Operative Techniques in Foregut Surgery [1 ed.]

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Editor Daniel Albo MD, PhD Dan L. Duncan Professor and Vice Chairman Director, GI Oncology Michael E. DeBakey Department of Surgery Houston, Texas

Editor-in-Chief Michael W. Mulholland MD, PhD Professor of Surgery and Chair Department of Surgery University of Michigan Medical School Ann Arbor, Michigan P.v

Contributing Authors Matthew Albert, MD Florida Hospital Orlando, Florida Daniel Albo, MD, PhD Dan L. Duncan Professor and Vice Chairman Director, GI Oncology Michael E. DeBakey Department of Surgery Houston, Texas Melissa M. Alvarez-Downing, MD Resident Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic Florida Weston, Florida Daniel A. Anaya, MD Associate Professor Chief Section of General Surgery and Surgical Oncology Operative Care Line Michael E. DeBakey VA Medical Center Department of Surgery Division of Surgical Oncology Baylor College of Medicine Houston, Texas Avo Artinyan, MD, MS

Assistant Professor of Surgery Division of Surgical Oncology Baylor College of Medicine American Cancer Society Cancer Liaison Physician Michael E. DeBakey VA Medical Center Houston, Texas Erik Askenasy, MD Assistant Professor of Surgery Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston, Texas Valerie Bauer, MD, FACS, FASCRS Attending Physician Bay Area Colorectal Surgical Associates Texas City, Texas Assistant Clinical Professor of Surgery Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine Houston, Texas David Berger, MD, MHCM Professor of Surgery Vice Chair of Surgery Michael E. DeBakey VA Medical Center Vice President Chief Medical Officer Department of Surgery Baylor College of Medicine Houston, Texas Jaime L. Bohl, MD, FACS Assistant Professor Department of General Surgery Wake Forest School of Medicine Winston-Salem, North Carolina Reshma Brahmbhatt, MD Resident Michael E. DeBakey VA Medical Center Department of Surgery Division of General Surgery Baylor College of Medicine Houston, Texas

Susan M. Cera, MD, FACS, FASCRS Clinical Professor Chief of Staff Department of Colorectal Surgery Physicians Regional Healthcare System Physicians Regional Medical Group Naples, Florida Clinical Professor Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic Florida Weston, Florida George J. Chang, MD, MS Associate Professor of Surgery Chief Colon and Rectal Surgery Department of Surgical Oncology The University of Texas MD Anderson Cancer Center Houston, Texas Robert R. Cima, MD, MA Consultant Division of Colon and Rectal Surgery Mayo Clinic Professor of Surgery Mayo Medical School Rochester, Minnesota Bidhan Das, MD Clinical Associate Professor Colon and Rectal Surgery Department of Surgery University of Texas Health Science Center at Houston Staff Surgeon Colon and Rectal Clinic of Houston Staff Colon and Rectal Surgeon Houston Methodist Center for Restorative Pelvic Medicine Staff Colon and Rectal Surgeon Memorial Hermann Hospital System Staff Colon and Rectal Surgeon CHI St. Luke's Health-Baylor St. Luke's Medical Center Houston, Texas Roosevelt Fajardo, MD, MBA, FACS Department of Surgery

Fundacion Santa Fe de Bogota Director Center for Innovation in Health and Education, Fundacion Santa Fe Assistant Professor Los Andes University School of Medicine Bogotá, Colombia Barry Feig, MD Professor Department of Surgical Oncology The University of Texas MD Anderson Cancer Center Houston, Texas Daniel L. Feingold, MD Associate Professor Department of Surgery Division of Colon and Rectal Surgery New York-Presbyterian Hospital Columbia University Medical Center New York, New York Wayne A.I. Frederick, MD Interim President Provost and Chief Academic Officer Howard University Hospital Washington, DC P.vi Kelly A. Garrett, MD, FACS, FASCRS Assistant Professor of Surgery Department of General Surgery Division of Colon and Rectal Surgery New York-Presbyterian Hospital Weill Cornell Medical College New York, New York Eric M. Haas, MD, FACS, FASCRS President Colorectal Surgical Associates, Ltd, LLP Program Director Minimally Invasive Colon and Rectal Surgery Fellowship University of Texas Health Science Center at Houston Clinical Associate Professor Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine

