Safe laparoscopic dissection of the gastroesophageal junction

Safe Laparoscopic Dissection of the Gastroesophageal Junction Lee L. SwansWm,

MD, FACS, John L. Pennings, MD, Po~-&~nd, Oregon

BACKGROUND: The laparoscopic approach to surgical diseases of the foregut is rapidly gaining acceptance. These new approaches, however, pit the unwary surgeon against potentially devastatiug complications. PATIENTS AND METHODS: Based on a retrospective review of 153 consecutive laparoscopic foregut surgeries performed at a designated laparoscopic center between August 1990 and June 1994, plus analysis of the records of 6 patients referred from outside our institution, we determined that the majority (15 of 16) of these complications were the result of violating one of five technical precepts: (1) safe use of esophageal dilators; (2) atraumatic retraction; (3) systematic dissection of the esophageal hiatus; (4) dissection under direct vision; and (5) use of appropriate suturing techniques. RESULTS: A retrospective review of our experience with laparoscopic gastroesophageal surgery shows an operative complication rate of 6.5%. The majority of these complications (7 of 10) were recognized at the time of occurrence and treated laparoscopically without subsequent complication. Two patients had delayed complications that required treatment. One patient developed adult respiratory distress syndrome, apparently not related to surgical technical error. The other patient required an additional laparoscopic surgery to correct a dissection error. This complication rate compares very favorably with those reported for open surgical techniques, that range from 14% to 22%. CONCLUSION: This report outlines 8nrgica.l precepts that, if violated, could lead to iatrogenic injury, which could result in severe morbidity if not recognized or properly treated.

iseasesof the lower esophagus, esophageal hiatus,and upper stomachcan have widely varying presentations, differing etiologies,and a full spectrumof treatments,both surgical and medical. Despite thesedifferences, there are severalelementsin commonfor all diseases of this areaof the body. Aside from malignanciesof the esophagusor stomach, all are essentially benign conditions associated

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From the Minimally Invasive Surgery Department, Legacy Portland Hospital and Oregon Health Sciences University, Portland, Oregon. Requests for reprints should be addressed to Lee L. Swanstrtim, MD, Minimally Invasive Surgery Department, Oregon Health Sciences University, 501 North Graham, Ste. 120, Portland, Oregon 97227. Presented at the Slst Annual Meeting of the North Pacific Surgical Association, Coeur d’ Alene, Idaho, November 10-l 1, 1994.

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with a great degreeof patient discomfort and, asa whole, have fairly effective medical alternativesto surgical treatment. One further elementin commonis the fact that surgical complicationsin this area are often devastating, resulting in unhappy patients at best or profound disability and death at worst. It is therefore imperative that surgeons utilize the utmost care in performing surgery for the diseasesinvolving the gastroesophageal junction.

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The charts and data sheetsof 153 casesinvolving laparoscopicprocedureswith dissectionof the gastroesophagealjunction performed at our institution were reviewed. All procedureswere done at a dedicatedlaparoscopiccenter andperformedby, or underthe direct supervisionof, the senior author (LLS). All surgery was performed under Institutional Review Boardprotocolsto ensurepatientsafety and to reinforce our policy of obtaining concurrentpreoperative, intraoperative,and postoperativeoutcomesdata. Proceduresperformed included Nissenand Toupet fundoplications, modified Heller myotomy, paraesophageal hernia reduction and repair, highly selective vagotomy, Taylor vagotomy procedure, completion or truncal vagotomy with drainageprocedures,andtranshiatalesophagectomy. Operationswere performed over a 4-year period between August 1990 and June 1994. Ten complications (6.5%) were identified. Charts and videotapesof all these caseswere carefully reviewed to identify technical errors leading to the identified complications. In addition, the records, operative findings, and videos (when available) of 6 additional patientswho were referred for treatment or casereview following complicationsfrom fundoplication procedureswere ti&zed to determinepoints of error. Operationsconductedat our laparoscopiccenter followed a surgical protocol emphasizingstepwisedissectionof the gastroesophageal junction. Thesestepsinclude: atraumatic elevation of the left lobe of the liver; proper lateral and inferior retraction of the stomach;division of the gastrohepatic ligament along the medialmargin of the caudatelobe; identification of the right crus; division of the endoabdominal fascia along the right crus fully exposing the crus to its base; division of the phrenoesophagealligament at the apex of the esophagealhiatus exposing the upper left crus; mobilization of the cardia of the stomach staying close to the stomachand esophagusto preserve the peritoneal covering of the left crus; division of the short gastric vesselsfor all fundoplications; liberal dissectionof the anterior mediastinalesophagus;posterior dissectionof the esophagusunder direct vision; creation of a generquswindow beneaththe esophagusby exposing the left ~X-LKuse of the phrenoesophagealepiphrenicfat pad asa handleto manipulatethe stomachand esophagus;useof the gastric fund& as an esophagealretractor in fundoplications to avoid graspingthe esophagus;liberal useof intracorporeal JOURNAL

