A short esophagus is the end result of
severe, long-standing GE reflux. Fibrosis, stricture and Barrett's
epithelium are frequently associated with this anatomical finding.
Technically, the shortening of the esophagus does not allow the surgeon to
perform a laparoscopic or an open Nissen Fundoplication without tension.
Thus, the lower esophagus has to be lengthened prior to constructing the
fundoplication.
Additional Instruments Needed:
1 - Premium Plus CEEA* 25
Disposable Stapling Instrument
1 - ENDO GIA* Universal
The anti-reflux procedure is initiated as described
above. A large GE window is created. It now becomes
essential to precisely locate the GE junction. The dissection of the
lesser gastric curvature and of the posterior aspect of the stomach is
extended downward so the entire upper portion of the stomach is mobilized
posteriorly in order to make the stomach very mobile. The short gastric
vessels are divided with the ULTRASHEARS* Instrument.
The lateral trocar site is enlarged to accommodate
the insertion of a CEEA* 25 stapling device (without a trocar). The detached
anvil is inserted and dropped into the intra-abdominal cavity. The CEEA*
stapler is inserted (retracted trocar in place). The trocar is exposed. An
ENDO BABCOCK* instruments and a non traumatic grasper are used to secure or
maintain the stomach immobile so the trocar can be "poked" through both the
anterior and posterior gastric walls.
A Bougie # 54 or 60 in inserted in the esophagus into the stomach. The
Bougie is used to guide the placement of the CEEA stapling device [right
against it].
By rotating the CEEA*, the posterior wall and the
trocar (through the anterior and posterior wall) is exposed. Using the ENDO
BABCOCK* Instrument, the trocar is removed from the stapler and from the
intra-abdominal cavity. The anvil is snapped, attached and the stapler
closed. The operator should verify the gastric wall is not wrinkled between
the jaws of the stapler. The stapler is fired leaving a 2.5 cm
round, stapled window. The stapler is removed, the trocar site tightened
with a facial suture and a 12 mm trocar inserted. An ENDO GIA* Instrument
stapling device is inserted via the newly formed window and closed parallel
to the lesser curvature.
The ENDO GIA* Instrument is fired in the direction
shown [against the bougie] and withdrawn. It sometimes needs to be fired twice. The gastric tube
of approximately 5 cm can be built or created to lengthen the lower
esophagus in intra- abdominal position. The procedure is then completed by
creating the Nissen Fundoplication around the gastric tube.
Proceed with the Standard
Fundoplication Technique
