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FIGURE 30-3 Completed laparoscopic Toupet fundoplication (part Nissen fundoplication).

Splenic injury may occur during mobilization of the fundus and division of the short gastric vessels.

Complications of the fundoplication fall into two general categories:

Mechanical failure. This results from either dehiscence of the suture line or, more commonly, herniation of an intact fundoplication through the diaphragm into the chest (recurrent hiatal hernia). Mechanical disruption occurs in up to 10%–20% of patients at 5 years after surgery. When it occurs, it may be totally asymptomatic, or it can result in significant dysphagia or recurrent GERD symptoms.

Fundoplication dysfunction due to improper construction. If the wrap is too long or too tight, the result is significant dysphagia or inability to belch or vomit. Vagal nerve injury may also result in poor gastric emptying. This symptom complex is known as “gas bloat syndrome” or “post-Nissen syndrome.”

Controversies and conclusions

Laparoscopic fundoplication is considered the procedure of choice in patients requiring surgical therapy for GERD. It provides good to excellent relief of “typical” symptoms in 85%– 90% of patients. Careful patient selection and preoperative evaluation is necessary to achieve these results.

Controversies. Numerous aspects of GERD treatment and surgical therapy continue to be debated. Some of the more important controversies are:

Medical versus surgical therapy. This topic is too detailed to discuss within the parameters of this text. However, increasing clinical data suggest that surgical therapy may be preferable to long-term medication in some patient populations. More data is needed to clarify this issue, especially the long-term efficacy and cost -effectiveness of laparoscopic fundoplication.

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Use of laparoscopic fundoplication in patients with Barrett's esophagus. Until recently, the mere presence of Barrett's esophagus was not felt to be an indication for fundoplication, as earlier data showed no reliable regression of Barrett's esophagus after surgical treatment. However, newer studies clearly show arrest of progression, relief of symptoms, and regression of metaplasia in some patients with Barrett's esophagus. The treatment of this complication of GERD is complex and in evolution; the choice of surgical therapy in patients with Barrett's esophagus should be considered on a case -by- case basis.

Preoperative evaluation of surgical candidates with GERD. “Standard” preoperative evaluation usually consists of upper endoscopy, evaluation of esophageal motility, and 24 -hour pH monitoring. Some surgeons believe that 24 -hour pH monitoring and esophageal motility studies are unnecessary in some or most patients. The development of newer and less invasive studies such as impedance monitoring and wireless pH probes is likely to have some impact in this area.

Laparoscopic surgery for peptic ulcer disease. All traditional surgical procedures for peptic ulcer disease are possible by using a laparoscopic approach, including parietal cell vagotomy (highly selective vagotomy), truncal vagotomy and pyloroplasty, and truncal vagotomy and antrectomy. Due to the effectiveness of medical therapy, elective ulcer procedures are performed infrequently. Little data exists comparing the effectiveness of laparoscopic and open ulcer surgery.

Indications

Intractability. Parietal cell vagotomy is usually indicated.

Bleeding. Usually, the bleeding point is oversewn, and a vagotomy and pyloroplasty are performed. Combined endoscopic and laparoscopic techniques are helpful if equipment and expertise is available.

Obstruction. Either vagotomy or pyloroplasty or vagotomy and gastric resection have been used in the few reported laparoscopic procedures for this indication.

Perforation. This is the most frequent indication for laparoscopic intervention in patients with peptic ulcer disease. Irrigation of the abdomen and use of an omental patch (Graham patch) in patients with small anterior duodenal ulcer perforations and minimal contamination of the peritoneal cavity is readily performed.

Contraindications

Suspicion of malignancy in a gastric ulcer

Severe bleeding or sepsis with hemodynamic instability should be treated with laparotomy.

Long -standing perforation with severe generalized peritonitis or extensive abdominal contamination

Technique. The critical steps of all procedures are essentially identical to their open counterparts.

Parietal cell vagotomy. The parietal cell mass is denervated, thus selectively eliminating vagal stimulus for gastric acid secretion. The anterior vagal trunk is identified and preserved. The small branches innervating the lesser curve of the stomach are divided by using an ultrasonic scalpel or surgical clips. The distal 5 cm of the esophagus are also skeletonized. The terminal branches innervating the antrum (the “crow's foot”) are preserved so that gastric emptying is normal.

