What are the indications for a simplified thoracoscopic hiatal hernioplasty with uncut gastroplasty in high risk patients?
N. Demos, I. Ahmad, J. Scalia, J. Woo,
S. Zaklama, C. Patel, M. Lewis, R. Deguzman,
D. Shih, A. Lin, S. Shih, W. Siegal (Jersey City)
After a personal experience of over 200 hiatal hernioplasties in over 25 years, we have performed 17 thoracoscopic hiatal hernioplasties (VATS). The technique used was perfected in the dog laboratory first, clinically adapted and reported in 1974 [1].
Technique
The technique of the stapled, uncut gastroplasty has been published elsewhere [1-8]. Unilateral ventilation is achieved with a double lumen tube (Mallinckrodt, St. Louis, Mo, USA).
Three or four portals are made 3 cm in length. The camera is inserted through the opening posterior and just superior to the angle of the scapula (Figure 1). At that time the left lung is collapsed by the anesthesiologist but not before the opening is made. Collapsing the lung before one opening is made might draw the heart close to the trocar with disastrous results. The second portal is made in the anterior axillary line anterior to the first opening. This portal is used for the Endo lung retractor and is omitted in completely collapsed lung. The other two portals are made six to seven centimeters vertically and inferior to the first two portals (Figure 1).
Figure 1. Positions of incisions for the video camera and instruments.
Gas insufflation is not required. The main instruments used are a bland cautery hook, Endo-Babcock, Endo-dissectors and Endo-Stapler (Autosuture, Norwalk, Conn,USA).
After the inferior pulmonary ligament is divided, the sides of the lower esophagus are dissected. The diaphragmatic hiatus is suspended by two Endo-Babcock holders or recently by two heavy silks driven through the chest wall and held by hemostats. Dissection proceeds around the stomach. The peritoneum is entered and cut around the stomach. More dissection is done in the retroperitoneal area. One is careful to either clip or cauterize and cut large vessels like the artery of "Belsey". However, it is never necessary to transect short gastric vessels. The anterior gastric wall then is pulled into the chest and stapled (Figure 2). Fundoplication follows with the very convenient Auto-suture Endo stitch with "00" silk (Figure 3). Three or four mattress sutures are taken for an 1.5 cm coaptation. In nonperistaltic esophagus partial plication is performed (Figure 4). The upper margin of the wrap is then fixed under the diaphragm. Use of Maloney endo-esophageal dilator can be omitted with enough experience.
Figure 2. Stapling of the anterior gastric wall in a 4 cm length.
Figure 3. A Satinsky clamp brings the anterior gastric wall around the cardia and neoesophagus to be sutured to the other side of the anterior wall in a 1 to 1.5 cm coaptation.
Just before the fundoplication is constructed, three single "0" sutures are taken on each side of the diaphragmatic hiatus but left untied. After the fixation of the plication complex under the diaphragm, the hiatal sutures are tied using either the knot pusher or, in small subjects, the index finger (Figure 5). The finger or a Maloney bougie test the tightness of the plication or the hiatal sutures.
In patients with very short esophagus the stapling may be performed lower than the cardia. The fundoplications then may be sutured under the diaphragm without tension leaving the cardia in the chest followed by a short tubular gastric segment above the diaphragm (Figure 6).
Figure 4. A. Completed total fundoplication. B. Partial fundoplication in the presence of esophageal spasm or aperistalsis. All sutures are taken on the gastric wall.
Figure 5. Transthoracic stapled, uncut Collis-Nissen. By permission from [7].
Figure 6. Our procedure conveniently adapted to very short esophagus.
Results
There was no mortality. The 12 totally VATS or thoracoscopically operated patients are enjoying good health without gastric acid suppression and without any complaints referable to gastroesophageal reflux (Table I). See Figure 7 for post-operative esophagram. Figure 8 shows the valve created by stapling and plication. No patient had disabling paraspinal and intercostal pain.
