Transabdominal esophagectomy

Esophageal myotomy is the most widely used procedure for the treatment of achalasia. Surgery can be performed via the left chest or abdominal cavity. The transthoracic approach is generally considered to be better. However, in elderly or infirm patients, the risk of transabdominal approach is less and the operation is faster. If a longer myometrial incision or simultaneous anti-reflux surgery is required, it is suitable for the application of the thoracotomy. If the patient's esophagus has undergone surgery, or other operations must be performed at the same time (such as resection of the upper iliac crest or repair of hiatal hernia), or suspected of having a cancer, the transthoracic approach is also appropriate. Treatment of diseases: esophagitis, gastroesophageal reflux disease Indication Transabdominal esophageal ablation is applicable to: 1. The medical treatment is not effective, the esophageal dilatation and flexion are obvious, or there are other pathological changes, such as supraorbital diverticulum, hiatal hernia or suspected cancer. 2. Have undergone dilatation treatment, or lead to gastroesophageal reflux and esophagitis. 3. The symptoms are severe and do not want to be esophageal dilatation. Contraindications 1. Patients with severe heart and lung function. 2. The nutritional status is low, and the hemoglobin is lower than 6.0g/L. Preoperative preparation 1. People with malnutrition should be corrected before surgery. They can be intubated through central venous, supported by parenteral nutrition or treated with internal medicine or dilatation, so that they can enter the liquid food by mouth. 2. Patients with pulmonary complications should be treated appropriately. 3. Because the food is retained in the esophagus, the esophagus has different degrees of inflammation. The esophagus should be inserted into the stomach tube once a day for 3 days before surgery, and the antibiotic solution is injected after washing. Repeat 1 time before anesthesia to remove the accumulated secretions overnight and leave the stomach tube. Premedication should not be given to pills or tablets. Surgical procedure Incision The median incision in the upper abdomen or the incision in the left median. 2. revealing the field After exploring the abdominal cavity, push the large and small intestines down, do not occupy the surgical field, pull the left lobe of the liver to the lower right, cut the triangular ligament and cut the peritoneal reflex of the junction of the diaphragm and the esophagus. 3. Free esophagus The vagus nerve was confirmed by blunt dissociation around the esophagus, and the distal end of the esophagus was wound around a gauze to expose the stenosis of the gastroesophageal junction. Free left vagus vagus nerve, if the vagus nerve obstructs the esophagus to move down, the vagus nerve is cut off, and the right branch is left behind. According to Heller's surgical requirements, the esophageal muscle layer is cut at least 5 to 8 cm. Since the esophageal abdomen is only 3 cm long, the vagus nerve must be cut and the esophagus can be pulled down. 4. Cut the esophageal muscle layer The left hand is holding the esophagus, the thumb is placed in front, and a small vertical incision is made in the anterior wall of the narrow center with a blade. The muscle fibers were separated by a blunt-right angle clamp, the ring muscle was exposed and cut, and the right angle forceps were separated into the deep layer until the submucosa. The muscle layer and the submucosa are easily peeled off, and the visceral head is cut into the muscle layer in the submucosal plane. The proximal end should include the 2 cm dilatation esophagus, and the distal end should be 1 cm below the gastroesophageal junction. 5. Separate the esophageal muscle layer After the muscle layer is incision, the muscle layer is released to both sides to half of the circumference of the esophagus, so that the mucosa can naturally bulge. Check whether the hemostasis at the incision of the muscular layer is sufficient and the mucosa is intact. The esophagus is inflated to check for air leaks. After confirming that hemostasis and mucosa are intact, the abdominal cavity is closed, and drainage is generally not allowed. 6. pyloricplasty It is advisable to perform pyloric angioplasty for the vagus nerve. In the anterior wall of the pylorus, longitudinal incision, transverse full-thickness suture, sphincter and ring muscle must be completely cut to facilitate gastric drainage. 7. Abdominal drainage If there is serious pollution during operation, a drainage strip or drainage tube can be placed next to the cardia to avoid postoperative axillary abscess or peritonitis.