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suturing to minimize trauma to tissues; and identification of the vagus nerves at all times.

RESULTS Laparoscopic gastroesophageal surgeries were attempted in 153 patients. In 152 patients the surgery was completed laparoscopically; 1 patient was converted to an open procedure because of dense adhesions secondary to previous gastric surgery. The indications for surgery included gastroesophageal reflux disease (117 cases), paraesophageal hernia (12), achalasia (13), peptic ulcer disease (lo), and squamous cell carcinoma of the esophagus (1). Of these 153 patients, 10 intraoperative complications were identified, for an overall incidence of 6.5%. Detailed analysis of our own complications and those of 6 other patients referred from outside identified technical principles that had been violated and had led to these errors.

Safe Use of Esophageal

Dilators

Perforation occurred in 1 patient because of simultaneously attempting to place both a bougie dilator and a nasogastric tube, causing the nasogastric tube to perforate the esophagus when the dilator was advanced. Postoperative bleeding requiring transfusion occurred in 1 patient from a linear mucosal tear in the distal esophagus extending to the cardia of the stomach. The tear resulted from attempting to pass a bougie through an angulated distal esophagus following a posterior crural repair.

Atraumatic

Retraction

Use of inappropriate instrumentation during stomach retraction on a redo fundoplication caused iatrogenic gastric perforation in 1 patient. It was repaired by laparoscopic suturing without sequelae. Additionally, 1 obese patient with a hypertrophied left liver lobe sustained a significant liver laceration resulting in a hematoma and increased hospitalization of 72 hours; no long-term problems resulted. An enterotomy occurred in 1 patient from entrapment of a loop of jejunum in an unprotected liver retractor during removal; it was repaired laparoscopically with no sequeIae. Lastly, 1 patient incurred a 1.5-cm diaphragmatic laceration due to the sharp comer of a poorly designed liver retractor; the laceration was repaired laparoscopically with no resulting problems.

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Dissection Under Direct Vision Two cases were referred to our institution following laparoscopic fundoplications during which an iatrogenic perforation of the esophagus or gastroesophageal junction occurred. One was the result of instrument trauma and the other was caused by electrocautery contact injury. Both occurred during the creation of the retroesophageal window. Both patients required operative intervention and had prolonged hospital stays. Review of the videos demonstrated that the posterior dissection was performed blindly using a 0” laparoscope, leading to these complications.

Suturing

Techniques

One outside patient was referred with a paraesophageal abscess. A videotape was available and, on careful scrutiny, demonstrated an extracorporeally tied suture sawing through the anterior esophagus, causing a full-thickness laceration. Percutaneous drainage was performed with an eventual resolution of the abscess.