One patient (#12) developed an asymptomatic paraesophageal hernia diagnosed on plain chest X-ray and esophagram. She had to have an open correction on the fifth postoperative day. At the time of the first and totally VATS operation, there was difficulty suturing the posterior or right diaphragmatic side of the crus. During the second (open) procedure the same difficulty was encountered, and special Teflon pledgets had to be used so that the sutures would not tear through the attenuated right side of the diaphragmatic crus. She is well by esophagram and asymptomatic 10 months after correction. There were two left lower lobe infiltrates in the totally VATS series.
Contraindication to the VATS technique
In two patients conversion to the open procedure was dictated by unexpected obliteration of the left pleural cavity (#1 & 2 of partial VATS group) (Table II). Severe obesity was the reason for conversion in one patient (#3). One patient was intolerant to unilateral ventilation (#5). In one patient (#4), the sharp cautery -- shears caused an inadvertent 4 mm cut into the stomach and conversion to open technique was deemed advisable.
Age by itself is no contraindication to the closed VATS technique. As a matter of fact advanced age is viewed as an indication of the VATS technique because of the easier postoperative recovery.
As experience is gained, the above reasons for conversion should not constitute contraindications to the "closed" VATS technique.
Two of the partial VATS patients, (#1 and #4), have had good lower esophageal manometry and esophagram. They have some heartburn requiring proton pump inhibitors. Both however are free of other disabling symptoms such as burping, nausea and vomiting present before surgery.
Discussion
The reason our uncut Collis-Nissen repair has been successfully used in a "closed" manner, is the simplicity and the limited dissection required. Our technique allows limited dissection of the lower esophagus and upper stomach without the need to transect the short gastric vessels. Because the fundoplication is performed upon the cardia and nearby stomach, the esophagus is not dissected up to the hilum, even in the cases of short esophagus [1-6]. The fundoplication performed around the neoesophagus created by the stapling, and the subdiaphragmatic fixation are performed with sutures taken only on the strong gastric wall. The net effect of this technique is to create a tension-free repair avoiding an upward pull or a tendency to a "slipped Nissen".
Figure 7. Postoperative esophagram after a totally VATS procedure.
The safety of the procedure is witnessed by the absence of leakage or the need for splenectomy in the entire series of open or closed operations. The use of only seromuscular sutures on the gastric wall (Figures 4 and 5) and the lack of extensive dissection are believed to be responsible for the safety of the stapled, uncut Collis-Nissen repair. Several perforations have been reported by the laparoscopic approach [9]. The incidence of reoperation in the totally VATS patients in five years' experience is one in 12 or 8.3%. In Jamieson's laparoscopic Nissen hiatal hernioplasties it was 8% in 136 patients followed for two and half years [10].
The incidence of reflux was zero in the 12 totally VATS procedures. Two of the partially thoracoscopic patients had reflux in spite of a well constructed fundoplication tested by post-op manometry and esophagram. Our total incidence of reflux: 2 of 17 or 11% in a longest follow-up of 5-1/2 years. Jamieson and co-workers' 155 patients who had laparoscopic surgery: the reflux was 14.2%, in a longest follow-up of 2-1/2 years. In one year follow-up, Rattner and Brooks had 5.4% recurrent postoperative reflux [11]. It is to be noted that in none of our VATS patients, total or partial, has there been a "slipped" Nissen. Eight of our totally VATS patients were discharged from the hospital 5-6 days postoperatively. The partly VATS patients had a median of 8.5 days postoperative hospital stay. No patient complained of the usual and at times disabling paraspinal, intercostal and rib pain encountered in open thoracotomies.
Figure 8. The valve created by the procedure seen by the retroflexed flexible endoscope inside the stomach.
Partly supported by the James Nicholas Research Fund
References
5. Demos NJ. Correction of paraesophageal hernia. NY State J Med 1977;77:1281-1283.