胃食管反流病：术中并发症（图文演示）

GASTROESOPHAGEAL   REFLUX   DISEASE:   INTRAOPERATIVE   COMPLICATIONS
Authors
J Marescaux
Abstract
The description of the intraoperative complications relating to gastroesophageal reflux disease covers all aspects of intraoperative complications.
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: perforations, hemorrhage, pneumothorax, emphysema, vagus nerve trauma.


中文版：胃食管反流病：术中并发症（中文图文演示）

1. Introduction
In the order of 5%:
1. Esophageal or gastric perforations
2. Hemorrhage
3. Pneumothorax
4. Mediastinal emphysema
5. Vagus nerve trauma

2. Perforations

Frequency:
- rare (approximately 1%);
- dangerous if not immediately recognized as they carry a mortality of 20 to 50%.
Mechanisms:
- placement of a bougie or nasogastric tube,
- traumatic manipulations of the esophagus sometimes attenuated by a inflammation,
- blind dissection in the absence of fixed anatomic landmarks.
What to do:
Primary closure of the perforation covered with the fundoplication.

3. Hemorrhage

Frequency:
- rare, often mild not requiring transfusions.
Mechanism:
Bleeding could originate from:
a. the abdominal wall, at a trocar insertion site;
b. a short gastric vessel;
c. a diaphragmatic artery, especially at the level of the left crus;
d. hepatic trauma with a retractor or instrument;
e. a splenic laceration.
What to do:
a. suture ligation;
b. and c. hemostatic control using bipolar coagulation;
d. compression with a retractor or use of argon beam coagulator;
e. use of Argon beam coagulator or fibrin glue.

4. Pneumothorax

Frequency:
- CO2 pneumothorax is a specific but benign complication of the laparoscopic approach;
- its incidence is approximately 3%, but is likely underestimated.
Mechanism:
It is caused by rupture of the pleura, more often on the left than on the right one, during a prolonged mediastinal dissection.
What to do:
The treatment of the pneumothorax involves modification of the ventilation parameters with the addition of PEEP (positive end expiratory pressure).
Thoracic drainage is not necessary: the postoperative chest radiograph is often normal as the CO2 is rapidly absorbed.

5. Emphysema
Frequency: rare
Mechanism:
Mediastinal and/or subcutaneous emphysema can present occasionally during or after an operation when the hiatal dissection is too deep or prolonged.
What to do:
The first therapeutic measure is to adjust the ventilatory rate with or without a reduction of the insufflated pressure.

6. Vagus nerve trauma

Frequency:
- rarely reported, as it often goes unrecognized.
Mechanism:
The nerve can inadvertently be divided using electrocautery or damaged by diffusion of electrocautery current:
1: during the dissection of the posterior aspect of the esophagus for the posterior vagus nerve.
2: during the dissection of the phrenoesophageal membrane for the anterior vagus nerve.
What to do:
Prevention: careful dissection and identification of the 2 nerves.