the rectus muscle with one or more branches. This inferior epigastric arcade is important to
preserve because it provides the blood supply to the rectus muscles and equally important from the
rectus muscles to the overlying skin and subcutaneous tissue via the “perforator vessels.” One
advantage of the rectorectus repair (in contrast to the wide onlay technique) is that mobilization of a
lateral skin/subcutaneous flap (and the obligate transection of the important perforators) is not necessary,
maximizing the blood supply to the skin edges and minimizing the subcutaneous “dead space.”
The retrorectus space should be mobilized to the lateral border of the rectus muscle, the cranial and
caudal extent of the hernia defect/hernia sac (FIG 5). The anterior rectus fascia and the linea alba need
to be preserved cranially and caudally to the hernia defect to allow for fixation of the prosthesis.
The cranial edge of the intact midline fascia is grasped with a Kocher clamp and retracted anteriorly to
allow cranial mobilization of a space (if possible preperitoneally) for at least 7 cm or up to the xiphoid (FIG
6A). This requires transection of the insertion of the posterior
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rectus fascia at the medial edge of the rectus muscle bilaterally, being careful not to disrupt continuity of
the anterior rectus fasciae with the linea alba; this maneuver may be performed totally in the
preperitoneal space. If the prior celiotomy incision extends cranial to the edge of the hernia defect, the
surgeon should palpate further cranially for areas of Swiss cheese defects or areas of fascial weakness;
if found, then the retrorectus space needs to be extended beyond the upper most defect. This maneuver
may require being intraperitoneal if the preperitoneal space was transgressed previously. If there is not, 7
cm of good, solid, anterior rectus/linea alba cranial to the defect or if the defect extends to the xiphoid,
then the insertion of the posterior rectus fascia onto the anterior rectus fascia will have to be transected
up to its junction with the xiphoid (FIG 6B). Also, the preperitoneal “triangular” fat pad posterior to the
xiphoid needs to be mobilized posteriorly off the undersurface of the xiphoid for 5 cm cranially—this is
easy and is an avascular plane; this maneuver will allow the prosthesis to extend under the xiphoid and
distal sternum to maximize the cranial surface area for tissue ingrowth/fixation (FIG 6C).
FIG 5 • Extent of retrorectus space. Lateral dissection is carried out to the lateral edge of the rectus
muscle, cranially if necessary up to and anterior to the costal margin, and caudally if necessary down to
the pubis, also exposing Cooper’s ligaments if extensive fixation is necessary.
FIG 6 • Cranial dissection of retrorectus space. A. The cranial dissection is aided by placing a clamp on
the midline fascia at the cranial-most extent of the hernia defect. Next, the medial insertion of the
posterior rectus fascia into the anterior rectus fascia is transected, being careful not to disrupt the
continuity of the anterior rectus fascia with linea alba cranially. This can often be completed
extraperitoneally. B. When it is necessary to mobilize fully up to the xiphoid, the medial fascial insertions
of the posterior rectus fasciae to the lateral xiphoid are transected and the triangular fat pad posterior to
the xiphoid is mobilized posteriorly off the posterior surface of the xiphoid, allowing creation of a
subdiaphragmatic space 3 to 5 cm behind the xiphoid/distal sternum. (continued)
FIG 6 • (continued) C. Fully mobilized retrosternal space, allowing the mesh to cross the midline behind
the xiphoid.
A similar maneuver is performed caudally (FIG 7). Caudal to the semicircular line, the posterior rectus
fascia disappears, and further caudal mobilization of the retrorectus space now becomes preperitoneal. If
the prior celiotomy incision did not extend caudal to the caudal extent of the hernia defect, then this entire
maneuver can often be done extraperitoneally. If the prior fascial incision extends further caudally, the
peritoneal cavity may need to be entered. Note, any redundant peritoneum and all the hernia sac should
be preserved to allow the peritoneum to be closed deep to the prosthesis caudally. This space should be
mobilized at least 7 cm, if not 10 cm, being certain again that the overlying fascia is neither weak nor has
any Swiss cheese defects. If necessary, mobilize all the way to the pubis (and maybe even mobilize
posterolaterally to Cooper’s ligaments for additional bony points of fixation of the prosthesis if the
musculofascial tissue of the anterior abdominal wall is weak or attenuated. Note, as discussed
previously, the lateral mobilization of the retrorectus space here should be accomplished fully under
vision because it is here that the deep inferior epigastric vessels are most frequently injured.
Several caveats: First, the retrorectus space extends cranial and anterior to the costal margin; the rectus
muscle does not insert on the costal margin but rather on the ribs 3 to 5 cm cranial to the costal margin.
Second, the intercostal nerves that supply the rectus muscle and
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overlying skin course on/near the anterior surface of the internal oblique muscle lateral to the rectus
muscle but perforate into the retrorectus space at the lateralmost border of the posterior rectus fascia—
these nerves should be preserved. Third, if there has been loss of rectus muscle and the retrorectus
space is narrow, the space can be extended to the space posterior to the internal oblique muscle but
anterior to the transversus muscle. This will preserve the innervation of the rectus muscle by the
intercostal nerves which run on/within the internal oblique muscle. A posterior component separation can
be performed if necessary (see Chapter 37).
FIG 7 • During caudal dissection of retrorectus space past the semicircular line, the posterior rectus
fascia transitions to the peritoneum, and now, further caudal dissection is in the avascular preperitoneal
space. Blunt dissection continues down to and posterior to the pubis if necessary, and lateral to expose
Cooper’s ligaments medial to the external iliac vessels. Care must be taken to protect the iliac vessels
and especially the deep inferior epigastric artery and vein, which are at the lateral aspect of the rectus
muscles posteriorly; this maneuver should be done under vision.
Full mobilization of the retrorectus space should extend 5 to 7 cm cranial to the hernia defect, 7 to 10 cm
to the hernia defect, and to the lateral edge of the retrorectus space.
Reconstruction of the Continuity of the Posterior Rectus Fascia across the Midline
Every attempt should be made to reapproximate the posterior rectus fascia in the midline, not only to
isolate the retrorectus space from the viscera but also to serve as the deep fascial layer “closing” the
hernia defect (FIG 8). This maneuver may be difficult at the cranial and caudal extent of the retrorectus
space or with very wide hernia defects. If not possible to reapproximate the posterior rectus fasciae or to
cover the exposed intraabdominal visceral with autogenous tissue (redundant sac, peritoneum, or rarely
omentum), then consideration should be given to bridging this defect with an absorbable prosthetic such
as polyglycolic acid (Vicryl® mesh, Ethicon, Inc or Dexon® mesh, Covidien, Inc) posterior to the synthetic
mesh. Use of the expensive bioprosthetics for this “bridge” is not indicated, because this bridge will not
be the stable, durable part of the hernia repair.
FIG 8 • Closure of the posterior rectus fascia. The medial edges of the posterior rectus fascia are
approximated in the midline, whereas the still-intact hernia sac is pushed posterior to this closure. If the
peritoneal sac is disrupted and the posterior rectus fascia cannot be approximated in the midline, an inlay of
absorbable synthetic mesh (Vicryl mesh, Ethicon, Inc) can be used to separate the intraperitoneal content
from the permanent mesh to be placed in the retrorectus space.
Insertion of the Prosthesis

