腹腔镜改进HILL胃镜：«SNOW »技术（图文演示）

10. Mobilization/esophagus
• Principles

The following structures are respectively dissected:
1. Inferior part of the lesser omentum
2. Phrenoesophageal ligament
3. Phrenogastric ligament

• Peritoneal layer opening


1. Caudate lobe of the liver
2. Right crus
3. Esophagus and anterior vagus nerve
4. Left crus
5. Aorta
The gastrohepatic ligament is divided. The dissection is continued across the attenuated phrenoesophageal ligament near its origin in the diaphragm, and then posteriorly over the left crus, exposing the esophagus, the right and left crura, and the esophagocrural grooves.

• Crura/ preaortic region dissection

1. Crural decussation
2. Right crus
3. Left crus
4. Arcuate ligament
5. Celiac trunk
The right crus is bluntly dissected on its left aspect, beginning slightly beyond the crural muscle decussation and continuing until the origin of the celiac trunk is visualized. The arcuate ligament is visualized during this operative step.

11. Suturing/crura
• Objective

The aim is to restore an anatomically correct position while preventing stenosis of the hiatus.

• Anterior esophageal retraction

The esophagus is retracted anteriorly, exposing both crura and the crural tendon, just proximal to its insertion into the median arcuate ligament.

• Repair of crural defect



The crural defect is closed with a 0 polypropylene (PPP) suture in a running fashion starting at the superior edge of the crural decussation. The hiatal opening is assessed as sufficient with a 1 cm open grasper.
The suture is tied, approximating the crural muscles without strangulation.

12. Esophagogastropexy
• Principles


By lowering the position of the cardia of the stomach, the normal anatomy of the ARZ is restored, thus enabling the recreation of the angle of His.

• Anchoring the cardia


The distal abdominal esophagus is fixed by suturing the posteriomedial wall of the cardia to the body of the crural decussation and tendon with a figure-of-eight 0 PPP suture.

• Esophagogastropexy

The EGV is re-established by suturing the fundus of the stomach to the entire length of the abdominal esophagus and to the diaphragm with a running, 2-0 PPP suture.

• Final suture strengthening



The final running stitch anchors the fundus to the diaphragm, while reinforcing and protecting the previous stitch (which included the stomach, crura, phrenoesophageal ligament and proximal end of the abdominal esophagus).
The phrenoesophageal ligament is then sutured to the proximal abdominal esophagus with several interrupted 4-0 PPP sutures.
The sutures are placed so as not to create tension or injure the vagus nerves.
The entire abdominal esophagus is now secured within the abdominal cavity, restoring both the LESE and the EGV.

13. Postop management

▶
The nasogastric tube is removed a few hours after the end of the procedure.
Fluid intake begins on the day of the procedure.
Solid intake begins on the first postoperative day.
The patient usually leaves hospital on the second postoperative day.

14. Reference

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