Other

An outside patient was referred who had complications related to a dissection error. Review of the videotape revealed that the surgeon did not begin the dissection at the gastrohepatic ligament and instead attempted to open the phrenoesophageal ligament directly. Dissection was begun too low and inadvertent hemitransection of the esophagus occurred. No bougie was in place to help identify the esophagus. The patient was converted for an open repair, but subsequently suffered subdiaphragmatic abscess requiring additional surgeries. Meticulous hemostasis is critical, and a safe energy source must be used to perform it. In our series, 1 patient, during lysis of adhesions, had a delayed small-bowel perforation secondary to a probable bum of the small bowel with cautery scissors. Also in our series, 1 patient underTHE AMERICAN

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going a Heller myotomy had a mucosal perforation with a monopolar electric hook while the mucosa was partially obscured by bleeding. The enterotomy required a second laparoscopic surgery for repair, prolonging the patient’s hospital stay but resulting in no long-term disability. The myotomy perforation was repaired laparoscopically with no sequelae. In our series, a third dissection error was identified in 1 patient who had a postoperative bleed requiring a two-unit transfusion secondary to poor hemostatic control during dissection. No operative intervention was required, but the patient was hospitalized for 96 hours, compared with an overall mean of 36 hours for this series of patients undergoing this procedure. Lastly, dissection errors were noted in 2 additional cases who were referred for medical-legal review. Tapes and records were available on each and showed the surgeons misidentifying the right crus as the left crus and mistaking the vena cava for the esophagus, resulting in massive hemorrhage, the death of 1 patient, and a 56-unit blood loss for the other.

Appropriate

Systematic Dissection

508

AND

A complication occurred in 1 patient in our series who developed severe adult respiratory distress syndrome on postoperative day 2, requiring prolonged ventilatory support before final resolution. Careful video review of this case demonstrated no technical errors. It is postulated that the patient’s pulmonary dysfunction may have been the result of intraoperative aspiration causing chemical pneumonitis. Similarly, postoperative gastrografin swallows, computed tomography scans, and abdominal and thoracic exploration revealed no technical errors.

COMMENTS Complications involving the gastroesophageal junction can be devastating, particularly if missed at the time of surgery. Since the majority of surgeries in this area are for benign disease, it is imperative that surgeons expend the highest effort to minimize operative complications. That is particularly true of laparoscopic foregut surgery, which, while offering enormous patient benefits, is prone to in-

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Atraumatic I liver retractor

Phrenoesophageal Gastrohepatic

ligam84-414

T

Caudate

R. CNS

Rgure 1. A. Gastroesophageai dissection is ahvays begun by retractirgthe left lobe of the liver, caudally retracting the stomach, and open ing the clear area of the gastrohepatic ligament to expose the right crus. B. Division of the phrenoesophageal ligament defines the esophageal hiatus and gives access to the anterior mediastinum. The epiphrenic fat pad is a resilient structure that is useful for manipulation of the gastroesophageal junction. C. An angled laparoscope allows the attachments of the gastric cardiaand esophagus to be dividedunder direct vk Sian. D. Dissection behind the esophagus and gastroesophageal junction is prone to disaster unless pe~ormed under direct vision.

creasedcomplications by its newness,two-~mension~ format, lack of tactile feedback, and technical difficulty. We presenta review of compiicationsincurred during 153 laparoscopicsurgeriesinvolvi& dissectionof the gastroesophagealjunction. In addition, the casesof 6 patietitsbreferred to us for complicatioilsfrom outsideinstitutionswere atso reviewed. In our own series,the in~ao~rative complication rate was6.5%, which included0% for esophagectomy and vagotomies, 5% for fundoplications, 15% for Heller myotomies, and 17% for paraesophageal hernia repairs. Although this incidenceof intraoperative complications is low comparedwith that publishedfor open procedures(14% to 22%),‘” we would like to seeit even lower. We believe that our current low incidence of complicaTHE AMERICAN

tions is due to our protocolized operative approach.These surgical protocols were developed through adherenceto basic, good laparoscopic techniques, our experience in teachingadvancedtechniquesto other surgeons,anda concurrent review of complicationsthat we have experienced aswell as thosereferred from outsidesources.This paper describes five key surgical fundamentals: safe use of esophagealdilators, a~a~ati~ retraction, systematicdissection of the esophagealhiatus, dissectionunder direct vision, and atraumatic suturing techniques. Violation of thesefundamentalscan lead to operative complications. Esophagealdilators are neededfor fundoplications, and we have alsofound themuseful for allowing accurateidentification of the esophagusby palpation of the previously JOURNAL