This repair is best accomplished with a meshed prosthesis. We prefer a large-pore, lightweight type,
such as ULTRAPRO™ (polypropylene, Ethicon, Inc), unless the patient is a laborer or a high-
performance athlete, in which case we choose a heavyweight mesh, such as Prolene® mesh (Ethicon,
Inc). This repair is designed for a meshed prosthesis and, because the repair is fully extraperitoneal,
there is no indication for ePTFE or a “coated” mesh—transgrowth from both the anterior and posterior
surfaces of the retrorectus space is encouraged.
We position a 12 × 12-in sheet of meshed prosthesis diagonally—this increases the craniocaudal length
available. This orientation allows a rapid and reliable fixation of each corner of the prosthesis to help in
determining the appropriate sizing of the mesh.
The mesh is fixed cranially and caudally. Cranially, a 1-cm horizontal mattress stitch is placed through the
mesh just lateral to the midline after doubling back the corner of the mesh onto itself. We use a no. 1
polydioxanone suture for nonbony points of fixation. A suture passer is inserted through a stab wound in
the skin into the retroxiphoid space (we prefer to use the more blunt, disposable Endo Close™ [Covidien,
Inc] or the Reverdin needle rather than the non-disposable metal Carter-Thomason device). The
surgeon’s hand is positioned between the entry site of the suture passer and the peritoneum to prevent
inadvertent puncture into the peritoneal cavity (FIG 9A). One end of the suture previously placed in the
mesh is grasped by the suture passer and pulled back out the stab wound (FIG 9B); this process is
repeated to withdraw the other end of the suture (FIG 9C) being certain to insert the suture passer
through the fascia about 1 cm from the first pass such that when tied together, there is at least a 1.5 cm
area of fascia incorporated in the knot. An identical suture fixation is performed on the other side of the
midline.
If the mesh extends posterior to the xiphoid, we use two permanent sutures (no. 1 polypropylene). After
placing a horizontal stitch through the mesh, the suture passer is inserted through the most caudal part of
the sternum
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rather than just through the cartilaginous xiphoid; this maneuver requires some force to push the suture
passer through the bony sternum.
FIG 9 • Fixation of prosthesis in retrorectus space. A. Laterally, a 3-mm stab wound is made in the skin
overlying the lateral-most aspect of the retrorectus space. Then, the appropriate spot in the prosthesis is
chosen before excising any redundant prosthesis. A 1-cm horizontal mattress suture is placed through
the prosthesis, leaving the ends long (˜20 cm). Next, a suture passer is placed into the stab wound and
advanced through the subcutaneous fat, anterior rectus fascia, and lateral rectus muscle into the
retrorectus space. B. One limb of the suture is then engaged in the suture passer and pulled back out the
stab wound. C. This maneuver is repeated, being cognizant of inserting the suture passer through the
anterior rectus fascia at least 1.5 cm away from the prior suture path. Multiple areas of fixation (≥7) on
each side are accomplished in similar fashion. None are tied until all the points of fixation are
accomplished.
The mesh is fixed at the caudal end of the retrorectus space. The mesh should be minimally taut but not
under tension because some amount of mesh shrinkage is expected—more if the heavyweight/small-pore
mesh is used.
If the prosthesis extends to the pubis, a permanent suture is used for mesh fixation to the pubis, leaving
about 3 cm of mesh that will extend posteriorly between the bladder and the pubis. A no. 1 polypropylene
suture on a heavy needle is first passed through the mesh and then into the bone of the pubis and back
out 1 to 2 cm from the insertion. This suture fixation is not to the periosteum but rather into the bony part
of the pubis. The needle is then passed back through the mesh 1 cm from the other end to give 1 cm of
mesh between the entry and exit points of the mesh. We use a minimum of four to five suture fixations
through the pubis and pubic tubercle and, on occasion, two or three similar sutures to the medial aspect
of Cooper’s ligaments bilaterally. As another alternative, Mitek bone anchors (DePuy, Norwood, MA) may
be used or a small passage through the pubis can be created using a bone drill. Use of a laparoscopic
tacker is not recommended and should be avoided—the fixation is not durable enough.
Once the prosthesis is sutured cranially and caudally, the fixation begins laterally. We place a Kocher
clamp
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on the medial edges of the anterior rectus fascia and bring the two sides in opposition to allow an
accurate measurement of the lateral distance from the midline for the lateral point of mesh fixation. The
mesh should be flat, without wrinkles. Start with the middle of the retrorectus space. The corners of the
mesh should be the middle of the distance from the cranial and caudal extent of the repair. A 3-mm stab
wound is then made on the anterior abdominal wall about 2 or 3 cm lateral to the lateral edge of the
retrorectus space—this provides a bit more “lateral” pull and is easier to pass the suture passer into the
retrorectus space. The mesh is folded over on itself to provide a two-layer fixation point in the mesh, and
a horizontal suture is placed. The two sutures are pulled out the stab wound individually being certain
that the two insertions of the suture passer are at least 1 cm apart on the fascia. The insertion of the
suture passer should be done fully under vision to be certain that the inferior epigastric artery/vein
complex is not injured, that the suture passer does not go through the posterior rectus fascia, and that an
exposed nerve is not incorporated in the horizontal suture.
Cranially and caudally, three additional transmural fixation sutures are placed per side.
Prior to tying down the transmural sutures, the excess prosthesis is excised. As the sutures are tied
down, the knot is pushed through the subcutaneous tissue to lie on the anterior surface of the fascia. The
surgeon’s hand should be placed in the retrorectus space to be certain that the mesh is pulled up firmly
when the knot is tied.
Once the mesh is fixed in place (FIG 10A), we put one or two closed suction drains into the retrorectus
space anterior to the mesh but posterior to the rectus muscle. The drains exit the abdominal wall cranially
rather than caudally where there are more skin bacteria (FIG 10B). The drains are removed the next day
and are there only to evacuate any blood or fluid that forms in the first 24 hours postoperatively. Because
this retrorectus space is compressed both anteriorly and posteriorly, seroma formation is rare.
Special Situations
Special situation 1. If the medial aspect of the rectus muscle has been resected or has atrophied, the
mesh can be placed lateral to the rectus muscle by developing a plane posterior to the internal oblique
muscle and
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anterior to the transversalis muscle (or even truly preperitoneal if that plane can be developed). In this
case, the transmural sutures are passed much more laterally through the external oblique
muscle/aponeurosis and internal oblique muscle.
FIG 10 • Circumferential fixation of the prosthesis. A. The prosthesis is fixed at the lateral, cranial, and
caudal edges of the retrorectus space. If necessary, the prosthesis is sewn/fixed to the distal sternum
and pubis. If the security/strength of fascial fixation is questionable cranially, the prosthesis can be sewn
to the costal margin and caudally to Cooper’s ligaments. The prosthesis should be flat and without
wrinkles but should not be taut because some shrinkage is inevitable. (continued)
FIG 10 • (continued) B. One or two closed suction drains are placed anterior to the prosthesis and
brought out cranially.
Special situation 2. If the retrorectus space extends anterior to the costal margin, we extend the mesh
into this space to maximize overlap. On occasion, the mesh can be fixed to the costal margin for added
support using a no. 1 polypropylene suture.
Closure of the Wound
Once the mesh is secured, the medial borders of the anterior rectus fascia are reapproximated anterior to
the prosthesis with a running no. 1 polydioxanone suture. Ideally, the rectus fasciae are sutured over the
mesh, even if under moderate tension. If the fascia cannot be reapproximated, then consideration should
be given to performing a components separation technique to allow autologous tissue closure over the
mesh. We try not to bridge a fascial defect with a retrorectus repair (and thus exposing the mesh to the
subcutaneous space) unless there are extenuating circumstances preventing either an intraperitoneal
sublay (covered anteriorly with the peritoneum or the hernia sac or the ability to add a components
separation technique to allow midline fascial closure) (see Chapter 37).
The subcutaneous tissue is closed with a running 2-0 polyglycolic acid suture and the skin with a dermal
(subcuticular) 3-0 polyglycolic acid suture. The stab wounds are glued with Dermabond™ (Ethicon, Inc).
INTRAPERITONEAL SUBLAY REPAIR (ALSO REFERRED TO AS INTRAPERITONEAL ONLAY
MESH)
The incision should be centered over the defect, resecting the prior incision and associated
subcutaneous scarring. Because the placement of the prosthesis will be intraabdominal, the length of the
incision needed will be determined by the amount of intraperitoneal adhesions and the ability to work
through the incision created to place the prosthesis safely.
Creation of Space for Prosthesis
Because the prosthesis will be placed intraperitoneally, there is no need to mobilize skin and
subcutaneous flaps unless a concomitant components separation is planned; thus, the peritoneal cavity
should be entered directly through the hernia sac (provided this can be done safely). The hernia sac
should not be further mobilized or resected at this time; it will be used as an autogenous tissue barrier to
close over the intraperitoneal prosthesis (as described later).
If there are no concerns about obstructing adhesions (obstructive symptoms preoperatively), the
dissection should free the intraperitoneal viscera off the posterior surface of the abdominal wall for 5 to 7
cm from the hernia defect circumferentially (FIG 11).
If the hernia defect extends to the xiphoid, a space is created under the xiphoid by mobilizing the
underlying triangular fat pad cranially for 5 cm.
If the hernia defect extends to the pubis, then the preperitoneal space posterior to the pubis is dissected
by mobilizing the space anterior to the bladder to allow fixation of the prosthesis to the bony pubis. For
large hernias, this retropubic preperitoneal space can be further mobilized to allow a broader fixation of
the prosthesis to Cooper’s ligaments on both sides.
Whenever possible, the omentum should be preserved and positioned between the posterior surface of
the
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prosthesis and the intestine—this maneuver will minimize adherence of the bowel to either the prosthesis.
FIG 11 • Intraperitoneal mobilization. The posterior surface of the anterior abdominal wall is dissected free
of any attachments of intraperitoneal content (bowel, omentum, liver) (see B). An intraperitoneal free space
is dissected 5 to 7 cm cranial, lateral, and caudal past the edges of the fascial defect.
Choice of Prosthetic
The prosthetic should allow transgrowth from abdominal wall but not adherence to the intraperitoneal
contents. Several choices are available. Prostheses made from ePTFE have been used, and there will
be no adherence of the viscera to its posterior surface, but there will also be no transgrowth into its
anterior surface—therefore, we do not suggest using an ePTFE prosthesis. Several “composite-type”
prostheses are available; these prostheses have two panels that are bound together—the anterior panel
is a meshed synthetic prosthetic (usually polypropylene or polyester) that allows transgrowth, whereas
the posterior panel is a thin layer of ePTFE that will prevent adherence of the intraabdominal viscera.
The third type of prosthesis is a meshed synthetic prosthetic (polypropylene, Dacron, or polyester) with
its underside coated (“protected”) with a nonadhesive, proprietary barrier designed by the manufacturer
to be hydrolyzed or reabsorbed in the first several days or weeks postoperatively; in so doing, this barrier
is designed to prevent the intraabdominal viscera from adhering to the posterior surface of the synthetic
mesh. In contrast, the anterior surface of the meshed prosthesis allows transgrowth from the posterior
surface of the abdominal wall.
Placement/Fixation of the Prosthesis
The prosthesis is fashioned to provide 5 to 7 cm of extension beyond the hernia defect circumferentially.
The size of the prosthesis will vary depending on whether the fascial edges of the defect will be able to
be sewn together or whether the defect will be bridged or patched; now is the time to determine this
before mesh fixation.
The mesh is sewn in place with multiple transmural sutures and not just by sewing the prosthesis to the
posterior fascial layers of the abdominal wall. It is best to start with the four “corners” to size the
prosthesis. A stab wound is made at least 7 cm lateral to the edge of the defect. Sutures are then passed
through the abdominal wall using some form of suture passer. See the details for suture placement as
described for the retrorectus repair (see FIG 9). The points of fixation require an intact fascia and not just
muscle or fat through which the suture is passed.
Attempts to fix the prosthesis to the undersurface of the abdominal wall from within the peritoneal cavity
are not as reliable; such attempts are relatively blind, and although the posterior rectus fascia can be
caught in the suture reliably, sutures placed lateral to the rectus muscle may only include the transversus
abdominis and internal oblique fasciae (and not the external oblique fascial aponeurosis) which are not
as strong or reliable for points for fixation.
We place transmural sutures at 1- to 2-cm intervals circumferentially (FIG 12). As a general rule, the
distance between the sutures should be roughly equivalent to the width of the horizontal mattress suture
bites in the prosthesis.
The goal of the suture fixation is twofold—first, to immobilize the prosthesis with a strong, stable anterior
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fixation and second, to obliterate completely any space between points of fixation where a loop of bowel
can slip between the anterior surface of the prosthesis and the posterior surface of the abdominal wall.
We stress that the transmural sutures should be placed close enough that there is no possibility that a
loop of bowel can “herniate” between these transmural sutures. An alternative technique is to place
several laparoscopic ports laterally to allow access after the wound is closed; then a laparoscopic tacker
can be used to tack down the edges of the mesh between points of suture fixation, similar to the
laparoscopic repair. We do not consider the use of a laparoscopic tacker alone without the use of
multiple closely spaced transabdominal sutures to provide an adequately fixed, durable repair.
FIG 12 • Placement of prosthesis. Using stab wounds and the suture passer (see FIG 9), multiple stab
wounds are placed at 1.5-cm intervals for placement of transmural suture fixation. Because the
prosthesis is intraperitoneal, many more areas of fixation are necessary to prevent intraperitoneal content
from slipping anterior to the mesh between the points of fixation.
For hernias that extend up to or within 5 cm of the xiphoid, the transmural fixation needs to pass directly
through—not the xiphoid—but the distal sternum into the retrosternal intraperitoneal space. We use two
permanent sutures in this region. These fixation sutures will fixate the prosthesis solidly and durably
under the xiphoid, minimizing suture pullout. Technically, this may be accomplished in a number of ways.
The Endo Close™ (Covidien Surgical) suture passer may be used, although it may become dulled or the
tip bent and may need to be replaced. Suture with a CTX or larger needle can be partially straightened
and passed through the distal sternum with some effort. The Reverdin needle is an excellent alternative,
allowing passage of suture from the internal to external direction; the sharpness and heavy body of the
instrument facilitate its use for this purpose. Again, avoid the too-sharp non-disposable metal Carter-
Thomason suture passer.
When the hernia extends caudally down to or within 5 cm of the pubis, the prosthesis should be sewn to
the pubis. We use at least four separate no. 1 polypropylene sutures on a large, heavy needle. The
needle should be passed through the bone of the pubis—not just the periosteum. If the tissues are too
dense to allow passage of the needle, a penetrating towel clamp can be used to create a small passage
through the bone or a bone drill may be needed. Alternatively, Mitek bone anchors may be used. Use of
the laparoscopic tackers is not recommended—these limited points of fixation are not reliable. An
additional 3 to 4 cm of the prosthesis can be positioned posteriorly between the bladder and the posterior
surface of the pubis.
Additional medial transabdominal fixation sutures can be placed circumferentially if there is concern about
stability of the lateral fixation sutures.
Closure of the Wound
We place one or two temporary, closed suction drains anterior to the prosthesis to encourage close
apposition of the peritoneum to the prosthesis.
The peritoneum and/or the preserved hernia sac is closed anterior to the mesh, providing an autologous
layer of tissue on top of the mesh.
The fascial edges of the hernia should be reapproximated. If there is tension, relaxing incisions or
components separation should be contemplated to allow for fascial closure. To restore anatomic position
of the abdominal wall musculature, close the fascial defect, and provide another layer of autogenous
tissue over the prosthesis. Alternatively, a more “closed” type of components separation, either
“laparoscopic” or “minimal incision,” perforator-sparing type can be performed understanding that these
approaches will only yield 3 to 4 cm of a medial advancement on each side (see Chapter 37). If the edges
of the fascia cannot be reapproximated, one can bridge the defect with an inlay of absorbable mesh of
polyglycolic acid using Dexon™ (Covidien Surgical) with the aim of temporarily relieving the tension on
the lateral fixation points. Use of second layer of a permanent synthetic prosthetic is not indicated
because the hernia repair has already been accomplished with the intraperitoneal permanent prosthesis.
Use of the
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expensive bioprostheses is discouraged because of prohibitive cost (versus the temporary absorbable
mesh) and the lack of defined efficacy either in relieving lateral tension or equally important as providing
a durable, onlaytype patch repair.
The incision is then closed with a running 2-0 polyglycolic suture and the skin with a running 3-0
polyglycolic acid dermal suture. The stab wounds are glued with Dermabond™ (Ethicon, Inc).
COMBINED RECTUS ROLLOVER/COMPONENT SEPARATION WITH PROSTHESIS UNDERLAY
General Considerations
This is a combination of several techniques to provide maximal medial reapproximation of the
musculoaponeurotic walls. It is particularly useful for large midline defects when the abdominal wall
musculature is largely intact. Closure of defects up to 15 cm in width are possible with this combination
technique.
The rectus rollover is a modification of a components separation technique. The anterior rectus
sheaths are incised vertically just medial to their lateral borders along their entire length. The anterior
rectus sheaths are then dissected off the muscle to a point 2 cm lateral to the medial edge of the
rectus muscles. During suturing, the sheath is rolled anteromedially (FIG 13).
The external oblique can be incised vertically just lateral to the rectus sheath as done for components
separation (see Chapter 37).
An underlay prosthesis is placed intraperitoneally, preperitoneally, or retrorectus and secured with
interrupted, transabdominal, horizontal mattress sutures.
Skin flaps are raised off the musculoaponeurotic walls bilaterally as for the wide onlay technique. Care
must be taken to not incise or buttonhole the fascial layers, but no fat should remain on the
musculoaponeurotic wall.
A vertical incision is made in the anterior rectus sheath, about 1 cm medial to the lateral border (see FIG
13). The anterior rectus sheath is mobilized off the anterior surface of the rectus abdominis with
electrocautery progressing in a medial direction to about 2 cm lateral to the medial border of the rectus
muscles.
A components separation division of the external oblique can then be created laterally, if needed, using a
vertical incision of the external oblique about 1 to 2 cm lateral to the lateral border of the rectus sheath
(see Chapter 37).
An underlay prosthesis is chosen based on the principles outlined earlier in this chapter. Sizing is to
provide an overlap of at least 5 cm circumferentially; ideally, the prosthesis will be sutured just outside
the lateral border of the rectus sheath. Horizontal mattress sutures are placed using a large needle such
as a CTX or a suture passer. The width of the horizontal mattress sutures should be about 1.5 cm, and
the spacing of the sutures should be the same.
Once all sutures have been placed, the prosthesis is snugged up to the abdominal wall. If the prosthesis
is placed intraperitoneally, the prosthesis is carefully examined to make certain no intraabdominal
contents have slipped between the sutures; this is done repeatedly as the sutures are pulled up and tied.
The fascia is then approximated in the midline using a running horizontal mattress suture; we prefer a no.
1 looped polydioxanone suture for this step. Bites are taken after medializing the anterior rectus sheath
(FIG 13); they should reapproximate the rolled-over edges of the anterior rectus fascia in the midline.
When completed, very near normal anatomy is restored, although the rectus muscles will not be
approximated (FIG 13).
FIG 13 • Completed intraperitoneal sublay with anterior rectus rollover fascial closure. Note medial edges of
rectus muscles not approximated.
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FLANK HERNIAS
General Considerations
Flank hernias (after a flank incision, such as kidney/ureter or anterior spinal access procedures) are
different functionally from most incisional hernias, as they have higher recurrence rates. Flank
pseudohernias are bulges in the musculofascial components of the lateral abdominal wall secondary to
denervation and should be noted prior to operation with a CT because surgical bolstering of
pseudohernia have not yielded satisfactory results.
Repair of a flank hernia is not as straightforward as repair of midline incisional hernias; the points of
fixation of the prosthesis are not as reliable. Although onlays and sublays (intramural or intraperitoneal)
have been described, we believe strongly that for these difficult hernias, an intramural, synthetic mesh-
based repair is best because it provides the most durable and reliable fixation of the prosthesis.
Step 1: Patient Positioning
If the hernia is located more medially and does not extend past the anterior axillary line, the patient is
placed in a “modified lateral” position with the ipsilateral side rotated medially to allow free access to as
far posteriorly as the posterior axillary line (FIG 14A).
If the hernia extends further laterally, then a full lateral position (FIG 14B) is necessary to allow access to
the posterior midclavicular line posteriorly.
Step 2: Development of Intramural Space
The prior skin incision should be excised down to the hernia sac. Unless necessary, try to stay
extraperitoneal.
Next, a plane is developed posterior to the internal oblique muscle but anterior to the transversalis
muscle (FIG 15). Attempts to stay in the preperitoneal space cranially can be difficult; caudally, this space
is much easier to develop. The goal is to create a space with a large surface area in which to place a
synthetic, meshed prosthesis. The space is mobilized to the costal margin cranially, as far laterally as
possible (posterior axillary line), to the anterior superior iliac crest caudally and to the lateral edge of the
rectus muscle medially.
If the hernia extends to the lateral edge of the rectus muscle, then the retrorectus space can be entered
and mobilized to the midline. The prosthesis lies between the very vascular internal oblique and
transversalis muscles to maximize transgrowth. This space is better vascularized than the preperitoneal
space.
Step 3: Fixation of Prosthesis
Once the intramural space has been mobilized with at least a 7- to 10-cm margins from the hernia defect,
the
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meshed prosthesis is fixed with transmural sutures. As described for ventral incisional hernia repairs
previously, multiple horizontal sutures of no. 1 polydioxanone are placed along the edge of the
prosthesis. Stab wounds are positioned at the extent of the space mobilized (FIG 15). Using a suture
passer, the ends of the sutures are separately grasped and tied down onto the surface of the abdominal
wall fascia. Because the mesh is placed intramurally, there is no concern for bowel becoming entrapped
between these sutures, thus the number of sutures should be determined by the quality of the tissue. If
the anterior fascia is weak or attenuated, the space needs to be developed further (see later “Special
Situations”).
FIG 14 • Positioning of patient for a flank herniorrhaphy. A. When the hernia/bulge does not extend lateral
to the anterior axillary line, the patient is placed in a “sloppy” lateral position allowing access to the posterior
axillary line. B. For defects extending to the midaxillary line, a true lateral position is necessary to allow
access to the posterior midclavicular line.
FIG 15 • Dissection of intramural space. The space between the internal oblique muscle and the
transversalis muscle/fascia (see insert) is created up to the costal margin cranially, laterally at least 7 to 10
cm, caudally to iliac crest, and medially to lateral border of the rectus muscle.
Step 4: Closure of the Wound

