Laparoscopic approach - a new stage

in the surgical treatment of

gastroesophageal reflux disease
(GERD)

Scientific Coordinator:
Iacub Vladimir,
Vladimir associate professor, MD, Ph.D
Authors:
Țugui Elena, Coceanji Irina, Bobeica Maria, Costru Elena

Chişinău 2010
 GERD
Represents subjective clinical
changes with or without the
histological modifications in the
abdominal esophagus, caused
by prolonged contact with
gastric juice (pH <4) appeared
when it is an imbalance between
aggressive factors and
protective factors.
Hiatal Hernia
Protrusion of the
upper part of the
stomach into the
thorax through a
tear or weakness in
the diaphragm.
 Incidence
by WHO
• Incidence of GERD for 2006-
2009 - 10-30%

• 1 for 10 adults (13%) have

more than 2 episodes of some
symptoms of the disease
weekly.

• Hiatus hernia appears at 63%

of patients with GERD and
reflux esophagitis.
 Materials and methods
!!! 2006-2009 – Municipal Clinical Hospital No:1 Chişinău.

40 patients
with HH
(GERD symptoms)

Group I: Group II:

15 HH patients 25 HH patients
operated by operated by
traditional open laparoscopic
surgery: surgery:
Men - 4 Men - 10
Women - 11 Women - 15
 Study Case
• General information: Patient - N. 49
years old was admitted to the Aseptic
Surgery unit in 10/11/2009, with the
diagnosis:
Hiatal Hernia, GERD.
• Complaints: epigastric cramps,
heartburn, nausea, lack of appetite,
constipation (6 days), pain in the left
hypochondrium.
• Medical history: the patient has a
medical history of increased retrosternal
pain (heartburn) continuing for two
weeks, with worsening of her state (she
also had noticed such pain before).
 Esophagogastroduodenoscopy
(EGD)

Histopathological esophageal
Preoperative biopsy examination

patient
Barium cineradiography
evaluation
ECG analysis

Complete blood and urine tests

EGD
09.XI.2009
Lower esophageal sphincter (LES)
relaxed, Z line absent (flap valve), sliding
up the gastric mucosa into the esophagus,
presence of the bell symptom, ulcers,
strictures, shortening of the Esophagus
Conclusion: IV degree reflux esophagitis,
axial HH.
Histopathological esophageal
biopsy examination
09.XI.2009
The lower end of
esophagus:
multilayered epithelium,
gastric mucosa with
intestinal metaplasia,
lymphocytic infiltration.

Conclusion:
Barrett’s esophagus.
Intestinal metaplasia.
Barium X-rays
10.XI.2009
The Esophagus is permeable
for Barite substance. The
stomach has the configuration
of hourglass. Stomach
evacuation is normal,
accompanied by duodenal-
gastric reflux.
In Trendelenburg position
HH and GER aren’t visible.

Conclusion: The stomach has

the configuration of hourglass.
Duodenal-gastric reflux.
 Diagnosis
The diagnosis is based on the general
information, complains, past
medical history and investigation
results (EGD, barium x-rays and
biopsy).

GERD, HH type I, IV degree Reflux

Esophagitis Savary-Miller and
Barrett’s esophagus.
Surgical treatment

• General anesthesia (i/v)

• Laparoscopic approach
11.11.2009, duration -45 min

Plastic repair of the

diaphragmatic crus.
Fundoplication Nissen-Rossetti
Stage I – esophageal
mobilization
1. A pneumo-peritoneum was
induced
2. Preview of hiatus by the
elevation of the left hepatic
lobe
3. Highlighting the right
diaphragm crus (dissection
of the gastro-splenic
omentum )
4. Highlighting the left
diaphragm crus
Stage II – creating retro esophageal
space
1. Full esophageal mobilization:
dissection begining from the
right part through the retro
esophageal areolar tissue

!!!!! Dissection has to be made with

a blunt instrument

!!! Creating an posterior window to

shift the gastric valve

2. Passing a band gauze through

the created space which allows
the mobilization of the inferior
part of esophagus and the
highlight of the hiatal arms.
Stage III – Cruroplasty
(posterior crural repair)
1. Approaching the hiatal
arms and stitching with
non-absorbable stitches.

!!! To avoid postoperative

dysphagia one suture is
made (for sustaining
enough periesophageal
space)
Stage IV - Nissen-Rossetti
Fundoplication
1. Passing of the gastric
fundus through the
posterior window;

2. The two gastric hemi-

valves are sutured with
two stitches which
incorporate the
esophageal muscular
layer.
Postoperative results
A. Short term:
• Duration : 45 min
• In intensive unit care: one day
• Postoperative analgesia: twice a day
• Postoperative complications: abs
• Hospital stay: 4 days
!!!! Barium cineradiography (the 3-th day):
Non-essential esophageal dilatation of the superior
sphincter. The Esophagus is permeable for
Barite substance
Postoperative results
B. Long term:
• Complete recovery: in 21
days

!!!! Histopathological
esophageal biopsy
examination made
second time
(11.10.2009):
In the lower end of
esophagus the intestinal
metaplasia disapeared.
 Study results

• Duration of surgery
(min)
 Intraoperative spleen injury:
In first group - 3 cases (20%)
 ±

Hospital stay: Group 1 - 9 days ± 2 days

Group 2 - 4 days ± 1 day
 ±

Recovery period :
Group 1 - 45 days± 10 days
Group 2 - 20 days ± 5 days
 Conclusions
Us a result of our study towards the
laparoscopic treatment of HH, GERD an
Esophagus Barrett we present following
conclusions:
– It is a mini invasive and more accessible method
treatment (100%)
– The surgical treatment’s timing is reduced
(100+/- 20 min)
– Intra-operative spleen damage is absent
– Post-operative pain is less accentuated
– Hospital staying is reduced
– Patients recover faster after laparoscopic surgery
then open surgery
Thank you !!!!!