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Figure 2. A. Extracorporeally tied, long, braided sutures can lacerate soft tissues. 6. lntracorporeal sutures are less likely to cause esophageal trauma.

placed bougie.4*5Thesedilators must be placed with great care, however. Initial placementof the dilators should not be relegatedto the anesthesiologistand shouldinsteadbe the surgeon’sresponsibility. If the esophagushasto be manipulatedduring dissectionof the hiatus,the bougie should be withdrawn, as attempts to elevate the esophaguswith the bougie in place can causecrush injuries to the wall of the esophagus.The surgeonmustbe aware that the esophaguscan becomeangulatedas a result of posterior crural closure and that trauma may occur during attemptsto advance the bougie. The anesthesiologistshouldbe cautioned to always watch the monitor when askedto advance the bougie and not to persistwhen there is resistance. Retraction of the stomachand esophagusis necessaryfor accurateidentification of anatomicallandmarks.Great care must be used when retracting to avoid injury to the stomach and esophagus.To avoid injury, surgeonsshould use only instruments specifically designed for atraumatic bowel and stomachretraction. When possible,graspingthe actual stomachshould be avoided, and at no time should the esophagusbe directly grasped.When the phrenogastroesophagealligament is divided, the epiphrenic fat pad is readily identified andprovides a tough and resilient handle for retraction of the gastrocsophagealjunction. Retraction of the liver is essentialfor laparoscopicgastroesophagealsurgery. An atraumaticliver retractor is critical, aspoorly designedliver retractors can causeliver, diaphragmatic, or even pericardial trauma. Such trauma resultsnot only in direct organ injury, but alsocausestroublesomebleeding that can obscurethe surgical field and detract from operative efficiency. In our experience, use of a l-inch stockinet placed over commercially available liver retractors hasproved helpful to minimize trauma and provide for secureadherenceof the liver retractor to the smooth liver capsule, A systematic approachto the identification of anatomic structures and the dissectionof the esophagealhiatus is critical. Efforts to blindly or randomly identify and dissect key structures can lead to disaster. Dissection should al510

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ways begin with the clear area of the gastrohepaticligament and should proceed cephaladalong the medial border of the caudatelobe. That allows identification of the right crus 100% of the time (Figure 1A). Once the right crus is identitied, the phrenoesophagealligament can be incised within the borders of the right and left crura (Figure 1B). Meticulous hemostasisis necessary,asbleeding can obscurecritical anatomical structuressuch asthe vagus nerves, wall of the esophagus,aorta, or phrenic vessels. Hemostasisis best achieved through safe energy sources.We prefer to usebipolar scissorsin order to prevent accidentalburnsto the esophagusor stomach.If complete circumferential dissection of the gastroesophageal junction is needed,division of attachmentsfrom the cardia of the stomachandesophagusto the diaphragm,spleen, and left crus must be performed (Figure 1C). Care must be taken to identify and control aberrantshort gastric vesselsor phrenic branchesthat coursethrough theseattachments. Once the anterior esophagealhiatus is widely opened,dissectionof the posterior and gastroesophageal junction is performed. Care is taken at all times to avoid injury to the vagusnerve and to maintainhemostasiswhile taking down aortoesophagealarterial branches.Adequate exposureof this posterior dissectionis obtained by atraumatically elevating the esophaguswith blunt instruments and anterior retraction of the gastroesophageal junction by manipulation of the epiphrenicfat pad. Dissectionof esophagealand gastric structuresunder direct vision is critical becauseof the absenceof tactile feedback in laparoscopicsurgery. Direct-vision dissectioncan only be accomplishedwith the useof angledlaparoscopes. A 30” scopeis helpful, but we have found a 45” or 50” laparoscopeto be optimal. With the scopelooking from right to left, direct visualization of the posterior esophaguscan be obtained. With this view, dissection of the posterior esophagusin the mediastinumand gastroesophageal junction can be performed (Figure 1D). The posterior window can be made under direct vision and instrumentspassed beneath the esophaguswithout the risk of injury that can occur when there are attempts at blind passage.In addition, dissection of the splenogastricattachmentsand the angleof His areall but impossiblewithout an angledscope MAY