A closed suction drain is placed anterior to the mesh brought out cranially.
The muscle and/or weakened fascial layers anterior to the mesh are reapproximated with a running
absorbable suture; the subcutaneous tissue and skin incision are closed with absorbable suture. All the
stab wounds can be glued with Dermabond™ (Ethicon, Inc).
Special Situations
Fixation to costal margin: When the musculofascial tissue cranial to the defect is attenuated or the
overlap is not at least 5 to 7 cm, the prosthesis can be sewn to the costal margin (FIG 16). We use no. 1
polypropylene sutures through and not around the rib; this provides a stable cranial fixation.
Fixation to iliac wing: A more common problem is when the musculofascial tissue caudal to the defect is
attenuated or retracted such that the overlap is inadequate; in this situation, we sew the edge of the
prosthesis to the anterior iliac spine and the more medial “wing” of iliac bone with no. 1 polypropylene
sutures; these sutures pass through the bone and not just in the periosteum (FIG 16). The sutures can
be placed from within the space created for the prosthesis; but this maneuver takes a bit of force. For
very young or large men, we have made an incision in the skin directly over the anterior iliac spine,
dissected down to the bone, and used a bone drill through this bone and into the intramural space.
Inadequate tissue medially and caudally: Often, the area medial to the anterior iliac spine is very
attenuated. In this situation, we will dissect into the preperitoneal space down to Cooper’s ligament and
the pubic tubercle behind the inguinal canal. These bony areas can serve as very stable points of medial
and caudal fixation of the prosthesis, again with no. 1 polypropylene sutures into and through the bone
(FIG 16).
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FIG 16 • Fixation of prosthesis. The prosthesis is fixed to the anterior fascia at the edges of the intramural
space created, again using multiple stab wounds and a suture passer. The prosthesis can also be sewn to
the costal margin cranially and the iliac crest caudally for a more secure fixation. For large flank hernias
extending medial to the lateral edge of the rectus muscles, the retrorectus space can be opened to
communicate with the intramural space created laterally. The cranial and caudal edges of the fascial defect
are then sewn together to cover the prosthesis.
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PEARLS AND PITFALLS
Indications ▪ Despite lack of systemic symptoms, an acute, nonreducible, incarcerated

incisional hernia is an indication for urgent exploration/repair.
▪ Review all previous operative notes—surprises in the operating room (OR) are
usually not welcome.
▪ When repairing a flank hernia, warn the patient that there may still be a bulge.
Even with a “successful” repair, these patients can be the least happy
postoperatively of all patients after repair of an incisional hernia.
▪ Heavy laborers or high-performance athletes will do better with abdominal wall

reconstruction (restoration of musculofascial continuity) rather than a
laparoscopic patch repair.
▪ For patients with lung disease or those with a history of pain intolerance, consider
postoperative epidural analgesia or a “one-shot” intrathecal analgesia.
Choice of ▪ Currently, there are no biologic prosthetics that provide as good a long-term
prosthetic outcome as a synthetic prosthetic.
▪ Large pore/lightweight, small pore/heavy weight, and ePTFE all have their
advantages/disadvantages. There is little, if any, role for ePTFE for onlay or
Rives-Stoppa sublay repair. A protected or “covered” meshed prosthesis of
polypropylene, Dacron, or polyester with a layer of either a rapidly absorbable
biologic barrier substance (to prevent visceral adherence) or ePTFE facing the
viscera for an intraperitoneal repair is preferable to a pure ePTFE because there
is no functional ingrowth into ePTFE. The classic role for ePTFE is when the
prosthesis needs to be watertight—for example, in the very rare patient with
ascites.
▪ For laborers or serious athletes, the small-pore/heavyweight prostheses will give

more support, but plan for 25%-30% shrinkage in size of the mesh.
▪ If the patient has developed suture granulomas in the past to permanent sutures,
avoid their use— suture granulomas predispose to superinfection.
Exploration ▪ When an unexpected suture granuloma is encountered during the incision,

of hernia consider aborting the procedure for worry of indolent, inactive bacterial
defect colonization unless you can excise the entire area (i.e., the suture, the associated
biofilm, and the cavity/wall are intact). Remove all foreign sutures, culture the
area, and use a 2-week course of focused antibiotics postoperatively—we
acknowledge that we have no evidence that this treatment is effective.
▪ Always look for a Swiss cheese defect along the prior fascial incision distant from
the presumed “isolated” hernia defect.
▪ When performing a Rives-Stoppa, retrorectus sublay repair in a patient who has

had a prior enterostomal takedown (e.g., after takedown of a Hartmann
procedure), be aware that a knuckle of bowel may protrude through a defect in
the posterior rectus fascia.
▪ If the patient has had a recent history of recurrent partial small bowel obstruction,
consider an intraperitoneal adhesiolysis in addition to the hernia repair.
▪ Weeks to several months after a prior incisional herniorrhaphy, point tenderness

laterally may be secondary to a suture granuloma at a fixation point. If possible,
inject a local anesthetic to “buy time” and wait for the suture to be reabsorbed. If
symptoms persist, locally explore that area and remove the suture.
Early ▪ Should a symptomatic seroma develop within the first postoperative month,
postoperative repeated percutaneous aspiration may prevent rupture through the incision and
seroma subsequent risk of superinfection of the prosthesis. If the seroma persists, then
consider a percutaneous drain. Nonresolving “seromas” usually represent the
development of a pseudobursa lined with mesothelial cells that produce fluid—if
large and symptomatic, these require operative excision of the entire lining. If the
seroma is asymptomatic, consider not intervening.
▪ When placing lateral fixation sutures, it is possible to encircle a somatic nerve—

the resulting early (1 day postoperatively) and persistent pain will follow the
dermatome or the distribution of the nerve—for example, intercostal,
genitofemoral, or circumflex iliac nerve—and may require early removal of the
offending suture, even prior to discharge.
Placement of ▪ For intraperitoneal sublay repairs, the surgeon should ALWAYS have his/her
fixation hand between the posterior surface of the prosthesis and the abdominal viscera
sutures when the sutures are tied. Likewise, there should be NO laxity or space between
fixation sutures or tacks.
POSTOPERATIVE CARE
Most patients will not need a nasogastric tube, but in extended complex repairs, especially with an
accompanying adhesiolysis, gastric decompression may be advisable.
The timing of removal of subcutaneous drains is controversial—drains serve as sites of potential bacterial
contamination, yet drains may minimize formation of seromas/pseudobursa. When placed intraperitoneally on
the anterior surface of prosthesis or in the retrorectus space, they should be removed early (1st postoperative
day). When placed subcutaneously after an extensive, subcutaneous flap mobilization, one must weigh the
risk of infection versus that of seroma when deciding to remove the drains. No evidencebased suggestions
can be offered.
OUTCOMES
Recurrence rates with these types of elective repair for anterior abdominal wall hernias (midline or
transverse incisions) should be less than 10% to 15% range. Many factors adversely affect recurrence
rates, such as multiple prior repairs, hernia size, impaired healing (steroid use, active smoking,
chemotherapeutic agents, obesity, etc). “Recurrences” for flank hernias are greater—note the recurrence
to the patient may be a “bulge” rather than a true musculofascial/prosthetic defect—preoperative
counseling of this possibility and intraoperative planning of the appropriate tension and secure placement
of fixation of the prosthesis will minimize this possibility.
Early or late (even years later) infection of the prosthesis occurs in ˜3% of patients. Prior wound
infections, usually with Staphylococcus species and especially methicillinresistant Staphylococcus
aureus (MRSA), appear to increase the risk of prosthetic infection. Whether preoperative clearance of
nasal, vaginal, and rectal MRSA colonization is effective is unproven.
Postoperative, subcutaneous wound infections require immediate, aggressive treatment to prevent
underlying infection of the prosthesis, even if there is autogenous tissue between the prosthesis and the
subcutaneous space.
A nonreducible bulge/mass that develops directly under the incision with the first 6 weeks is likely a
seroma and often does not require further investigation; ultrasonography will differentiate seroma from
recurrence. Not all seromas require intervention, and many will reabsorb over time. Cognizance of this
possibility will prevent unnecessary aspiration or especially placement of a drain, both of which can
introduce bacteria and secondary infection. Fever, pain, increase in size, or nonresolution warrant
aspiration.
COMPLICATIONS
Bleeding/hematoma—usually contained
Seroma—appears within first several weeks postoperatively; if persistent for weeks or months, suspect
formation of a mesothelial-lined pseudobursa. These are more common with an onlay prosthesis,
especially ePTFE or when the herniorrhaphy is combined with an abdominoplasty.
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Subcutaneous wound infection—˜2% to 5% but depends on extent of lateral dissection
Skin necrosis at medial edge of incision after wide lateral mobilization of a skin/subcutaneous flap; with
an abdominoplasty, minor wound problems may approach 40%.
Prosthetic infection, both early (first 2 months) or late (months to years later)—3%
Recurrence—approximately 10% to 15%; often, the recurrence is at the cranial or caudal end of the prior
hernia defect
Radiculopathy from a somatic nerve trapped by a fixation suture, though rare, can complicate an
abdominal wall reconstruction.
Suture granuloma at fixation site
Small bowel obstruction from the intraperitoneal part of the hernia mobilization and prosthetic placement
of the prosthesis; the obstruction is either related to adhesions or rarely between adjacent fixation points
if the space left was too large or too loose. In theory, the fixation suture can trap a loop of bowel within
the suture—this should lead to a very early obstruction 1 or 2 days postoperatively.
Unrecognized enterotomy at the time of hernia repair
REFERENCES
1. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for
incisional hernia. N Engl J Med. 2000;343:392-398.
2. Sanders DL, Kingsnorth AN. The modern management of incisional hernias. Br Med J. 2012;344:37-42.
3. Iqbal CW, Pham TH, Joseph A, et al. Long-term outcome of 254 complex incisional hernia repairs using
the modified Rives-Stoppa technique. World J Surg. 2007;31:2398-2404.
4. Kingsnorth AN, Shahid MK, Valliattu AJ, et al. Open onlay mesh repair for major abdominal wall hernias
with selective use of components separation and fibrin sealant. World J Surg. 2008;32:26-30.
5. Poelman MM, Langenhorst BLAM, Schellekens JF, et al. Modified onlay technique for the repair of the
more complicated incisional hernias: single-centre evaluation of a large cohort. Hernia. 2010;14: 369-374.
6. Stoppa R, Louis D, Henry X, et al. Postoperative eventrations: apropos of a series of 247 surgically treated
patients. Chirurgie. 1985;111: 303-305.
7. Sakorafas GH, Sarr MG. Intraparietal retrorectus tension-free prosthetic mesh: a simple and effective
method of repair of complex ventral hernias via a modified Stoppa technique. Surgical technique. Acta Chir
Belg. 1999;99:109-112.
8. Petersen S, Schuster F, Steinbach F, et al. Sublay prosthetic repair for incisional hernia of the flank. J
Urol . 2002;168:2461-2463.
9. Burger JWA, Luijendijk RW, Hop WCJ, et al. Long-term follow-up of randomized controlled trial of suture
versus mesh repair of incisional hernia. Ann Surg. 2004;240:578-585.
10. Flynn DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? Ann
Surg. 2003;237:129-135.
11. Mudge M, Hughes LE. Incisional hernia: a 10-year prospective study of incidence and attitudes. Br J
Surg. 1985;72:7-71.
12. Van der Linden FT, van Vroomhoven TJ. Long-term results after surgical correction of incisional hernia.
Neth J Surg. 1988;40:127-129.
Chapter 36
Incisional Hernia: Laparoscopic Approaches
Todd Heniford
Kristopher Williams
DEFINITION
Incisional hernia is defined as any abdominal wall defect occurring at the site of previous operation or
scar. Laparoscopic incisional hernia repair uses prosthetic mesh reinforcement, much like as originally
described by Stoppa,1 applied through minimally invasive operative techniques with reliable success.2
Incidence of incisional hernia following laparotomy exceeds 20% with over 2 million laparotomies
performed in the United States annually, a factor contributing to the estimated 348,000 ventral hernia
repairs in 2006.3,4
Recurrence rates for primary suture hernia repair have been reported to be as high as 54%,5 which have
been reduced by more than half with the use of mesh reinforcement.6,7
Diastasis recti
Seroma
Hematoma
Hypertrophic scar
Desmoid
Abdominal scar endometrioma (at sites of previous cesarean or hysterectomy incisions)
Soft tissue sarcoma

A detailed general health history should be obtained including past medical history, current medications,
allergies, social habits (alcohol, illicit drug use, smoking history) as well as previous adjuvant treatments,
which may impact any attempt at operative repair (e.g., previous pelvic or abdominal radiation). Consideration
of other common abdominal pathology, such as symptomatic cholelithiasis or colon cancer, may need
evaluation prior to hernia repair and results should be documented.
A detailed history regarding obstructive symptomology (nausea, vomiting, passage of flatus, bowel frequency,
abdominal pain) the patient may have experienced in the recent or distant past should be recorded.
For all patients undergoing evaluation of incisional hernia, medical records should be obtained and reviewed,
emphasizing surgical history and operative reports from previous pertinent surgeries and hernia repairs.
Attention should be directed toward specifics of previous abdominal operations, especially hernia repairs:
anatomic location of initial hernia defect, previous attempts at hernia repair, presence and type of previously
placed mesh, location of any previously placed mesh (intraperitoneal, preperitoneal, retrorectus, fascial onlay,
etc.), method of mesh fixation, and previous operative complications. Also, the extent of previous skin and
subcutaneous dissection and the presence and extent of a components separation can be very helpful.
The presence of comorbidities known to be associated with increased risk of postoperative wound
complications or recurrence (current or smoking history, obesity, diabetes, immunocompromised status,
cirrhosis, chronic obstructive pulmonary disease [COPD], current or chronic infections such as urinary or
pulmonary infection, history of previous mesh or other methicillin-resistant Staphylococcus aureus [MRSA]
infections), as well as any history of previous or current wound infections and any current abdominal wall
wound issues should be noted.
A complete physical exam should be performed paying particular attention to the existence and location of
abdominal scarring, nonhealing wounds, erythema that may indicate deeper pathology, identification of any
abdominal wall defects (either incisional or primary), presence and nature of hernia contents within defects,
reducibility of hernia contents, and tenderness to palpation of noted defects. Fascial defect size should be
estimated to aid in preoperative planning.
Other physical findings or review of symptoms points may alert a surgeon to medical issues that require
workup prior to surgery, such as heart failure, COPD, vascular disease, liver or kidney disease.
A thorough examination should be performed looking for the existence of other potential hernia sites (umbilical,
inguinal, femoral, parastomal, etc.), which may be addressed at the time of surgery. By neglecting other
potential hernias, the opportunity to repair them at the same time as the primary hernia may be lost.
The presence of a gastrointestinal stoma, active wound infection, or chronic draining sinus tracts should also
be taken into account, as these situations influence operative planning, risk counseling, and may influence an
open versus a laparoscopic repair. A laparoscopic repair with synthetic mesh placement is not appropriate for
an actively infected field.
The presence of peritoneal signs (abdominal rigidity, guarding, rebound tenderness) should alert the surgeon
to the likelihood of intraabdominal issues and may mandate an emergent laparotomy.