Vagotomy and pyloroplasty. The vagotomy is performed by mobilizing the esophagus and locating the anterior and posterior trunks. Visualization is usually superior to that seen during laparotomy. The trunks are divided between surgical clips and a 1-cm segment is excised. The pyloroplasty is performed by mobilizing the duodenum (Kocher maneuver) and making a 3-cm horizontal incision centered over the pylorus but perpendicular to the muscle fibers. The incision is then closed vertically in one or two layers (Heineke -Mikulicz pyloroplasty).

Vagotomy and antrectomy. The vagotomy is performed as for vagotomy and pyloroplasty. The antrectomy is performed by dividing the stomach and duodenum at the appropriate landmarks by using a laparoscopic stapling device. The anastomosis (usually a Billroth II reconstruction) may be either handsewn or stapled.

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Complications are generally the same as those seen after open ulcer surgery:

Incomplete vagotomy. Inadequate dissection and division of vagal fibers during either parietal cell or truncal vagotomy may result in persistent hyperacidity and persistence or recurrence of peptic ulcers.

Parietal cell vagotomy. Delayed gastric emptying due to excessive denervation at the crow's foot or perforation of the lesser curvature of the stomach from ischemia are two unique complications of this procedure.

Postgastrectomy syndromes. Just as after traditional gastric surgery, laparoscopic vagotomy or ablation of the pylorus may result in postgastrectomy syndromes such as diarrhea, dumping syndrome, afferent loop syndrome, and nutritional deficiencies.

Other gastric procedures. Essentially all traditional gastric surgical procedures have been performed by using a laparoscopic approach. Most are used infrequently, with the exception of Roux -en -Y gastric bypass for morbid obesity.

Gastrojejunostomy may be performed for benign or malignant obstruction of the duodenum, such as for palliation of unresectable pancreatic cancer.

Insertion of gastrostomy or jejunostomy tubes for feeding or decompression

Wedge -resection of gastric masses. Combined endoscopic and laparoscopic approaches are being used with increasing frequency for treatment of ulcers and gastric polyps.

Major gastric resection, including esophagogastrectomy , is performed in small numbers at some centers. Though the technical feasibility of these operations is clearly established, their utility as routine procedures is uncertain. Specifically, laparoscopic resection for potentially curable cancer of the esophagus or stomach is NOT considered the approach of choice at the present time.

F Laparoscopic surgery for morbid obesity

The introduction of laparoscopic techniques and increasing awareness of the obesity epidemic has dramatically increased the number of surgical procedures performed for morbid obesity. Several different laparoscopic surgical procedures are currently performed, including Roux -en -Y gastric bypass, vertical banded gastroplasty, biliopancreatic diversion, and adjustable gastric banding. The majority of surgeons in the United States perform laparoscopic Roux-en -Y gastric bypass , though adjustable gastric banding is gaining popularity.

Indications. It is assumed that candidates for surgery have failed vigorous attempts at nonsurgical methods of weight loss. Most surgeons follow the recommendations of a 1991 National Institutes of Health (NIH) consensus conference, which are based on both the patient's degree of obesity and comorbid conditions. Degree of obesity is measured by body mass index (BMI), defined as the patient's weight in kilograms divided by the square of their height in meters:

BMI > 40 kg/m 2 without the presence of significant comorbidity

BMI between 35–40 kg/m 2 with the presence of certain comorbidities, including severe cardiopulmonary problems (sleep apnea, pickwickian syndrome, obesity -related cardiomyopathy), severe diabetes mellitus, or physical problems interfering with lifestyle (severe joint disease, interference with employment)

Contraindications. Prior to the operation, patients must clearly understand the long-term lifestyle and physiologic changes that will occur after surgery. All patients in whom open obesity surgery is appropriate are potential candidates for a laparoscopic approach, though several relative contraindications exist. They include BMI > 50 (“superobesity”), age > 60 years , severe psychiatric illness , and lack of motivation or understanding to follow postoperative care programs.

Technique. Numerous variations in technical details exist, though the basic elements of the procedures are fairly constant.