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to look over the cardia of the stomach (Figure 1C). Doing this dissection under poor visualization runs the risk of bleedingfrom the upper short gastric or phrenic vesselsor even splenic injury. Two general techniques of laparoscopic suturing have beendescribed.6Theseare extracorporealtying techniques and intracorporeal suture-tying techniques.We feel that each has its place. Extracorporeal ties are useful for approximating structuresunder tension, such as the widely separatedcrus during hiatal repairs.On the other hand, this review hasgraphically demonstratedthe potential for complication when extracorporeal ties are placed in delicate structu:s such as the esophagus.Long, braided sutures pulled through soft tissuescan easily cause lacerations (Figure 2A). It is also difficult for the surgeonto accurately assesstension on the suture while focused on extracorporeally tying the knot. Although intracorporeal sutures are more difficult to learn and initially can prove frustrating to surgeons,we are convinced that they are less traumatic to the tissues and therefore preferable when sewing the esophagusor making other critical repairs in soft tissues(Figure 2B). We believe that following thesetechnical considerations will avoid the majority of intraoperative complications in this new field of surgery.

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therapy to surgical options. Reports of laparoscopictruncal vagotomies,highly selectivevagotomies,esophagomyotomies, fundoplications, and esophagogastrectomies representanexciting new frontier for the laparoscopicsurgeon. However, these samelaparoscopicproceduresare being scrutinizedby critical overseers,suchasthird-party payers, government agencies,and surgical colleagueswho do not perform advancedlaparoscopicprocedures.As wasthe case with biliary surgery, grave concern exists that ill-prepared surgeonswill be pushed by the market-driven medical economy to perform advancedlaparoscopicproceduresand that patientswill suffer the consequences. For all thesereasons,it is imperative that laparoscopicsurgeonsperform all laparoscopicsurgeries,and in particular thosethat involve the gastroesophageal junction, with the utmost attention to the appropriate indications, safesttechniques,and timely recognition and treatmentof complications.

REFERENCES

1. Low D, Anderson R, llves R, et al. Fifteen to twenty year results after the Hill antireflux operation. J Thorac Cardiovusc Surg. 1989; 98:444-450. 2. Polk H. Fundoplication for reflux esophagitis: misadventures with the operation of choice. Ann, Surg. 1976;183:645%652. 3. Urschel JD. Complications of antireflux surgery. Am JSurg. 1993; 165:68-70. 4. DeMeester TR, Stein HJ. Minimizing the side effects of antireCONCLUSION flux surgery. World .I Surg. 1992;16:335-336. Surgical treatmentof foregut diseasesis increasinglybe- 5. Ellis FH. The Nissen fundoplication. Ann Thoruc Surg. 1992;54: ing approachedlaparoscopically.This developmentin sur- 1231-1235. gical technique has causedjustifiable excitement among 6. Soper NJ, Hunter JH. Suturing and knot tying in laparoscopy. In: surgeonswho believe a less morbid, minimally invasive MacFadyen B, Ponsky J, eds. The Surgical Clinicb of North America. approach may shift treatment from conservative medical Philadelphia: W.B. Saunders Co.; 1992:1139-1152.

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