Although physical exam is the gold standard of diagnosis, obese body habitus, abdominal scarring, and the
presence of previously placed mesh may preclude physical diagnosis of an incisional hernia. For these
reasons, computed tomography (CT) is a valuable tool for diagnosis and operative planning in cases of a
suspected incisional hernia (FIG 1).
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FIG 1 • CT incisional hernia. A 51-year-old female with multiple gastric revisions since undergoing original
gastric bypass, eventually resulting in completion gastrectomy. CT shows 7-cm incisional hernia defect
containing normal-caliber small bowel with intraluminal contrast.
Advantages of CT imaging for the evaluation of incisional hernias are multifactorial: accurate diagnosis in
cases of obscure or small defects; proper identification of hernia contents (small bowel, colon, solid organs,
omentum, etc.); definition of defect size; location of previously placed mesh; distinction from other or
concomitant potential diagnoses (seroma, abscess, hematoma, etc.); identification of bowel incarceration;
obstruction or possible ischemia, necrosis, or perforation; and planning of where to enter the abdomen safely.
When feasible, it is helpful for the operating surgeon to review the actual CT images, as the information
discussed earlier may not be included in a radiologist’s reading of the films. It is also helpful to have CT
images available to be viewed intraoperatively as they can serve as a reference during the operative
procedure.
Colon cancer screening with colonoscopy or other appropriate means is often considered for those patients
who have reached appropriate age for screening, have a significant family history, or other colonic symptoms
prior to hernia repair.
SURGICAL MANAGEMENT
For elective procedures, in the weeks leading up to repair, attempts should be made at optimization of
preoperative patient factors associated with increased risk of postoperative wound complications: smoking
cessation, evaluation and maximization of nutrition status, tight blood glucose control, weight loss in the
obese, or elimination of open wounds through local wound care.8
Appropriate intravenous antibiotic prophylaxis should be administered prior to incision and repeated as
needed to provide adequate prophylactic coverage depending on length of procedure and drug half-life.9
Venous thromboembolism prophylaxis should be provided, such as lower extremity serial compression devices
or subcutaneous prophylactic dose heparin prior to induction of anesthesia, assuming no contraindications.9
Following induction of anesthesia, the abdominal wall is reexamined to confirm the borders of the defect in
question and to identify the presence or location of previous mesh, signs of infection, or other issues.
Intraoperative urinary and gastric decompression are recommended.
Iodophor-impregnated adhesive skin drape may be used to minimize mesh contact with skin surfaces and
therefore reduce the risk of mesh infection, although this has not been proven in randomized clinical trials.
Positioning
The patient should be positioned supine with arms adducted and tucked at sides of body with adequate
padding of pressure points to avoid neurologic pressure injury. This allows movement of the surgeon and the
assistant on each side of the table during the operation (FIG 2).
Semilateral or lateral decubitus position may be favored for repair of flank or lumbar hernias.
The patient should be secured to the operating table to allow steep positioning or rolling of the table as
required during the procedure.
Laparoscopic monitors should be positioned over the working space to allow direct vision by both the primary
surgeon and assistant.
FIG 2 • Patient positioning. The patient is placed supine on the operating table with arms adducted and monitors
positioned toward the head of the table. The surgeon stands on either side of the patient, depending on hernia
location, with the assistant directly opposite.
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TECHNIQUES
INITIAL ACCESS
A safe window of intraperitoneal access is usually available in areas distant from site(s) of previous
surgery, although an open, “cut-down” technique can be performed near or within a hernia if the surgeon
prefers.
Often, safe entry is found just inferior to the tip of the 11th rib, between midclavicular and anterior axillary
lines (FIG 3).
Open cut-down technique is most often performed with identification of individual abdominal wall layers
as each is entered, but some surgeons use a port that allows visualization of the abdominal wall layers
with the laparoscope as the trocar is slowly advanced into the abdomen.
Pneumoperitoneum is established at 12 to 15 mmHg.
FIG 3 • Initial port placement. Safe areas of initial trocar placement via the cutdown technique are often
found just inferior to the 11th rib between the midclavicular line and the anterior axillary line.
PLACEMENT OF WORKING PORTS

Using an angled (30- or 45-degree) scope, a brief general inspection of the abdominal cavity checking for
organ injury, which may have occurred during initial access, is performed.
Working port placement is based on target defect location, optimization of working space, and
triangulation of working instruments, if possible. Ports that are too far caudal or cephalad may limit
freedom of motion of the port due to the hip or rib cage (FIG 4).
Ideal port placement allows sufficient working space between ports and target defect. The distance
between individual ports should allow a range of motion that prevents ports from colliding or limiting
motion. Ports should not be too close to the hernia defect as this limits visualization for mesh placement
or mesh fixation.
Additional 5-mm trocars are placed under direct visualization (FIG 5).
Often, two 5-mm trocars are placed laterally on same side as initial access port, usually between anterior
and midaxillary lines.
One or two 5-mm trocars can be placed on the contralateral side of initial access port for adhesiolysis or
to facilitate mesh fixation.
FIG 4 • Working port triangulation. Figure A shows diagrammatic representation of working triangulation to
target defect. Figure B is an intraoperative view of working ports.
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FIG 5 • Port sizes and position. Positioning of initial 10-mm port and 5-mm working ports for midline
periumbilical incisional hernia. Two 5-mm ports are placed on the ipsilateral side of initial access and a
single 5-mm port is placed on the contralateral side.
LYSIS OF ADHESIONS AND DEFINITION OF HERNIA DEFECT

Pneumoperitoneum assists in dissection as countertraction is provided by weight of dependent omentum
and bowel to expose safe tissues planes (FIG 6).
Meticulous lysis of adhesions is performed using sharp dissection with minimal judicious electrocautery to
avoid thermal spread and bowel injury (FIG 7).
The majority of operative time is often spent performing the adhesiolysis. An enterotomy can increase the
risk of mesh infection and, in cases of gross spillage, placement of prosthetic mesh is contraindicated. A
bowel injury may result in the need for conversion to an open procedure, may necessitate the use
biologic mesh or hernia closure without mesh, or the need for staged repair.
Freeing the adhesions along the entire length of incision often allows the surgeons to identify all defects
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(“Swiss cheese” or buttonhole abdominal wall defects), which otherwise may have gone unnoticed and
therefore unrepaired (FIG 8).
FIG 6 • Lysis of adhesions. Pneumoperitoneum assists in dissection.
FIG 7 • Lysis of adhesions. Meticulous adhesiolysis performed to expose entire length of incision.
FIG 8 • Swiss cheese defect. Multiple defects can be seen following complete exposure of incision
length.
Hernia contents can be reduced by applying gentle traction using nontraumatic graspers.
Simultaneous external manual compression of the hernia sac is helpful in reducing contents (FIG 9).
The hernia sac is left in situ.
The hernia defect edges are measured externally and marked on patient’s skin.
FIG 9 • External manual reduction. External pressure applied to abdominal wall can aid in intraoperative
reduction of hernia contents.
Length and width of the abdominal wall defect is precisely measured intraabdominally using a narrow
plastic disposable ruler introduced through a port.
A spinal needle is used to penetrate the abdominal wall along the internally visualized defect edges to
accurately define boundaries (FIG 10).
The falciform ligament and umbilical ligaments may be taken down to allow flush placement of mesh
against anterior abdominal wall.
FIG 10 • Measurement of defect. Figure A shows diagrammatic representation of defect measurement using
a narrow disposable ruler and spinal needles to define exact borders. Figure B shows intraoperative defect
measurement.
MESH PREPARATION AND INTRAPERITONEAL INTRODUCTION

An appropriately sized sheet of mesh is chosen and tailored to overlap defect edges by minimum of 4 to 6
cm circumferentially. Proper mesh to fascia overlap allows for even distribution of intraabdominal forces
across peritoneal surface of the mesh and aids in holding the mesh in place according to Laplace’s law
(FIG 11).10
Use of a mesh product constructed with a visceral adhesion barrier to prevent the formation of future
adhesions is highly recommended.
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For large single defects, greater mesh to fascia overlap is recommended to resist intraabdominal forces
acting to push the mesh through the defect.
It may be necessary to sew multiple sheets of mesh together in order to fashion a single sheet large
enough to provide adequate defect coverage (FIG 12A).
FIG 11 • Intraabdominal forces on mesh. The intraperitoneal mesh is held in place by the intraabdominal
forces acting to push the mesh against the abdominal wall as long as sufficient mesh/defect overlap of 4
to 6 cm is obtained.
Size 0 or 1 permanent, monofilament sutures are placed at the midpoints of each side of the tailored
mesh (FIG 12B).
Corresponding points of reference are marked on the external abdominal wall to allow proper orientation
once the mesh is placed intraabdominally (FIG 13).
FIG 12 • Tailoring of mesh. Mesh is fashioned to provide 4 to 5 cm of mesh/defect overlap and

permanent sutures are placed at the midpoints of mesh edges. Multiple pieces of mesh may be stitched
together to obtain a final mesh of sufficient size as seen in Figure A. Figure B shows the placement of
midpoint sutures along the edges of the mesh.
FIG 13 • Orientation of mesh. Figure A shows how the external abdominal wall is marked to ensure
proper orientation of mesh placed inside the abdominal cavity. Figure B shows the mesh overlying the
marked external abdominal surface.
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Mesh is then rolled from opposing edges in scroll-like fashion (which facilitates intraabdominal unfolding)
and compressed to allow passage through trocar site (FIG 14).
Using a grasper from the contralateral port site, the rolled, compressed mesh can then be pulled
intraabdominally (FIG 15).
Using two graspers, the mesh is unfurled within the peritoneal cavity. This is simplified by holding the
center of the mesh with one grasper while pushing the rolled edge with second grasper.
FIG 14 • Rolling of mesh. Mesh is rolled in a scroll-like fashion from opposite sides inward to allow passage
through trocar site.
FIG 15 • Introduction of mesh. Rolled mesh can be pulled intraabdominally from the contralateral 5-mm port
site.
FIXATION OF MESH
The mesh is properly oriented based on previously marked points of reference.
Previously placed sutures (at midpoints along edges of mesh) are brought through the abdominal wall
using a suture passer device under direct laparoscopic vision. Through the same skin incision, the suture
passer enters the fascia in two locations a centimeter apart to create a fascial bridge between the tails of
suture resulting in a full-thickness abdominal wall “bite” (FIG 16).
It is recommended that the first suture to be passed transfascially be the one closest to a structure of
potential concern (xiphoid, pubis, iliac crest, costal margin, stoma, etc.) to allow for optimal view of the
structure(s) in question.
Each suture is passed with identical technique.
The transfascial sutures are pulled taut to confirm accurate mesh positioning, defect coverage, and to
ensure that the mesh is taut against the abdominal wall at the time of fixation. Repositioning of previously
marked reference points may be required to ensure proper mesh placement. It is very important that the
mesh be tightly stretched across the abdominal wall; if the mesh is loosely applied, it will balloon out into
the defect and result in the appearance of a recurrence.
The initial two transfascial sutures are tied.
The position of the mesh is rechecked prior to tying the remaining sutures.
Using a 5-mm laparoscopic tacking device, the mesh perimeter is stretched out and secured into place by
placing
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tacks no further than 1 cm apart to prevent bowel herniation between the mesh and abdominal wall. The
tacks are also close enough to the mesh edge to prevent folding of the mesh. Placement of tacks is
facilitated by external manual palpation of the tip of the tacking device (FIG 17A).
FIG 16 • Suture passer technique. Previously placed permanent sutures along the mesh edges are
brought through the abdominal wall using a suture passer device.
A second row of tacks placed just inside the first row (“double crown” technique) is used by some
surgeons to ensure there is no sagging of the mesh and to eliminate “dead space” between the mesh
and abdominal wall (FIG 17B).
Additional full-thickness 0-0 transfascial sutures are placed every 4 to 8 cm circumferentially using the
suture passer device (FIG 18). Larger defects require additional suture fixation to limit the mesh from
eventrating into the fascial defect.
After individual sutures are tied, the subcutaneous tissues and skin overlying the transfascial suture
knots should be released using upward traction with a hemostatic clamp to avoid dimpling of the skin.
Laparoscopic inspection of the abdominal cavity is performed to ensure adequate defect coverage
(proper mesh position, attachment, and mesh/fascia overlap), hemostasis at areas of adhesiolysis, and
that no bowel injury occurred.
FIG 17 • Tacking technique. Accurate placement of tacks is facilitated by external palpation of the tacker tip
as seen in Figure A. Figure B shows completed defect coverage with two rows of tacks in place to eliminate
sagging of the mesh.
FIG 18 • Full-thickness suture technique. Additional fullthickness transabdominal sutures are placed every 4
to 6 cm along the edge of the mesh using the suture passer device.
CLOSURE
Fascia for all size 10-mm or larger port sites is closed with an adequate absorbable suture either
externally or by using the suture passer device and laparoscopic visualization.
Skin incisions overlying all port sites are often closed with size 4-0 absorbable suture and covered with
sterile dressings or skin adhesive.
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PEARLS AND PITFALLS
Preoperative ▪ Preoperatively, review CT images as available.

