PREOPERATIVE DIAGNOSIS: Achalasia.
POSTOPERATIVE DIAGNOSIS: Achalasia.
PROCEDURES PERFORMED:
1. Robotic-assisted laparoscopic Heller myotomy with Dor fundoplication.
2. Intraoperative endoscopy.
3. Intraoperative manometry.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 50 mL.
TUBES PLACED: An 18-French Foley catheter.
COMPLICATIONS: None apparent.
DISPOSITION: To the PACU.
CONDITION: The patient’s condition was stable.
INDICATIONS: This is a patient with an 8-month history of dysphagia and was recently diagnosed with achalasia based upon manometry as well as Barium swallow and it was recommended the patient undergo elective Heller myotomy with partial fundoplication utilizing intraoperative manometry guidance.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table in the supine position for Heller myotomy with partial fundoplication. Bilateral lower extremity compression boots were placed on the legs and turned on. General endotracheal anesthetic was administered.
The patient was positioned on the table in low lithotomy position with the legs in adjustable stirrups. Both arms were tucked by the side and an 18-French Foley catheter was placed with return of clear yellow urine. An endoscope was introduced through the mouth and passed down the esophagus. The esophagus was empty but had appearance consistent with achalasia.
The endoscope was passed into the stomach easily. The abdomen was prepped with ChloraPrep and draped with paper drapes, cloth towels, and a paper laparoscopy sheet. A time-out was taken to confirm the patient and the procedure. Antibiotics had been given within the hour. Compression boots were on and Foley catheter was draining clear yellow urine.
An umbilical puncture was made after infiltrating 0.5% Marcaine. A Veress needle was placed through the umbilicus. The intraperitoneal location of the tip of the needle was confirmed with a positive saline drop test and a low opening pressure of 4 mmHg.
The abdomen was insufflated to a pressure of 15 mmHg with low flow carbon dioxide insufflation upon which a 12 mm Xcel trocar was placed through the midline 17 cm below the xiphoid process with the laparoscope within the lumen of the trocar to place it under direct vision.
Once this was introduced into the abdominal cavity, anterior abdominal insufflation was maintained at a pressure of 15 mmHg with high flow carbon dioxide insufflation. Four additional trocars were then placed under direct vision.
A 5 mm trocar was placed along the patient’s right costal margin 17 cm from the xiphoid process. An 8 mm trocar was placed along the patient’s left costal margin 17 cm from the xiphoid process. Two operating trocars were placed 12 cm down from the xiphoid process and approximately 4 cm on either side of the midline. These were both 8 mm trocars as well.
Once all these trocars were placed, the patient was positioned in reverse Trendelenburg position and a 5 mm flexible liver retractor was passed through the right subcostal trocar and positioned under the lateral segment of the left lobe of the liver to expose the area of the GE junction.
The patient was noted to have a small hiatal hernia without any other abnormalities. Intraoperative manometry was carried out which revealed a very high pressure zone from 46 to 44 cm from the incisors. At this point, the robot was brought in and each of the arms were docked to the trocars and the robotic instruments were placed. Trocars were placed on the right and left side and a Harmonic scalpel was placed on the patient’s left side.
Attention was directed to the area of the GE junction. The cardia of the stomach was grasped and retraced downwards into the left and the phrenicoesophageal ligament was incised along the lesser curvature aspect of the stomach and held towards the diaphragm across anteriorly to expose the entire anterior esophagus, the right and left crural fibers of the diaphragm.
Once this was adequately cleared, the gastroesophageal fat pad was elevated and excised. Posteriorly, the confluence of the right and left crural fibers were identified and the hiatal hernia was repaired with a single 0 Ethibond suture tied intracorporeally.
At this point, attention was directed to the esophagus. This was treated with a concentrated epinephrine solution at the end of the Kitner sponge following which the fundoplication was begun. It should be noted that the manometry was carried out over a guidewire prior to placement of the manometry catheter.
The endoscope had been introduced into the duodenum. A guidewire was passed and the manometry catheter was placed over the guidewire. The manometry catheter and the endoscope were left in place in the esophagus and attention was directed to the esophageal muscles, which were incised utilizing a hook cautery dissector first incising the longitudinal muscle, and then circular muscle and heading a distance of approximately 6 cm proximally along the esophagus and down approximately 4 cm across the cardia until we were beyond the squamocolumnar junction as identified endoscopically.
In doing this dissection, a small incision was made into the esophageal mucosa which was repaired with a single figure-of-eight 4-0 Vicryl suture. This was later air tested with the endoscope and there was no evidence of any leakage from there or any other parts of the myotomy.
Once this was completed, repeat manometry revealed a decrease in the high pressure zone; although, there was still some pressure at the level around 46 cm. There were no additional muscular fibers. This was completely denuded down to mucosa.
At this point, a partial anterior fundoplication, Dor fundoplication, was created placing two sutures on the left side, one between the fundus, the left crus of the diaphragm and the left cut edge of the myotomy; approximately 2 cm below this, a second suture from the fundus to the left cut edge of the myotomy.
The area of the myotomy was then covered and then the fundus was rotated around the front of the mucosa and sutured placing two sutures between the fundus and the cut edge of the myotomy and the right crus and then two additional sutures between the fundus and the cut edge of the myotomy placing each of these approximately 2 cm apart to complete the anterior fundoplication.
All these sutures were placed intracorporeally with 2-0 Ethibond sutures. Once this was completed, the fundoplication was inspected and was in good position without any abnormal angulation.
The upper abdomen was irrigated with kanamycin saline solution. The robotic arms were disengaged and we went back to the laparoscopic view and the three 8 mm trocar sites as well as the 12 mm trocar sites were closed utilizing the transabdominal suture passer placing figure-of-eight sutures of 0 Vicryl in each of these under direct vision. Once these were all placed, the abdomen was desufflated and these were tied down.
The abdomen was reinsufflated and the closures were inspected through the 5 mm trocar and all these were airtight and intact. The abdomen was desufflated through the 5 mm trocar which was removed. The trocar sites were all closed with interrupted 3-0 Vicryl sutures and the skin was approximated with Dermabond dermal adhesive. The patient was transported to the PACU in stable condition.
