腹腔镜改进HILL胃镜：«SNOW »技术（图文演示）

LAPAROSCOPIC   MODIFIED   HILL   ESOPHAGOGASTROPEXY:   «   SNOW   »   TECHNIQUE
Authors
J Marescaux
Abstract
The description of the laparoscopic modified Hill esophagogastropexy: ''Snow'' technique covers all aspects of the surgical procedure used for the management of gastroesophageal reflux.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, mobilization of esophagus, suturing of crura, esophagogastropexy.
Consequently, this operating technique is well standardized for the management of this condition.

英文版：腹腔镜改进HILL胃镜：«SNOW »技术（中文图文演示）

1. Introduction

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The Hill gastropexy (Hill, Ann Surg, 1967) aims at restoring normal physiological antireflux mechanisms without adverse effects and with a low recurrence rate.
Our open surgery technique has been standardized since 1987 and has been performed laparoscopically since 1991 for type I and type II hiatal hernias.

2. Anatomy
• Anti-reflux zone

1. Lesser omentum
2. Left lobe of the liver
3. Esophageal hiatus
4. Diaphragm
5. Pleura
6. Spleen
The normal ''anti-reflux zone'' anatomy (ARZ) is composed of a 2 to 5 cm segment of esophagus fixed below the hiatus to the diaphragm, crura and stomach by ligamentous attachments. Maintenance of normal relationships between these structures is essential to the integrity and function of anti-reflux mechanisms.

• Crura/ stomach attachments

1. Triangular ligament
2. Phrenoesophageal ligament
3. Gastrophrenic ligament
4. Gastrosplenic ligament
5. Short gastric vessels
6. Left kidney
7. Toldt’s fascia
8. Crura of the diaphragm

• Mechanisms
• Principles

1. Anterior vagus nerve
2. Lesser omentum (cut off)
3. Crura
4. Aorta
5. Esophagogastric angle
6. Cardia of the stomach
Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:
- the esophagogastric valve (EGV),
- the lower esophageal 'sphincter effect' (LESE).

• Esophagogastric valve

Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:
- the esophagogastric valve (EGV),
- the lower esophageal 'sphincter effect' (LESE).

• LES effect




Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:
- the esophagogastric valve (EGV),
- the lower esophageal 'sphincter effect' (LESE).

• Crura

1. Right crus
2. Left crus
3. Crural decussation
4. Crural tendon
5. Median arcuate ligament
6. Aorta

3. Classification
• Hiatal hernias

1. Thoracic esophagus
2. Thoracic cavity
3. Right crus
4. Left crus
5. Abdominal esophagus
6. Fundus of the stomach
Hiatal hernias cause most gastroesophageal reflux diseases (GERD).

• Type I hiatal hernias
• Classification

Type I, or sliding hiatal hernias, have an intact attenuated phrenoesophageal ligament.
They can be subclassified according to 3 anatomically distinct stages of evolution.

• Stage 1

Sliding hiatal hernias occur when the abdominal esophagus migrates through the hiatus while the gastroesophageal junction (GEJ) and stomach remain below.
As the abdominal esophagus migrates, the EGV disappears due to the widening of the esophagogastric angle, and the LESE diminishes due to the loss of anatomical relationships and extrinsic pressures.
This may not be appreciated on endoscopy or barium study.
This would explain the reports of GERD without a hiatal hernia.

• Stage 2

Stage 2 sliding hiatal hernias occur when the gastroesophageal junction and stomach migrate above the diaphragm.
The EGV can reform above the diaphragm, preventing reflux.
This may explain reports of sliding hiatal hernias without GERD.

• Stage 3

Stage 3 sliding hiatal hernias have a shortened esophagus with fixation of the gastroesophageal junction above the diaphragm due to scarring.
True stage 3 hiatal hernias are rare.

• Type II hiatal hernias

Type II, or paraesophageal hiatal hernias, occur through a defect in the phrenoesophageal ligament.
The gastroesophageal junction nonetheless remains in the abdominal cavity.

4. Indications

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Indications for this procedure are as follows:
- type I and II hernias;
- intolerance or noncompliance to continuous medical treatment (required for treatment of GERD);
- complications of GERD (hemorrhage, ulcer).

5. Operating room set-up
• Patient

- general anesthesia;
- supine position;
- legs adducted (placed together);
- reverse Trendelenburg (not mandatory);
- dual lumen gastric tube;
- urinary catheter (not mandatory).

• Team

1. The surgeon stands on the patient's left.
2. The assistant stands on the patient's right.
3. The scrub nurse stands on the surgeon's left.

• Equipment

The first monitor is used by the surgeon.
The second monitor is used by the assistant.
The laparoscopic and video units are on the patient's right.

6. Trocar placement
• Anatomical landmarks

1. Xiphoid
2. Costal margin
3. Midline
The procedure is performed with 5 trocars (three 10 mm trocars, two 5 mm trocars).
An important principle is to place ports so as to prevent the instruments from interfering with each other.

• Trocars

Port A is 10mm in size, accommodates the laparoscope and is positioned on the midline above the umbilicus.
Port B is 5mm in size, accommodates the grasping forceps and is positioned in the right upper quadrant.
Port C is 10mm in size, accommodates the liver retractor and is positioned in the right subcostal area.
Port D is 10mm in size, accommodates the atraumatic grasper and is positioned in the left subcostal area.
Port E is 5mm in size, accommodates the dissecting and suturing devices and is positioned in the left upper quadrant.

7. Instrumentation
• Instruments

A: 30° or 45° laparoscope
B: Grasping forceps
C: Liver retractor
D: Atraumatic grasper
E: Hook dissector and scissors for diathermy, suction-irrigation device, needle holder

• Optical device

A: 30° or 45° laparoscope

• Operating devices

B: Grasping forceps
E: Hook dissector and scissors for diathermy, suction-irrigation device, needle holder

• Retracting devices

C: Reusable liver retractor, disposable liver retractor
D: Atraumatic grasper

• Optional devices

8. Major principles

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The laparoscopic Hill gastropexy aims at restoring both normal anatomy and physiological antireflux mechanisms. It involves:
- freeing of the abdominal esophagus;
- retroesophageal cruroplasty;
- posterior gastropexy down to the origin of the crura;
- recreation of the angle of His with a gastropexy sutured to the diaphragm.

9. Exposure
• Reverse Trendelenburg

The reverse Trendelenburg position causes the spontaneous lowering of the abdominal organs, giving a greater exposure of the operative field. However, it is not mandatory.

• Gastric clearance

A dual lumen gastric tube is placed to decompress the stomach.
It is removed at the beginning of the reapproximation of the crural defect.

• Reducing the hernia

The liver and falciform ligament are retracted.
The hernia is reduced with graspers via the operating trocars.