imaging
▪ Images should be available for reference during procedure.
Port placement ▪ Improper triangulation of working ports to target defect leads to inefficient
working space and increases level of procedural difficulty.
▪ Placing ports too close to the hernia leads to added difficulty in mesh
placement and may result in mesh covering working ports.
Bowel injury ▪ Gross contamination or large enterotomies likely requires conversion to open
during procedure procedure and possibly the need for a staged repair or the use of biologic or
biosynthetic mesh.
▪ If little or no contamination is present and the enterotomy is small, primary

laparoscopic repair may be acceptable with either immediate (no
contamination) or delayed (significant contamination) herniorrhaphy.
Mesh placement ▪ Inadequate fixation of mesh edges risks folding of mesh and subsequent
recurrence.
▪ Insufficient mesh/defect overlap (4 to 5 cm) or lack of appropriate fixation may

lead to repair failure.
▪ Not fixating the mesh so that it is taut across the abdominal wall risks
eventration of mesh into the hernia sac after desufflation.
Unrecognized ▪ Examination of patients to diagnose an unrecognized bowel injury early in the

bowel injury postoperative course
Failure to close ▪ Risks future port site hernia and possible bowel incarceration
larger port sites
(10 mm or
greater)
POSTOPERATIVE CARE
Patients are monitored postoperatively as for standard laparoscopic procedures and either discharged same
day or admitted, depending on presence of significant comorbidities, recovery from anesthesia, and adequate
pain control.
Pain control measures should be initiated in the immediate postoperative period and continued 1 to 4 weeks
following surgery as dictated by clinical assessment during follow-up.
OUTCOMES
In a large series of 850 laparoscopic ventral hernia repairs performed spanning 9 years and an average
of 20.2 months of follow-up, an overall complication rate (13.2%) was observed; the most common of
which being prolonged ileus (3%) and seroma (2.6%). A recurrence rate of 4.7% was seen and was
associated with large defect size, obesity, previous open repairs, and postoperative complications.2
In the largest quality-of-life outcomes study to date comparing laparoscopic and open ventral hernia
repairs from a multinational, prospective, self-reported database at 1-, 6-, and 12-month follow-up,
laparoscopic repair was associated with decreased quality of life (pain and movement limitation) in the
short term (1-month follow-up) but was equivalent to open repair at 6 and 12 months. An overall
recurrence rate of 5.7% was observed at 1 year; 5.2% recurrence for laparoscopic versus 6.0% for open.
There was also no difference in overall complications (deep venous thrombosis [DVT], ileus, urinary
problems, pneumonia, fistula formation, and reoperation). However, laparoscopic ventral hernia repair
was associated with decreased hospital length of stay of almost 2 days and fewer surgical site infections
compared to open repairs (0.3% for laparoscopic versus 3.0% for open).11
Laparoscopic incisional hernia repair has proven to be a safe and effective option for hernia repair and
may actually be favored in certain patient populations, such as the morbidly obese, due to decreased
rates of wound complications as compared to open ventral hernia repair.12
COMPLICATIONS
Prolonged postoperative ileus
Seroma
Hematoma
Prolonged transfascial suture site pain
Mesh infection
Bowel or bladder injury
Recurrence
DVT
Cardiac or pulmonary problems
Anesthesia complications
REFERENCES
1. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg. 1989;13:545-554.
2. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic repair of ventral hernias: nine years’ experience
with 850 consecutive hernias. Ann Surg. 2003;238:391-399; discussion 399-400.
3. Poulose BK, Shelton J, Phillips S, et al. Epidemiology and cost of ventral hernia repair: making the case
for hernia research. Hernia. 2012;16:179-183.
4. Read RC, Yoder G. Recent trends in the management of incisional herniation. Arch Surg. 1989;124:485-
488.
5. Anthony T, Bergen PC, Kim LT, et al. Factors affecting recurrence following incisional herniorrhaphy.
World J Surg. 2000;24:95-100; discussion 1.
6. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for
incisional hernia. N Engl J Med. 2000;343:392-398.
7. Novitsky YW, Porter JR, Rucho ZC, et al. Open preperitoneal retrofascial mesh repair for multiply
recurrent ventral incisional hernias. J Am Coll Surg. 2006;203:283-289.
8. Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: review of the literature and
recommendations regarding the grading and technique of repair. Surgery. 2010;148:544-558.
9. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national
initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322-330.
10. Cobb WS, Kercher KW, Matthews BD, et al. Laparoscopic ventral hernia repair: a single center
experience. Hernia. 2006;10:236-242.
11. Colavita PD, Tsirline VB, Belyansky I, et al. Prospective, long-term comparison of quality of life in
laparoscopic versus open ventral hernia repair. Ann Surg. 2012;256:714-723.
12. Tsereteli Z, Pryor BA, Heniford BT, et al. Laparoscopic ventral hernia repair (LVHR) in morbidly obese
patients. Hernia. 2008;12:233-238.
Chapter 37
Incisional Hernia Repair: Abdominal Wall Reconstruction Options
Michael J. Rosen
DEFINITION
The field of abdominal wall reconstruction has seen significant advances in the past decade. A
resurgence in the concept of recreating a functional dynamic abdominal wall through reconstructing the
linea alba and restoring normal anatomy of the abdominal wall unit has fostered several innovative
techniques to achieve these goals. The foundation for much of our understanding of abdominal wall
reconstruction can be linked to pioneering surgeons such as Oscar Ramirez, Renee Stoppa, and Jean
Rives. These reconstructive surgeons brought forth the concepts of performing fascial releases of the
anterior abdominal wall compartments to provide advancement of the midline fascia. Although each of
these surgeons and several of the newer techniques that will be described in this chapter differ in the
exact mechanism in which fascial advancement is obtained, the underlying concept of achieving fascial
advancement to reconstruct the midline is a constant.
When considering which approach is indicated for reconstructing the abdominal defect that the surgeon
is faced with, it is helpful to provide general categories of the various abdominal wall reconstructive
techniques. In the authors’ opinion, the most clinically relevant classification scheme is based on
preservation of the anterior abdominal wall neurovascular blood supply and the need to raise large
lipocutaneous flaps to gain access to the lateral abdominal wall. In general, minimally invasive
approaches preserve the abdominal wall blood supply and avoid large skin flaps. Examples of such
techniques include endoscopic component separation, posterior component separation, and periumbilical
perforator sparing approaches, whereas, the standard open approach does not typically preserve the
anterior abdominal wall blood supply.
This chapter will focus on some of the more advanced reconstructive techniques to repair large
abdominal wall defects. Prior to discussing each of these approaches, it is imperative to understand that
not all ventral hernia repairs will require these approaches. In fact, most abdominal wall defects less than
10 to 15 cm in maximal width can be repaired using a standard Rives-Stoppa-Wantz approach. This
technique will be described in detail in another chapter in this textbook. In the authors’ opinion, this
approach should always be initially considered prior to moving on to more advanced techniques.
When planning an abdominal wall reconstruction, the most important first step is to clarify patient’s
expectations for a successful outcome as well as the surgeon’s. Not all defects, particularly in the setting
of contamination or infection, can or should be repaired in a single setting. Often, the initial attempt at
clearing the infectious source or reconstructing the gastrointestinal (GI) tract takes precedence and
formal reconstruction should be delayed. In these cases, the patient should understand that they will
likely have a ventral hernia at the end of the procedure that eventually will need to be repaired.

Basic cardiac and pulmonary risk stratification are essential.
Skin preparation is critical, and an experienced wound care nurse is invaluable. Treating any subcutaneous
cellulitis or breakdown can significantly improve soft tissue coverage at the time of formal reconstruction.
Optimization of nutritional status is also important. This can include supplemental, enteral, or parenteral
feeding when necessary. It is also important to point out that patients with an ongoing infectious nidus,
particularly infected synthetic mesh, can be very difficult to obtain a positive nitrogen balance.
Many patients with large ventral hernias also suffer from morbid obesity. The ideal approach to managing
obesity in the setting of a complex ventral hernia is challenging. No doubt, substantial weight loss prior to
surgical intervention is optimal. However, the best approach is unclear, but options include medically
supervised weight loss or bariatric surgery. This can be particularly challenging in symptomatic incarcerated
hernias in which there is little time to achieve or obtain clearance for weight loss surgery.
Preoperative smoking cessation is mandatory in our practice prior to complex abdominal wall reconstruction.
Smoking has been clearly linked to impaired wound healing and in the author’s opinion is an absolute
contraindication to complex abdominal wall reconstruction.
Obtaining and reviewing all old operative records is extremely important. Understanding what type of mesh
and in what layer in the abdominal wall it was placed can help guide your approach. In addition, it is important
to clarify if one of the lateral abdominal wall muscles were already released because it can lead to lateral
abdominal wall laxity if it is rereleased. Likewise, the surgeon might choose another muscle to release to
access an undissected plane.

Routine radiologic imaging with an abdominal-pelvic computed axial tomography (CAT) scan is particularly
useful in complex ventral hernia repairs. These scans can provide valuable information as to the size of the
defect and presence of loss of domain, the absence or destruction of important components of the abdominal
wall, and the presence of remnant prosthetic materials.
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More advanced radiologic imaging such as magnetic resonance imaging (MRI) or angiogram to look for
periumbilical perforator vessels is not routinely performed in our practice.
Preoperative antibiotic and deep venous thrombosis prophylaxis is routinely given. Typically, a first-generation
cephalosporin will suffice, but in cases of prior or active methicillin-resistant Staphylococcus aureus (MRSA)
infection, Vancomycin is added.
Nasogastric tube decompression and Foley catheters are routinely inserted.
Perioperative anesthesia management is critical to success in large abdominal wall reconstructions. It is
important that the patient remains completely relaxed during the procedure as this greatly improves exposure
of the abdominal wall. In addition, in larger abdominal wall reconstruction, there is often some level of
compartment syndrome at the conclusion of the procedure. It is important to keep these patients intubated for
a 24- to 48-hour period until their airway pressures normalize.
SURGICAL MANAGEMENT
As with any hernia repair, it is critically important that the surgeon has a firm understanding of the anatomy of
the abdominal wall prior to manipulation. The abdominal wall is basically composed of the two rectus muscles
running longitudinally and the three lateral muscles on each side of the abdominal wall. Each performs a
valuable function for the abdominal wall, and any disruption can cause impairment in core physiology.
Understanding the neurovascular anatomy of the anterior abdominal wall is particularly important for optimizing
the results of each of these approaches. The rectus muscle receives its innervation from the T7-T11
intercostal nerve routes. These nerves run above the transversus abdominis and below the internal oblique
muscles in the lateral abdominal wall. They penetrate the linea semilunaris and segmentally innervate the
rectus muscle. It is very important to preserve these nerves in any reconstruction; otherwise, the rectus muscle
will atrophy and prevent any hope for a functional abdominal wall (FIG 1). One important consideration for a
posterior component separation is that the transversus abdominis muscle actually forms the posterior sheath
of the rectus muscle in the upper two-thirds of the abdomen.
FIG 1 • Innervation of the anterior abdominal wall. Note the intercostal nerves run in the lateral abdominal wall
in between the internal oblique and transversus abdominis muscle.
The blood supply of the anterior abdominal wall is slightly more complex (FIG 2). The rectus muscle receives
its blood supply both laterally from the intercostal vessels and from a superior and inferior branch of the
inferior epigastric vessel. The blood
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supply to the skin and subcutaneous tissues of the midline is also important to understand to limit ischemic
problems during reconstruction. The skin does receive some limited supply from the lateral intercostal vessels,
but the majority comes from deep inferior epigastric perforator vessels. These vessels typically lie within 5 cm
cephalad and caudad to the umbilicus. This relationship is particularly useful when performing a periumbilical
perforator sparing component separation.
FIG 2 • Blood supply to the anterior abdominal wall. Note location of the medial row of perforators off the inferior
epigastric providing blood supply to the medial aspect of the skin.
Positioning
Regardless of the abdominal wall reconstructive technique chosen, some basic technical aspects remain
constant. A wide surgical preparation including the entire abdomen, lower chest, and upper legs is performed
with a chlorhexidine solution. All stoma sites are oversewn to minimize spillage. An iodine-impregnated
dressing is routinely applied to cover the entire abdominal wall.
TECHNIQUES
INCISION
The surgical incision is typically performed in a midline fashion and all other old scars or skin ulcerations
are completely excised.
ADHESIOLYSIS
The abdominal cavity is entered and a complete adhesiolysis is performed to free up the entire abdominal
wall all the way to the gutters. This step is critical, as the abdominal wall will be limited in its mobility if it
remains fixated to the viscera.
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CONCOMITANT PROCEDURES AND REMOVAL OF ALL FOREIGN MATERIAL
Any concomitant GI surgery is completed and all prior synthetic material is removed from the abdominal
wall. In our opinion, removing prior synthetic material allows the new prosthetic to actually grow into the
abdominal wall and reduces seromas and mesh infections. After the intraperitoneal portion of the
procedure is completed, a countable towel is placed over the abdominal viscera to prevent inadvertent
injury during dissection of the abdominal wall.
POSTERIOR COMPONENT SEPARATION TECHNIQUE
A posterior component separation is basically an extension of the standard Rives-Stoppa-Wantz repair.
The initial procedure begins in a similar fashion. The linea alba is identified and grasped with Kocher
clamps. To avoid confusion and misidentification of appropriate planes, the clamps must be placed on the
medial edge of the rectus muscle and not on the hernia sac. If the clamps are on the hernia sac, the
dissection will proceed in a subcutaneous plane. Next, an incision of the posterior sheath is made
approximately 1 cm off the linea alba. It is important to identify the rectus muscle, which will avoid creating
a subcutaneous or preperitoneal plane of dissection (FIG 3).
The posterior rectus sheath is then separated off the rectus muscle using electrocautery, carefully
preserving the inferior epigastric vessel. This dissection plane is facilitated by placing upward traction on
the rectus muscle and medial traction on the posterior sheath with Kocher clamps. Typically, small
posterior branches off the epigastric vessels can be coagulated.
The lateral extent of this dissection continues until the perforating intercostal nerves and vessels are
identified. These nerves as mentioned are critical to preserve to maintain a functional innervated rectus
muscle. They also are the landmark of the linea semilunaris, that is, the lateral extent of the rectus
muscle. In a standard Rives-Stoppa-Wantz repair, the dissection is completed at this point (FIG 4).
FIG 3 • The posterior rectus sheath is incised 1 cm lateral to the linea alba to gain access to the
retrorectus space.
If more advancement is needed to provide mobilization for the posterior sheath or anterior sheath, or
provide a larger compartment for an adequate-sized piece of mesh, then a posterior component
separation is performed.
This dissection is usually started in the upper third of the abdomen. In this location, the transversus
abdominis muscle actually forms the posterior sheath and does extend medial to the linea semilunaris.
The incision is begun approximately 0.5 cm medial to the intercostal nerves. The initial incision should
involve the fascial covering of the muscle, and it is extended throughout the length of the posterior rectus
sheath. When performing this release, it is always important to confirm that it is not disrupting the
intercostal nerves.
Next, the transversus abdominis muscle is released medial to the linea semilunaris. This is facilitated by
the use of a right-angle clamp in the upper third of the abdomen under the muscle (FIG 5). Below this
muscle is the peritoneum and can be quite thin on the medial side.
As the dissection continues caudally, the muscle belly of the transversus abdominis is replaced with a
fascial layer. This layer is also incised, leaving the transversalis fascia and peritoneum in the lower third
of the abdomen (FIG 6).
Once the entire transversus abdominis is released, the dissection is continued laterally. Again, this
dissection plane is below the transversus abdominis muscle and above the peritoneum/retroperitoneum.
The lateral extent of this
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dissection is the lateral edge of the psoas muscle. This plane can be extended cephalad to the costal
margin, sweeping the peritoneum off the diaphragm.
FIG 4 • The posterior rectus sheath is separated off the rectus muscle until the lateral edge of the rectus
is identified by the presence of the perforating intercostal nerves.
The posterior sheath is incised at its insertion into the linea alba to connect each side of the abdomen.
This is continued at least 5 cm above the incision and typically can be performed to the xiphoid process.
In upper abdominal hernias, the insertion of the posterior sheath is released from the xiphoid, and the
dissection is continued to the fatty triangle underneath the sternum and toward the central tendon of the
diaphragm.
Inferiorly, the bladder is separated off the anterior abdominal wall. In suprapubic hernias, the pelvis is
exposed, including the pubis, Cooper’s ligaments, and the space of Retzius.
The posterior sheath, peritoneum, and transversalis fascia are reapproximated in the midline, completely
excluding the mesh from the bowel. Any fenestrations are sutured closed. In cases of large defects of the
posterior sheath, Vicryl mesh can be used.
FIG 5 • The transversus abdominis muscle is incised to expose the peritoneum below. Note the
intercostal nerves are preserved as this release occurs medially.
It is very important that the posterior sheath is closed safely because bowel can herniate through the
posterior closure and become incarcerated below the mesh.
A large sheet of unprotected medium-weight large-pore polypropylene mesh is typically placed in the
retrorectus space.
Several transfascial sutures are placed at the lateral edge of the mesh. The sutures are placed under
tension so as to allow the midline closure to be off weighted. These sutures also set the tension on the
mesh that prevents buckling when the midline is closed over the mesh (FIG 7).
Drains are placed over the mesh and below the rectus muscle and removed when less than 30 mL per
day of output.
The midline fascia is reapproximated with running or interrupted slowly absorbable monofilament sutures.
The skin is closed in layers.
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FIG 6 • In the lower third of the abdomen, the transversus abdominis is mainly fascia and is released to
expose the peritoneum.
FIG 7 • Mesh is placed as a sublay with lateral transfascial sutures and the midline closed without buckling
of the mesh.
COMPONENT SEPARATION TECHNIQUE