Roux-en -Y gastric bypass. The stomach is divided by using a stapler into two portions: a very small 15 - to 30 -mL proximal gastric pouch that serves as the new food reservoir, and the remainder of the stomach, which is left in situ and drains into the duodenum. The proximal pouch is then connected to a Roux limb about 50–60 cm in length to re-establish gastrointestinal continuity.

Gastric banding. A tunnel is created behind the proximal stomach. A 15 -mL balloon is placed into the stomach by the anesthesiologist at the gastroesophageal junction to determine

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where to place the gastric band. A device consisting of a Silastic band and attached balloon (the gastric band) is placed around the outside of the stomach and is sutured in place to prevent slippage. The gastric band functionally divides the stomach into a small proximal pouch and the remainder of the stomach. The balloon is attached to a subcutaneous inflation port, which allows the size of the gastric pouch to be adjusted postoperatively.

Complications. Gastric bypass and gastric banding are very different procedures in terms of surgical trauma and physiologic changes. Gastric bypass requires division of the stomach; two surgical anastomoses; and bypass of the stomach, duodenum, and proximal small intestine. Gastric banding places a small, inert cuff around the proximal stomach without entering or bypassing any of the gastrointestinal tract. Their morbidity differs accordingly.

Roux-en -Y gastric bypass. Anastomotic complications include anastomotic leak (3%–5%),

anastomotic stricture (5%–12%), marginal ulcer (2%–8%), internal hernia causing small bowel obstruction (1%–2%). Metabolic complications include dumping syndrome (2%–5%), gallstone formation , and vitamin and mineral deficiency (especially iron, Vitamin B 12 , folate, and calcium).

Gastric banding. Most complications are band related , such as erosion, stenosis, and slippage of the band. They occur in about 3%–8% of patients.

Controversies and conclusions

Surgical outcomes after gastric bypass. There are two ways to measure the success of a surgical procedure for morbid obesity: the degree of weight loss and the resolution of comorbidities such as diabetes and sleep apnea. Typical weight loss after gastric bypass (laparoscopic or open) is 50%– 70% of excess weight at 1 year and 70%–80% at 3–5 years. Sleep apnea, diabetes, hypertension, and cholesterol and lipid disorders improve or completely resolve in many patients with successful weight loss.

Conclusions. Both laparoscopic gastric bypass and gastric banding are safe and effective methods of short-term weight loss , though long-term efficacy for both procedures cannot yet be determined.

Laparoscopic gastric bypass appears to be a more effective weight loss procedure than laparoscopic gastric banding, though it is associated with a higher rate of serious complications.

Weight loss and resolution of comorbidities appears similar after open and laparoscopic gastric bypass , though definitive conclusions cannot yet be drawn. Limited evidence suggests the following: Fewer serious complications occur after laparoscopy; operating time is longer after laparoscopy; laparoscopy results in less blood loss, fewer ICU visits, reduced length of hospital stay, and earlier return to normal activity.

The appropriate role and indications for various laparoscopic procedures remains uncertain. Most surgeons in the United States favor gastric bypass. Gastric banding has the advantage of being easily reversible and may play a role in young, elderly, and highly motivated patients and

in those with lower BMIs (30–40 kg/m 2 ).

G Laparoscopic colectomy

Indications. Laparoscopic colectomy is commonly performed for most elective conditions requiring colon resection. It is not frequently used in emergency cases. The utility of laparoscopy depends on the anatomic location of the lesion, the body habitus of the patient, and the acuity of the problem.

Colon polyps, including incompletely resected polyps at colonoscopy and familial polyposis

Arteriovenous malformations (elective resection for bleeding)

Diverticular disease (elective resection for bleeding or recurrent episodes of diverticulitis)

Formation and takedown of intestinal stomas

Sigmoid or cecal volvulus

Repair of rectal prolapse, particularly sigmoid resection and rectopexy

Crohn's disease or ulcerative colitis (particularly ileocecal and left colon resection)

Elective resection of potentially curable colon cancer

Palliative resection of incurable colon cancer (obstruction or bleeding in a patient with unresectable liver metastases)

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Contraindications

Acute inflammatory processes. Patients with acute diverticulitis or severe active inflammatory bowel disease are very difficult from a technical standpoint and may be more prone to complications such as ureteral injury.

