Plate 41

Fundoplication may be considered in certain patients with symptomatic reflux gastritis associated with esophagitis. Esophagitis with stricture and paraesophageal hernia are other possible indications. A preliminary trial of repeated dilatations may be instituted when there is evidence of a stricture of the lower end of the esophagus. The procedure may be indicated in infants and children with gastroschisis or omphalocele repair or those with gastroesophageal reflux associated with brain injury.

Substernal pain, especially in the recumbent position, difficulty in swallowing, and recurrent bouts of aspiration pneumonia are commonly associated with roentgenologic evidence of gastroesophageal reflux. Esophagoscopy with manometric studies and intraluminal pH measurements are indicated. The latter studies may be extended over a 24-hour period of observation. Barium studies of the entire gastrointestinal tract may demonstrate a duodenal ulcer or other disorders. A gastric analysis, as well as serum gastrin determinations, should be made. Antacid therapy, elevation of the head of the bed, and effective weight reduction in obese patients may decrease the severity of symptoms.

Surgical procedures are designed to prevent acid peptic reflux and to restore normal sphincteric function. When reflux esophagitis is associated with duodenal ulcer, either parietal cell vagotomy or truncal vagotomy and pyloroplasty should be considered.

Pulmonary function studies are indicated in patients with a history of aspiration pneumonia. Antacid therapy is maintained. Systemic antibiotics may be given. Nasogastric intubation should be instituted.

General anesthesia with endotracheal intubation is employed.

The patient is placed in a comfortable supine position on the table with the feet slightly lower than the head.

The area from the nipples downward to the symphysis is shaved. The skin over the sternum, lower chest wall, and the entire abdomen is cleaned with the appropriate antiseptic solutions.

A liberal incision starting over the xiphoid and extending down the midline to the umbilicus is made (Figure 1). In the obese patient, the incision should extend to the left and slightly below the umbilicus. When the xiphoid is elongated, it is removed to enhance the exposure of the esophagogastric junction. Active arterial bleeding in either xiphocostal angle is controlled with a transfixing suture of 00 silk.

The peritoneum is opened and the abdomen explored with special attention given to the gallbladder, duodenal bulb, and the size of the esophageal hiatus. A considerable portion of the stomach may be up in the chest as a result of the enlarged hiatus opening.

It is important to develop good exposure of the margins of the esophageal hiatus. The exposure is improved by dividing the relatively avascular triangular ligament of the left lobe of the liver and rotating it toward the midline (Figure 2). It is retracted medially by a large S retractor applied to a moist pad placed over the mobilized left lobe (Figure 3).

The peritoneum over the esophagus is incised and the esophagus mobilized with the index finger of the right hand (Plate 17, Figure 7). The vagus nerves are not divided unless the operative, laboratory, roentgenographic, and clinical studies verified gastric hypersecretion with evidence of duodenal deformity and a concurrent drainage procedure such as a pyloroplasty is also planned. It is important to divide and ligate the uppermost portion of the gastrohepatic ligament in order to provide exposure for the “wraparound” of the fundus. The uppermost portion of the gastrohepatic ligament is grasped by a long pair of right-angle clamps (Figure 3). The contents between the clamps are divided, and each side is tied with 00 silk to ensure adequate control of the left phrenic artery (Figure 3). This may include the hepatic branch of the vagus nerve. The cuff of peritoneum at the esophagogastric junction may include considerable extra tissue due to trauma from the hiatus hernia. Additional sutures may be required to control bleeding in this area. Such sutures must not include the vagus nerves unless vagotomy is indicated by an associated duodenal ulcer and measured high acid values. The peritoneum to the left of the esophagogastric junction should be divided meticulously with great care to avoid tearing of the splenic capsule.

Downward traction with a rubber tissue (Penrose) drain about the esophagus is maintained to completely reduce the funds of the stomach into the peritoneal cavity. A small S retractor is introduced posterior to the esophagus to provide exposure to the hiatus (Figure 4). The margins of the hiatus are grasped with long Babcock forceps to facilitate the placement of two or three interrupted sutures of 0 silk for closure of the hiatus posterior to the esophagus (Figure 4). The hiatus is narrowed to the point where the index finger can be inserted easily alongside the esophagus. Alternatively, many surgeons prefer to size the opening with passage of a large esophageal dilator usually ranging between 56 and 60 French. The decision for or against vagotomy depends upon the finding of the duodenal ulcer or preoperative findings of gastric hypersecretion.

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