Anterior component separation is typically performed if the skin will require undermining to gain
advancement for closure. In addition, if the retrorectus space or the preperitoneal or retroperitoneal
space cannot be accessed, an anterior component separation can be performed with intraperitoneal
mesh placement.
Placing Kocher clamps on the linea alba provides medial retraction, whereas rake retractors are placed
on the dermis and retracted superiorly. Using electrocautery, the subcutaneous tissues are undermined
to the lateral abdominal wall.
These lipocutaneous flaps are created to the inguinal ligament and several centimeters above the costal
margin. In a standard open component separation, all of the medial row perforator vessels are sacrificed.
Therefore, the skin flap is supplied by the intercostal vessels approaching laterally.
The release is performed by incising the external oblique muscle. It is imperative that this incision does
not violate the linea semilunaris. This can occur if the release is begun too medially and will result in a
full-thickness defect in the lateral abdominal wall, which is very challenging to repair. There are no clear
anterior anatomic landmarks to define the linea semilunaris or the external oblique. It is helpful to grip the
rectus muscle in between the thumb and fingers and feel the indentation at the lateral extent of the rectus
muscle (FIG 8). The incision in the external oblique should be placed approximately 2 cm lateral to the
identified linea semilunaris.
A 1-cm incision is made parallel to the linea semilunaris. The orientation of the muscle fibers below
should be confirmed. If the fibers are oriented in a vertical direction, it is likely that the anterior rectus
sheath has been incised.
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To confirm, a right-angle clamp can be placed below the external oblique muscle and passed medially. If
in the correct plane, the tip of the instrument will not be able to traverse the linea semilunaris. If the
incision was erroneously placed on the anterior rectus sheath, the clamp will not meet resistance, and the
incision should be closed and the dissection continued laterally.
FIG 8 • Bimanual palpation to confirm the linea semilunaris location.
The external oblique is then released from the inguinal ligament to 3 to 4 cm above the costal margin.
This can typically be performed with electrocautery (FIG 9). It is important to avoid injuring the internal
oblique fascia or muscle complex below to avoid bulging and herniation.
A component separation is more than a fasciotomy of the external oblique muscle. After the muscle is
released, the external oblique muscle is dissected in the avascular plane in between the external and
internal oblique to the posterior axillary line. This dissection allows the rectus complex to slide medially.
A component separation should typically be performed bilaterally to allow for equal redistribution of forces
on the eventual repair. In certain circumstances, such the presence of a stoma or a prior transverse
incision, unilateral releases can be performed.
If further advancement is necessary, the posterior rectus sheath can be separated off the rectus muscle.
This incision is made approximately 1 cm lateral to the linea alba on the posterior rectus sheath. The
posterior rectus sheath can be separated off the rectus muscle to the linea semilunaris if necessary.
An appropriately sized mesh is placed as a sublay. Typically, this is placed in the intraperitoneal position.
Depending on the indications of the case, a synthetic or biologic mesh might be appropriate.
One of the major drawbacks of the anterior component separation is skin flap ischemia and wound
breakdown. There are several techniques to minimize this risk. First, the skin flap should only be created
as far lateral as needed to access the external oblique release and not all the way to the posterior axillary
line. Second, redundant skin should be readily excised. This will limit the dead space and remove the
most ischemic area. In certain cases, this can require a formal panniculectomy. However, most cases can
just be performed using a vertically oriented elliptical incision. Some authors have advocated quilting
sutures, securing the flaps to the anterior abdominal wall.
FIG 9 • Bilateral open component separation procedure completed.
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PERIUMBILICAL PERFORATOR SPARING COMPONENT SEPARATION
The rationale for preserving the periumbilical perforator vessels is to decrease the risk of skin flap
necrosis, infection, and dehiscence. This technique takes advantage of the fact that the majority of the
perforator vessels supplying the medial aspect of the skin originate within 5 cm of the umbilicus. This
approach might be particularly useful in high-risk patients such as those with obesity, diabetes, or
concomitant stomas.
The periumbilical approach is indicated in any patient undergoing a component separation. However, in
cases that require extensive subcutaneous skin dissection, it is often not feasible to perform. When
removing an infected onlay mesh, or if significant skin advancement is necessary, a standard anterior
open component separation as previously described is indicated.
The periumbilical component separation technique is performed by creating subcutaneous tunnels to
access the anterior aspect of the external oblique muscle.
The dissection is begun in the epigastric area. A lighted retractor can be very helpful to minimize the size
of the tunnel while providing exposure (FIG 10). The skin and subcutaneous tissues are dissected off the
anterior rectus sheath to a point 2 cm lateral to the linea semilunaris. This can be confirmed by manual
palpation as described in the anterior open release. Once this lateral point is reached, the dissection
continues inferiorly. The dissection should extend to a point several centimeters above the umbilicus.
FIG 10 • Use of lighted retractor to begin tunnel to the lateral abdominal wall while preserving the
periumbilical perforator vessels.
The suprapubic dissection is carried out in a similar fashion. Once the lateral extent is reached, the
tunnels are connected in the lateral abdominal wall.
It is important to understand that there is a fairly large amount of subcutaneous tissue that remains
attached to the midline (FIG 11). If the periumbilical perforator vessels are skeletonized, they often will
thrombose.
Once the tunnels are connected and the external oblique identified, it is incised similar to a standard
open component separation. It is also separated off the underlying internal oblique muscle.
Additional advancement can be obtained from division of the posterior rectus sheath. If feasible, the mesh
can be placed in this retrorectus space, with the lateral limit being the linea semilunaris.
If not feasible, an appropriately sized mesh can be placed intraperitoneally.
The midline fascia is then reapproximated and the skin closed. Drains should be placed in the lateral
tunnels.
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FIG 11 • Completed periumbilical release with intact medial row of perforator vessels.
PEARLS AND PITFALLS

Operative ▪ One of the most common pitfalls associated with abdominal wall reconstruction is
planning underestimating the limitations of what each of these procedures can accomplish. In
patients with massively large defects more than 30 cm in width and damaged, fibrotic,
fixed abdominal walls, there is little hope for a definitive repair. It is critically important
that both the patient and the surgeon have reasonable expectations as to what
abdominal wall reconstruction procedures can actually achieve.
▪ Preoperative optimization of the patient is one of the most important steps in
predicting a successful outcome. Weight loss is encouraged; optimization of diabetes
control and smoking cessation are mandatory.
Difficult ▪ The xiphoid and suprapubic region can be difficult to achieve maximal advancement
anatomy and should be avoided early in one’s experience.
▪ In many cases of complex abdominal wall reconstruction, the umbilicus must be
resected. Patients must be aware of this issue preoperatively.
Avoid ▪ Understanding the anatomy of the anterior abdominal wall is very important to
denervation ensure a successful outcome. Special consideration should always be given to the
innervation and blood supply to the abdominal wall musculature and skin during
manipulation.
Inability to ▪ Although it is always optimal to bring the midline together and reconstruct the linea
reapproximate alba, it is not always safe or feasible. If excessive tension results and the patient
the midline manifest hemodynamic instability or respiratory embarrassment, the closure should be
aborted and a bridged repair is appropriate.
▪ These advanced reconstructive procedures are not simply fasciotomies. Much of the
advancement achieved is a result of separating the muscle layers from each other to
provide advancement.
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POSTOPERATIVE CARE
Abdominal wall reconstruction is a major surgical procedure that results in a significant physiologic impairment
to the patient. Because many patients undergoing abdominal wall reconstruction have multiple comorbidities,
careful perioperative management is important to maximize outcomes.
Reestablishing the midline in a large defect can have early consequences to respiratory mechanics. If the
plateau pressures rise by greater than 6 mmHg after fascial closure, patients remain intubated overnight.
Airway pressures are reassessed in the morning to plan for extubation.
Epidural catheters are routinely used in patients undergoing major abdominal wall reconstruction. These
catheters are typically maintained for up to 5 days, depending on return of bowel function and level of pain.
Early resumption of oral intake is highly discouraged in this patient population. Because most of these patients
have increased intraabdominal pressure after the reconstruction, some form of ileus is common. To avoid
retching and potential breakdown of the repair, we avoid initiating a diet until the return of flatus. However,
routine nasogastric tube decompression is not necessary.
Most patients undergoing complex abdominal wall reconstruction are hospitalized for 5 to 7 days. Depending
on the complexity of the procedures, some patients remain in the intensive care unit for several days.
Patients are encouraged to ambulate early.
Because these procedures create significant dead space, drains are placed. Drains should be removed when
the output is less than 30 mL per day. In patients with subcutaneous drains, these may remain for several
weeks.
Perioperative antibiotics are continued for up to 24 hours, unless otherwise indicated.
Most patients are allowed to return to activity within 6 weeks of surgery and unrestricted activity at 3 to 6
months, depending on the case. Abdominal binders are continued for the first 6 weeks and then as needed for
comfort.
OUTCOMES
There are very little comparative studies evaluating the outcomes of each of these approaches head-to-
head. In fact, it is likely that these studies will never be completed, as the heterogeneous nature of the
patients who develop incisional hernias precludes any one approach ever being ideal. Most series are
from single centers with high-volume abdominal wall reconstructive practices. In the selected references,
each article provides reasonable outcomes as to the expectations for each procedure.
COMPLICATIONS
Wound morbidity is common after complex abdominal wall reconstruction.
Wound cellulitis should initially be treated with broad-spectrum antibiotics. In most cases, the skin does
not need to be opened. If the erythema does not improve within 24 to 48 hours, the incision should be
opened, cultured, and drained. In cases with clinical signs of sepsis, the surgeon should have a low
threshold to perform an abdominal pelvic computed tomography (CT) scan.
Skin necrosis should be treated with early debridement and wound care. In certain cases, delayed
primary closure can be performed.
Seromas are very common after abdominal wall reconstruction and most do not require any intervention.
If they are symptomatic, they can be drained under sterile conditions.
SUGGESTED READINGS
1. Krpata DM, Blatnik JA, Novitsky YW, et al. Posterior and open anterior components separations: a
comparative analysis. Am J Surg. 2012;203(3):318-322; discussion 322.
2. Novitsky YW, Elliott HL, Orenstein SB, et al. Transversus abdominis muscle release: a novel approach to
posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012;204(5):709-
716.
3. Blatnik JA, Krpata DM, Pesa NL, et al. Predicting severe postoperative respiratory complications following
abdominal wall reconstruction. Plast Reconstr Surg. 2012;130(4):836-841.
4. Rosen MJ, Fatima J, Sarr MG. Repair of abdominal wall hernias with restoration of abdominal wall
function. J Gastrointest Surg. 2010;14(1):175-185.
Chapter 38
Umbilical, Epigastric, Spigelian, and Lumbar Hernias
Filip Muysoms
DEFINITION
A primary ventral hernia is an abnormal protrusion of the contents of the abdominal cavity or of
preperitoneal fat through a defect in the abdominal wall that developed spontaneously without trauma to
the abdominal wall or prior surgery as the cause of the hernia.1
An umbilical hernia is a primary ventral hernia with its center at the umbilicus.
An epigastric hernia is a primary ventral hernia in the midline between the umbilicus and the xiphoid.
A spigelian hernia is a primary ventral hernia in the area of the fascia spigelian aponeurosis.
A lumbar hernia is a primary ventral hernia in the lumbar area.
In contrast to umbilical and epigastric hernias, the hernia sac of a spigelian hernia or lumbar hernia is
covered with an intact layer of abdominal wall muscle. For spigelian hernias, this is the external oblique
muscle (FIG 1), and for lumbar hernias, the latissimus dorsi muscle.
Primary ventral hernias are classified according to the diameter of the hernia defect as shown in Table
1.2
Subcutaneous lesions at the site where primary ventral hernias occur, like lipoma, sebaceous cysts,
metastatic lesions, and trocar site metastasis.
Caveat: Epigastric lipoma: In a patient with a clinical subcutaneous lipoma near the midline above the
umbilicus, an epigastric hernia should always be suspected.
Abdominal wall tumors: desmoid tumors (or fibromatosis), soft tissue sarcoma, metastatic lesions.
Caveat: A “Sister Joseph’s nodule” is an umbilical swelling that might be mistaken for an umbilical hernia
but is the manifestation of intraperitoneal carcinomatosis.
Secondary ventral hernias: incisional hernia, trocar site hernia, and recurrent ventral hernias after
previous repair.
FIG 1 • Spigelian hernias are defects of the insertion of the transversus abdominis muscle and/or internal
oblique muscle to the lateral border of the rectus muscle sheath (the spigelian aponeurosis). The external
oblique muscle covers the hernia sac superficially.