Large or bulky inflammatory masses or tumors

Rectal cancer is considered a relative contraindication. There is insufficient data available regarding the efficacy of the laparoscopic approach for routine use in cancers below approximately 15 cm from the anal verge.

Technique. The difficulty of laparoscopic colectomy is highly dependent on the disease process, the location of the lesion, and the degree of obesity. The right colon and sigmoid colon are easiest to resect, the descending colon and rectum are intermediate in difficulty, and both flexures and the transverse colon are hardest to resect. Polyps and arteriovenous malformations are relatively easy to resect, and acute and chronic inflammatory conditions are much more difficult.

Intraoperative colonoscopy should be used liberally to localize lesions such as polyps and to determine margins of resection.

Two types of laparoscopic colectomy are currently used:

Laparoscopic -assisted colectomy. This is the most popular procedure. The colon is mobilized completely by using laparoscopy. Division of the colon and colon mesentery may be performed either inside the abdomen or extracorporeal, whichever is easiest. A suitable incision is then made for extraction of the specimen and performance of the anastomosis. The two ends of the colon are then anastomosed outside the body just as for open colectomy.

Intracorporeal colectomy. The entire procedure including mobilization, division of the colon and its mesentery, and anastomosis of the colon are performed under laparoscopic guidance. However, an incision is still necessary for specimen extraction. A good example of this procedure is sigmoid resection with transanal end -to -end anastomosis (EEA) stapled anastomosis.

Hand-assisted laparoscopic surgery. Colon resection is one of the more frequent indications for the use of HALS. It facilitates blunt dissection of peritoneal attachments and tactile localization of masses and inflammation. Some surgeons use HALS as an intermediate step between true laparoscopic colectomy and conversion to open colectomy.

Complications

Hemorrhage. This complication may occur from either the mesentery or the suture or staple line. Laparotomy may be necessary for control.

Infection

Superficial wound infection

Intra -abdominal abscess

Anastomotic leak. Occurs in approximately 5% of cases

Postoperative small bowel obstruction. Recent data suggest that laparoscopic colectomy results in significantly fewer episodes than open colectomy (2%–4% vs. 10%–12%)

Controversies and conclusions

Laparosopic colectomy is technically challenging when compared with other laparoscopic procedures for a variety of reasons.

Outcomes after laparoscopic colectomy are difficult to generalize; studies often compare several different surgical procedures performed for a variety of different indications performed in heterogeneous patient populations by surgeons with varying experience.

Advantages of laparoscopic colectomy include decreased hospital stay and recovery time, decreased incidence of wound complications, and decreased need for pain medication and subsequent respiratory embarrassment. Disadvantages of laparoscopic colectomy when compared with open colectomy are longer operative times and relatively high technical difficulty.

The use of laparoscopic colectomy in patients with potentially curable colon cancer. Recent data show that laparoscopic colectomy and open colectomy are equivalent oncologic procedures with similar overall survival, diseasefree survival, wound recurrence, and surgical complications.

Appropriate patient selection and surgeon experience are critical factors in achieving this equivalence.

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Oncologic equivalence between open and laparoscopic colectomy has NOT been demonstrated for rectal cancer.

H Diagnostic laparoscopy

Indications

Acute pelvic or lower abdominal pain. The differentiation of acute appendicitis from other problems (e.g., pelvic inflammatory disease, ovarian torsion, or hemorrhagic cyst of ovary) is greatly facilitated by laparoscopy.

Tubal ectopic pregnancy. Fallopian tube excision or incision with evacuation of the tubal pregnancy can be accomplished laparoscopically.

Ovarian torsion or infarction. Laparoscopic treatment options include detorsion or resection of the ovary.

Infertility. Laparoscopy is invaluable in establishing some causes of infertility, including adhesions, endometriosis, and tubal stricture. Adhesiolysis and endometriosis ablation are possible laparoscopic procedures. Additionally, egg harvest for in vitro fertilization is accomplished with the laparoscope.

Staging of uterine or cervical malignancy. Intra -abdominal disease can be staged with aortic and iliac lymph node sampling.