Symptoms can range from an asymptomatic presentation to acute incarceration with bowel obstruction and/or
strangulation.
Many small umbilical or epigastric hernias are asymptomatic, and often, the patient is not even aware of
having a small abdominal wall defect.
A swelling at the hernia site is often the first sign of a hernia. This swelling is usually present for a long time
period and gradually increases in size (FIG 2).
The presence of a reducible swelling, enlarging when straining (Valsalva maneuver), is pathognomonic for an
abdominal wall hernia, but not all hernias are reducible and can hinder the clinical diagnosis in those hernias.
The swelling of an epigastric hernia is often mistaken for a subcutaneous lipoma (FIG 3).
Pain intensity is not always correlated with the size of the hernia defect. Small hernias can cause a sharp pain,
whereas umbilical hernias can be quite large without significant pain. The pain is caused by herniation of
abdominal contents or of preperitoneal fat through the defect.
For some hernias that are not palpable, such as spigelian hernias, abdominal wall pain can be the first
presenting symptom and diagnosis might only be possible by imaging.
Acute pain due to incarceration of intestines or omentum is very intense and sharp. Incarceration can be
intermittent and resolve by lying down and manual compression of the hernia sac. Reduction of an
incarcerated hernia allows the patient to be operated on electively after appropriate preoperative workup. If
manual reduction is not possible, an emergency operation to reduce the hernia is indicated.
Intestinal obstruction and vomiting due to incarcerated small bowel sometimes is the primary presentation in
patients who have a subclinical hernia. In obese patients and for spigelian or lumbar hernias, the incarcerated
hernia is sometimes not clinically visible or palpable.
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Table 1: Classification of Primary Ventral Hernias According to the European Hernia

Society Classification
EHS Primary Abdominal Wall Hernia Diameter Small Medium ≥2- Large
Classification cm <2cm 4cm ≥4cm
Midline Epigastric
Umbilical
Lateral Spigelian
Lumbar
Reprinted from Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional
abdominal wall hernias. Hernia. 2009;13:407-414.
Late presentation of an incarcerated hernia includes sepsis from bowel ischemia and intestinal perforation.
This can evolve into peritonitis or enterocutaneous fistula.

For diagnosis of an umbilical or epigastric hernia, clinical examination is sufficient for the majority of patients.
Imaging is rarely needed for most patients.
Imaging with ultrasound or computed tomography (CT) scan can be helpful to measure the hernia defect size
in irreducible hernias or obese patients. Sometimes the size of the hernia defect will influence the therapeutic
approach, for example, open or laparoscopic technique.
For spigelian and lumbar hernias, imaging with ultrasound or CT scan is often needed to make the diagnosis:
spigelian hernia (FIG 4), lumbar hernia (FIG 5).
CT scan imaging of the abdominal wall allows sizing the defect to see the hernia sac contents and to detect
signs of intestinal obstruction.
SURGICAL MANAGEMENT
Small primary umbilical, epigastric, or lumbar hernias do not require an operation, unless they are painful,
increase in size, or cosmetic considerations are present. For spigelian hernias, a surgical repair is indicated
even for asymptomatic patients because they hold an increased risk of incarceration compared to the other
primary ventral hernias.
FIG 2 • Typical clinical presentation of an umbilical hernia with an umbilical swelling increasing in standing
position and while straining (Valsalva maneuver).
FIG 3 • This patient not only has an umbilical hernia but also a supraumbilical swelling from a concomitant
epigastric hernia.
FIG 4 • A. CT of a patient with a left-sided spigelian hernia. The hernia defect is located lateral to the rectus
sheath. The hernia sac contains a loop of the sigmoid colon. The external oblique muscle covers the hernia
sac. B. 1 (white) The hernia defect in the abdominal wall muscles just lateral to the recuts sheath. 2 (yellow)
The hernia sac with a sigmoid colon loop 3 (red) the intact external oblique muscle covers the hernia sac.
There is no consensus whether a suture repair for small primary hernias is sufficient or if every primary ventral
hernia should be treated by mesh reinforcement.3 For inguinal hernias and incisional hernias, the current
recommendation is to use mesh in all patients because of the proven decrease in recurrences. Therefore,
recurrent umbilical or epigastric hernias should be repaired using a mesh prosthesis, as they are considered
to be incisional hernias. Most surgeons agree
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that only small (<2 cm) primary ventral hernias should be repaired without mesh reinforcement.
FIG 5 • A. CT of a patient with a right-sided lumbar hernia. The hernia defect is located lateral to the
quadratus lumborum muscle. The hernia contains some retroperitoneal fat. The latissimus dorsi muscle covers
the hernia sac. B. 1 (white) The hernia defect in the abdominal wall muscles just lateral to the quadratus
lumborum muscle. 2 (yellow) The hernia sac with retroperitoneal fatty tissue. 3 (red) The intact latissimus
dorsi muscle covers the hernia sac. Green arrows: the names of the different muscle involved.
The mesh used to repair abdominal wall hernias can be placed at different positions in relation to the
abdominal wall layers. Five positions can be defined: onlay, inlay, retromuscular, preperitoneal, and
intraperitoneal (FIG 6).1
Laparoscopic repair of ventral hernias is a technique with promising short-term results.4 The technique is safe
but long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral hernia is
efficacious.4
Based on the size and the localization of the hernia, a decision will be made about the preferred approach in
the individual patient: mesh or primary repair/open or laparoscopic technique.
Although some centers perform the repair of small umbilical or epigastric hernias under local anesthesia as a
routine, most centers prefer a general anesthesia for the comfort of the patient and the surgeon. Regional
anesthesia through a sensory blocking of the anterior abdominal wall, by a transversus abdominis plane block
(TAP block), is another less practiced option for postoperative pain control.
For incarcerated hernias with bowel obstruction, adequate preoperative measures with nasogastric tube
suction and rapid “sequence intubation” should be considered to minimize aspiration risk.
FIG 6 • Different positions of the mesh in relation to the abdominal wall layers to repair a ventral hernia by
mesh reinforcement. (From: Winkler MS, Gerharz E, Dietz UA. Narbenhernienchirurgie. Übersicht und aktuelle
Trends. Urologe. 2008;47:740-747, with permission.)
Preoperative cleaning and disinfection of the umbilicus is helpful in decreasing the bacterial load during the
operation.
Antibiotic prophylaxis as a routine is not indicated for most hernia repairs because they are clean operations
with a low risk of wound infection. In the presence of risk factors for wound infection, antibiotic prophylaxis at
induction of anesthesia should be considered.
Positioning
Patients treated for primary ventral hernias are usually positioned in a dorsal decubitus. Lumbar hernias are
positioned in a 90-degree or 45-degree lateral decubitus to expose the lumbar region (FIG 7).
For laparoscopic approach of ventral hernias, the position of the surgeon and the video equipment is
determined by the localization of the hernia. It is important to have a wide lateral accessibility of the abdominal
wall, because the trocars are placed very laterally to obtain access to hernias on the midline.
FIG 7 • Intraoperative positioning of a patient with a 45-degree lateral decubitus for open approach of a left-sided
lumbar hernia.
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TECHNIQUES
SUTURE REPAIR
Incision
For umbilical hernias, the incision of the skin for primary repair can be within the umbilical rim, thus
leaving a nearly invisible scar postoperatively. The incision can be placed either cranial or caudal,
depending on the site of the hernia sac. It is recommended not to incise the umbilical rim for more than
180 degrees because of the increased risk of devascularization of the umbilical skin after further
dissection of the hernia sac, leading to skin necrosis and wound infection.
FIG 8 • A-F. Intraoperative pictures of an umbilical hernia repair by open approach.

For epigastric, spigelian, or lumbar hernias, the incision will be directly above the hernia.
The skin is retracted with small Volkmann retractors and the subcutaneous layer incised down to the
fascia, exposing one side, cranial or caudal of the hernia defect (FIG 8A).
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Dissection of the Hernia Sac
Starting at the lateral side of the hernia defect, the hernia sac, usually containing preperitoneal fat and/or
omentum, is encircled using a curved hemostat clamp. The clamp is pushed through to the other side of
the hernia defect (FIG 8B).
The top of the hernia sac is dissected of the umbilical skin, taking care not to injure the skin (FIG 8C).
This will expose the opposite side of the hernia defect (FIG 8D).
Reduction of the Hernia Sac
The hernia sac and its contents are reduced through the hernia defect behind the abdominal wall
muscles (FIG 8E). Careful control of hemostasis of the preperitoneal region is performed.
Sometimes, the contents of the hernia sac are too voluminous to be reduced through the hernia defect.
This is often the case in umbilical hernias with herniation of omental fatty tissue and in epigastric hernias
with preperitoneal fat. In these patients, we can either resect the herniated fatty tissue or we can enlarge
the hernia defect.
In patients with acute incarcerated hernias, the hernia sac should be opened and the herniated bowel
inspected for viability. In case of doubt, a bowel resection should be considered.
Closure of the Hernia Defect by Primary Closure
The fascial edges of the defect are identified and isolated from the subcutaneous tissue and from the
preperitoneal tissue for 5 to 10 mm (FIG 8F).
We close the umbilical and epigastric hernias in a horizontal line. Several options for suturing technique
(separate sutures, running suture, or “vest-overpants” plication sutures) (FIG 9A-C) and materials
(monofilament vs. braided sutures; nonabsorbable, slowly absorbable, rapid absorbable) are available.
Similar to the recommendations to close midline laparotomies, we recommend a running suture with small
bites (5 mm from the fascial edge and 5 mm between stitches) using a long-term absorbable
monofilament suture (FIG 9B).
Closure of the Skin
The skin is sutured either subcutaneously or with separate superficial sutures.
FIG 9 • Several techniques are available for closure of the hernia defect. A. Closure with separate sutures.
B. Closure with running sutures. C. Closure with a vest-over-pants plication, commonly known as the Mayo
Clinic technique.
OPEN MESH REPAIR WITH A FLAT MESH

Incision
This depends on the localization of the hernia. For umbilical hernias, placing a flat mesh will require an
incision that is larger than the incision needed for primary closure or for placement of an umbilical ventral
patch. Often, a horizontal omega incision (Ω) is chosen. For epigastric, spigelian, or lumbar hernias, the
incision is directly over the hernia sac (FIG 10).
Dissection of the Hernia Sac and the Hernia Defect
For umbilical and epigastric hernias, this is similar as for primary hernia repair (FIG 8B-E).
For spigelian and lumbar hernias, an intact muscle layer covers the hernia sac. This is why these hernias
can become quite large before they become clinically evident. For a spigelian hernia, the overlying
external oblique muscle has to be opened to access the hernia sac. The muscle fascia is split in the
direction of its fibers, which is from lateral downward in a ±45-degree angle toward the midline. The
hernia sac is thus exposed and contains preperitoneal fat. The sac is reduced underneath the other
abdominal wall muscles and the defect is measured.
Closure of the Hernia Defect and Mesh Augmentation
Usually in open surgery, the mesh is used to augment the primary fascial closure of the hernia defect.
There are several options for positioning the mesh in relation to the abdominal wall as shown in FIG 6.1
Onlay position: The mesh is positioned on top of the fascia underneath the subcutaneous tissue. After
closure of the hernia defect, a dissection of the subcutaneous plane is performed for several centimeters
around the defect to allow enough overlap of the mesh beyond the margins of the defect.
Inlay position: The mesh is placed inside the hernia defect, which is not closed, and the mesh is sutured
to the
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margin of the defect. There is a large consensus amongst surgeons that this is not a good way to perform
a mesh repair because of the lack of overlap between the mesh and the defect. The amount of overlap is
considered to be critical to diminish the risk for recurrence.
FIG 10 • Incisions to perform an open primary ventral hernia repair will depend on the localization of the
hernia.
Retromuscular position for midline hernias: For umbilical and epigastric hernias, the mesh will be placed
behind the rectus abdominis muscle and in front of the posterior rectus fascia. To get enough overlap, a
dissection in this plane is needed in all directions for several centimeters. In the cranial and caudal
direction, this dissection involves incision of the posterior rectus fascia to allow placement of the mesh
behind an intact linea alba. The posterior layer of the rectus fascia is closed. The flat mesh is placed in
the dissected retromuscular plane. The anterior rectus fascia is closed in front of the mesh.
Retromuscular position for lateral hernias: For spigelian and lumbar hernias, the mesh is placed behind
the intact superficial muscle layer, the external oblique muscle or the latissimus dorsi muscle,
respectively. The mesh is placed on top of the closed hernia defect, on the internal oblique muscle or on
the quadratum lumborum muscle, respectively.
Preperitoneal position: Another option is to place the mesh behind the posterior rectus fascia, or for
lateral hernias, behind the transversus abdominis muscle. The preperitoneal space has to be created by
dissecting the peritoneum of the fascia of the deepest abdominal muscle. It is not always easy to develop
this plane without creating holes or tears in the peritoneum. These have to be closed if a regular mesh
without a protective antiadhesive layer is used.
Intraperitoneal position: There is a consensus that if we want to place a mesh in the intraperitoneal
position, thus in contact with the intestines, we have to use a mesh with a protective antiadhesive layer.
Unprotected polypropylene or polyester meshes holds an increased risk of causing adhesions and
complications such as bowel obstructions, bowel erosions, and fistula.
Fixation of the Mesh
Several options for fixation of the mesh are available, depending on the mesh positioning.
For meshes in an intraperitoneal or preperitoneal position, transabdominal sutures can be used. These
sutures will fixate the mesh underneath the abdominal wall muscles.
Suturing the mesh to the posterior fascia or muscular layer can hold the meshes in a retromuscular
position. Avoiding transabdominal sutures will avoid the pain related to these sutures.
For a mesh in the onlay position, sutures can be placed of the mesh to the anterior fascia.
Fixation with glue applied to the surface of the mesh is a first alternative to the use of sutures.
Another alternative to the sutures are self-fixating meshes. These meshes have a mechanical fixation
either with small gripping hooks or by glue impregnated in the mesh, which becomes active in contact
with the moisture of the tissues.
The size of the mesh and the overlap of the mesh beyond the hernia defect are of critical importance to
avoid recurrences.
Closure of the Hernia Defect
It is recommended that the fascia defect be closed if possible, which is usually the case in primary ventral
hernias. A mesh augmentation rather than a bridging of the hernia defect by the mesh is preferred.
The anterior fascia is closed over the mesh in all repairs except an onlay mesh. In the onlay position, the
hernia defect is closed before placing the mesh.
Closure of the Skin
The skin is sutured either subcutaneously or with separate superficial sutures.
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OPEN MESH REPAIR WITH A VENTRAL PATCH
Incision
The incision needed for repair with a ventral patch is smaller than the incision to place a flat mesh. It is
similar to the incision for suture repair. It is recommended not to incise the umbilical rim for more than 180
degrees because of the increased risk of devascularization of the umbilical skin after further dissection of
the hernia sac, leading to skin necrosis and wound infection.
The skin is retracted with small Volkmann retractors and the subcutaneous layer incised down to the
fascia, exposing one side, cranial or caudal of the hernia defect (FIG 8A).
The dissection of the hernia sac and reduction of contents is the same as the open primary repair
technique.
Dissection of the Plane to Position the Mesh Device
The mesh devices have an antiadhesive layer similar to the meshes used in an intraperitoneal position.
Thus, the intraperitoneal placement is considered to be safe. If this is done, we consider it of utmost
importance that the preperitoneal fat around the hernia is dissected from the abdominal wall around the
hernia defect to allow contact between the mesh and the muscular fascia. This is most important cranial
to the umbilical hernia, where the round ligament of the liver and its fatty tissue will hinder a correct flat
placement of the mesh.
FIG 11 • A-K. An umbilical hernia is repaired using a round mesh device (Proceed Ventral Patch™,
Ethicon, Johnson & Johnson) of 6.4-cm diameter. We preferably place the mesh in a preperitoneal
position if possible. The mesh is fixed with sutures to the hernia defect, using two central fixation strips,
and we usually close the hernia defect on top of the mesh.
Note: FIG 11C and 11D— In this patient, a mesh of 6.4-cm diameter will be placed. To illustrate the size
of dissection needed underneath the posterior rectus fascia, we have measured and drawn a circle of
6.4-cm diameter. (continued)
Alternatively, it is possible in most patients to develop the plane behind the posterior rectus fascia without
major damage to the peritoneum. The development of the preperitoneal plane is done through the hernia
defect. This allows placement of the mesh device in a preperitoneal position and may allow for better
contact between mesh and fascia, resulting in better ingrowth while avoiding the possible disadvantages
of an intraperitoneal mesh. When using a mesh device, I (personal opinion of the author) always try the
preperitoneal placement. Only in cases of failure to develop the preperitoneal plane an intraperitoneal
position is done.
The hernia defect can be measured using Hegar dilators to correctly evaluate the size of the defect and
classify the hernia accordingly. Because the diameter of the mesh devices does not allow a large overlap
beyond the hernia defect, we recommend limiting the repair of ventral hernias with mesh devices to small
hernias not larger than 2 cm (FIG 11A).
Isolate the fascia margin from its underlying peritoneum, grasping the fascia edge with the small
Volkmann retractors.
Develop the preperitoneal plane by blunt dissection with the finger if the hernia defect is large enough to
allow this (FIG 11B). Sometimes, slightly enlarging the hernia defect is needed to allow introducing a
digit.
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FIG 11 • (continued)
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The dissection of the preperitoneal plane is helped by introducing a gauze in the space created.
The preperitoneal dissection should be extended far enough to allow easy and flat application of the
mesh (FIG 11C,D).
It is important to perform a good hemostatic control of the dissection plane to avoid postoperative
hematoma around the mesh.
Introduction of the Mesh Device
The mesh device is removed from the package after changing surgical gloves.
The mesh device is 6.4 cm in diameter and has two central strips allowing the mesh to be pulled against
the abdominal wall and fixed to the hernia defect (FIG 11E).
The mesh is folded in a manner not to break the internal memory ring at the margin of the mesh and
grasped with a clamp (FIG 11F).
While lifting the cranial fascia edge with the retractor, the mesh is pushed in the preperitoneal plane
through the hernia defect (FIG 11G).
With two nontraumatic forceps, the mesh is unfolded and checked for a correct flat position.
The mesh is pulled against the abdominal wall by the central strips, controlling for a correct flat
positioning of the mesh (FIG 11H).
Fixation of the Mesh Device
Most round mesh devices for the treatment of small ventral hernias have two central fixation strips to fix
the device to the margins of the hernia defect. The caudal strip is fixed to the lower margin of the hernia
defect with a U-shaped suture of a slowly absorbable monofilament suture (FIG 11I).
The strip is cut directly above the suture, leaving no mesh material above the fascia (FIG 11J).
The same is done with the cranial strip that is sutured to the upper margin of the hernia defect.
Closure of the Hernia Defect
Closure of the hernia defect is recommended. It separates the mesh device in the intraperitoneal or
preperitoneal position from possible postoperative wound infections.
As for the primary hernia repair, several options for suturing technique and materials are available:
separate sutures, running suture, or vest-over-pants plication sutures (FIGS 9A-C and 11K).
Closure of the Skin
The skin is sutured either subcutaneously or with separate superficial sutures. A sterile bandage is
placed.
LAPAROSCOPIC MESH REPAIR
Creation of the Pneumoperitoneum and Trocar Placement
The surgical field should be prepped and draped widely, with good exposure of the lateral parts of the
abdomen. The trocars are placed very laterally to allow for a good view of the anterior abdominal wall
and optimal angles when placing the tacks to fixate the mesh (FIG 12). For a midline hernia or for a right
spigelian hernia, the trocars will be placed on the left side. For a left-sided spigelian hernia, the trocars
are placed on the right side.
The pneumoperitoneum is created with the use of a Veress needle placed subcostally. Alternatively, an
open access can be performed with placement of a blunt trocar.
Three trocars are placed in the flank on the anterior axillary line (FIG 12). When a large mesh is used,
fixation on the surgeon’s side will need an extra contralateral trocar to allow the tacks to be applied. For
most primary ventral hernias, three trocars on one side are sufficient.
Adhesiolysis, Hernia Reduction, and Preconditioning of the Abdominal Wall
Adhesiolysis, which is sometimes very difficult and timeconsuming in laparoscopic incisional hernia
repair, is usually not a major issue in primary ventral hernias. If any adhesions are present, they are most
often between the omentum and the hernia sac. Adhesiolysis has to be performed carefully, avoiding the
use of cautery or other energy sources to minimize the risk of an inadvertent bowel injury.
The peritoneum of the hernia sac is reduced. Care is taken not to injure the overlying skin while
dissecting the sac. The skin above an umbilical hernia may be very thin.
It is important to precondition or prepare the area of the anterior abdominal wall that will be in contact with
the intraperitoneal mesh. This is a part of the operation called “preparing the landing zone” and involves
the removal of the fatty tissue and peritoneum around the hernia defect.5 Above the umbilicus, the
falciform ligament of the liver will be removed from the abdominal wall. Below the umbilicus, the fat
between the plica umbilicalis mediana of both sides will be dissected down from the abdominal wall, thus
exposing the posterior part of the rectus muscles.
The defect of the hernia can be left open (i.e., bridging technique: the defect is covered and “bridged” by
the intraperitoneal mesh) or can be closed (i.e., mesh augmentation: the intraperitoneal mesh is covering
the closed hernia defect). (See video 1: closure and video 2: defect left open in the accompanying
eBook.) There is no consensus whether closure of the hernia defect has advantages to the bridging of
the defect.
Mesh Placement and Fixation of the Mesh
The mesh used during laparoscopic ventral hernia repair needs an antiadhesive side that will be in
contact with the viscera. Many different meshes are available for this purpose.5
It is mandatory to have a good overlap of the mesh beyond the hernia defect. An overlap of at least 5 cm
in all directions is considered a minimum (FIG 13). This is necessary because all meshes shrink over
time. Moreover, it is important to position the mesh symmetrically around the hernia defect. Because of
the sharp angle between the abdominal wall and the tacker device, there is a tendency to push the mesh
away from the surgeon’s side, resulting in an asymmetric mesh placement.
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FIG 12 • Drawing of the intraoperative setting and trocar positions for a laparoscopic ventral hernia
repair.
FIG 13 • A good symmetrical positioning of the mesh with ample overlap beyond the hernia defect is
needed.
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FIG 14 • Fixation with sutures and tackers during laparoscopic ventral hernia repair.
Several devices are available for the fixation of the mesh.5 Some of the tackers are absorbable. There is
no consensus if the mesh can be adequately fixed with tackers alone or if the addition of transabdominal
sutures is needed. Most reported techniques involve a combination of sutures and tackers (“suture and
tackers technique”) (FIG 14) or the use of a double row of tackers (“double crown technique”) (FIG 15).
During the initial experience, the use of four cardinal sutures to orient and position the mesh is very
helpful (FIG 16).
FIG 15 • “Double crown” fixation during laparoscopic ventral hernia repair.
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FIG 16 • Double crown fixation with four cardinal sutures orientation for laparoscopic ventral hernia repair.
PEARLS AND PITFALLS
Indications ▪ Small asymptomatic umbilical, epigastric, or lumbar hernias do not need repair and a
“watchful waiting” policy can be proposed.
▪ Spigelian hernias need surgical treatment because they hold an increased risk of
incarceration.
▪ Incarcerated hernias should be operated in emergency.
Medical ▪ For most umbilical and epigastric hernias, medical imaging is not necessary for
imaging diagnosis and treatment planning.
▪ Spigelian and lumbar hernias can often only be diagnosed with medical imaging, if
they are clinically not palpable.
Mesh repair ▪ Suture repair is only applicable in small ventral hernias.

▪ A mesh repair will decrease the risk for recurrent ventral hernia.
▪ Several mesh positions and surgical approaches are possible.
▪ A good overlap of the mesh beyond the hernia defect margin is important to
compensate for mesh shrinkage.
Laparoscopic ▪ A mesh with antiadhesive properties has to be used for intraperitoneal placement.
repair ▪ Flat and symmetric positioning of the mesh around the hernia defect is the goal.
▪ The abdominal wall around the hernia in contact with the mesh should be adequately
prepared and fatty tissue removed.
▪ Several mesh fixation alternatives exist, without a clear consensus on the optimal
approach.
▪ Closure of the hernia defect is optional during laparoscopic ventral hernia repair.
POSTOPERATIVE CARE
Repair of primary ventral hernias can most often be performed in an ambulatory setting. Restriction of lifting
heavy weight and intense sporting activities for 2 weeks is advocated. An abdominal binder to support the
hernia repair can have a positive impact on early ambulation and pain control.
OUTCOMES
Nationwide Danish follow-up data 41 months after surgery show a reoperation rate for recurrence of 4%
and a total clinical recurrence rate of 15%.6
From the same Danish database, we know that umbilical and epigastric hernia repair has a low morbidity
and mortality but a high readmission rate mostly because of wound
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problems, seroma formation, or pain.7 Moreover, many patients complained about pain and discomfort 3
years after elective repair of a small umbilical or epigastric hernia.8
COMPLICATIONS
Seroma
Hematoma
Surgical site infection
Mesh infection
Recurrence
Chronic pain
REFERENCES
1. Muysoms F, Campanelli G, Champault GG, et al. The development of an international online platform for
registration and outcome measurement of ventral abdominal wall hernia repair. Hernia. 2012;16:239-250.
2. Muysoms FE, Miserez M, Berrevoet F, et al. Classification of primary and incisional abdominal wall
hernias. Hernia. 2009;13:407-414.
3. Aslani N, Brown CJ. Does mesh offer an advantage over tissue in the open repair of umbilical hernias? A
systematic review and meta-analysis. Hernia. 2010;14:455-462.
4. Sauerland S, Walgenbach M, Habermalz B, et al. Laparoscopic versus open surgical techniques for
ventral or incisional hernia repair. Cochrane Database Syst Rev. 2011;(3):CD007781.
doi:10.1002/14651858.CD007781.pub2.
5. Muysoms FE, Kyle-Leinhase I, Novik B, et al. Mesh fixation alternatives in laparoscopic ventral hernia
repair. Surg Technol Int. 2012;22:125-132. doi:pii: sti22/25.
6. Helgstrand F, Rosenberg J, Kehlet H, et al. Reoperation versus clinical recurrence rate after ventral hernia
repair. Ann Surg. 2012;256: 955-958.
7. Bisgaard T, Kehlet H, Bay-Nielsen M, et al. A nationwide study on readmission, morbidity, and mortality
after umbilical and epigastric hernia repair. Hernia. 2011;15:541-546.
8. Erritzøe-Jervild L, Christofferson MW, Helgstrand F, et al. Long-term complaints after elective repair for
small umbilical or epigastric hernias. Hernia. 2013;17:211-215. doi:10.1007/s10029-012-0960-z.

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Editor

Daniel Albo MD, PhD

Daniel Albo, MD, PhD

Avo Artinyan, MD, MS

Valerie Bauer, MD, FACS, FASCRS

David Berger, MD, MHCM

Jaime L. Bohl, MD, FACS

George J. Chang, MD, MS

Robert R. Cima, MD, MA

Roosevelt Fajardo, MD, MBA, FACS

Wayne A.I. Frederick, MD

Eric M. Haas, MD, FACS, FASCRS

Karin M. Hardiman, MD, PhD

Andrew G. Hill, MD, EdD, FRACS, FACS

Joshua S. Hill, MD, MS

Lillian S. Kao, MD, MS

Cherry E. Koh, MD, MBBS (Hons), MS, FRACS

Joël Leroy, MD, Hon FRCS

Luis Jorge Lombana, MD

Jacques Marescaux, MD, FACS, Hon FRCS, Hon FJSES

John H Marks, MD, FACS, FASCRS

Arden M. Morris, MD, MPH

Didier Mutter, MD, PhD, FACS

Alessio Pigazzi, MD, PhD

Scott E. Regenbogen, MD, MPH

Tarik Sammour, BHB, MBChB, PhD

William Sanchez, MD, FACS

Michael J. Solomon, MB ChB, BAO, MSc, FRACS

Andrew Stevenson, MBBS, FRACS

John H. Stewart, IV MD, MBA

David Taylor, MBBS, FRACS

Kathrin Mayer Troppmann, MD, FACS

Theodoros Voloyiannis, MD, FACS, FASCRS

Konstantinos I. Votanopoulos, MD, PhD, FACS

Y. Nancy You, MD, MHSc

Acquisitions Editor: Keith Donnellan

PATIENT HISTORY AND PHYSICAL FINDINGS

IMAGING AND OTHER DIAGNOSTIC STUDIES

Severe esophageal dysmotility

INITIAL HIATAL DISSECTION

FIG 9 • Resultant anterior 180-degree dissection.

SHORT GASTRIC VESSEL LIGATION

POSTERIOR GASTRIC ATTACHMENTS

FIG 11 • Reduction of the posterior sac.

HERNIA SAC EXCISION

FIG 15 • Adequate mediastinal dissection as evidenced by 360-degree encirclement of the esophagus up to

ASSESSMENT OF INTRAABDOMINAL ESOPHAGEAL LENGTH

PEARLS AND PITFALLS

Inadequate ▪ If redo fundoplication is being performed, it is imperative to obtain preoperative

Intraabdominal ▪ Inadequate mediastinal dissection results in incomplete abdominal length of the

PATIENT HISTORY AND PHYSICAL FINDINGS

IMAGING AND OTHER DIAGNOSTIC STUDIES

Hiatal hernia of 5 cm or more

INTRAABDOMINAL RETRACTION AND BOUGIE PLACEMENT

FIRST STAPLE TRAJECTORY

SECOND STAPLE TRAJECTORY

PEARLS AND PITFALLS

Inadequate ▪ It is sometimes disconcerting to staple onto an endoluminal foreign body (dilator),

Inadequate ▪ Inadequate mediastinal dissection results in incomplete abdominal length of the