Houston, Texas Karin M. Hardiman, MD, PhD Assistant Professor of Surgery Department of Surgery Division of Colorectal Surgery University of Michigan Health System Ann Arbor, Michigan Andrew G. Hill, MD, EdD, FRACS, FACS Colorectal Surgeon Department of General Surgery Middlemore Hospital Professor of Surgery and Head South Auckland Clinical School Faculty of Medical and Health Sciences University of Auckland Auckland, New Zealand Joshua S. Hill, MD, MS Surgical Oncologist Department of General Surgery Division of Surgical Oncology Levine Cancer Institute Charlotte, North Carolina Mehraneh D. Jafari, MD Department of Surgery School of Medicine University of California, Irvine Orange, California Douglas W. Jones, MD Resident Department of General Surgery New York-Presbyterian Hospital Weill Cornell Medical College New York, New York Lillian S. Kao, MD, MS Professor Vice Chair for Quality Department of Surgery University of Texas Health Science Center at Houston Houston, Texas Hasan T. Kirat, MD

Department of Colorectal Surgery Cleveland Clinic Foundation Cleveland, Ohio Cherry E. Koh, MD, MBBS (Hons), MS, FRACS Department of Colorectal Surgery Royal Prince Alfred Hospital Clinical Research Fellow Surgical Outcomes Research Centre University of Sydney Sydney, New South Wales, Australia Sang W. Lee, MD Associate Professor of Surgery Department of Surgery Weill Cornell Medical College New York, New York Steven A. Lee-Kong, MD Assistant Professor Department of Surgery Division of Colon and Rectal Surgery Columbia University Medical Center Colon and Rectal Surgery New York-Presbyterian Hospital New York, New York Joël Leroy, MD, Hon FRCS IRCAD/EITS Department of General, Digestive and Endocrine Surgery University Hospital of Strasbourg Strasbourg, France Edward A. Levine, MD Department of Surgery Section of Surgical Oncology Wake Forest School of Medicine Winston-Salem, North Carolina Mike K. Liang, MD Assistant Professor of Surgery Department of Surgery Division of General Surgery Michael E. DeBakey VA Medical Center Baylor College of Medicine Houston, Texas

Kathleen R. Liscum, MD Chief Section of General Surgery Ben Taub General Hospital Associate Professor of Surgery Division of General Surgery Michael E. DeBakey VA Medical Center Department of Surgery Baylor College of Medicine Houston, Texas Luis Jorge Lombana, MD Colon and Rectal Surgeon Hospital Universitario San Ignacio Associate Professor of Surgery Pontificia Universidad Javeriana Bogotá, Colombia Jacques Marescaux, MD, FACS, Hon FRCS, Hon FJSES IRCAD/EITS Department of General, Digestive and Endocrine Surgery University Hospital of Strasbourg Strasbourg, France John H Marks, MD, FACS, FASCRS Chief Division of Colorectal Surgery Director Minimally Invasive Colorectal Surgery and Rectal Cancer Management Fellowship Lankenau Medical Center Professor Lankenau Institute of Medical Research Wynnewood, Pennsylvania Craig A. Messick, MD Clinical Assistant Professor Department of Surgical Oncology Section of Colon and Rectal Surgery The University of Texas MD Anderson Cancer Center Houston, Texas Stefanos G. Millas, MD Assistant Professor Department of Surgery University of Texas Health Science Center at Houston

Houston, Texas Somala Mohammed, MD Resident Michael E. DeBakey VA Médical Center Department of Surgery Baylor College of Medicine Houston, Texas Arden M. Morris, MD, MPH Associate Professor of Surgery Chief Division of Colorectal Surgery University of Michigan Health System Ann Arbor, Michigan P.vii Matthew G. Mutch, MD Associate Professor of Surgery Department of Surgery Section of Colon and Rectal Surgery Washington University School of Medicine St. Louis, Missouri Didier Mutter, MD, PhD, FACS IRCAD/EITS Department of General, Digestive and Endocrine Surgery University Hospital of Strasbourg Strasbourg, France Govind Nandakumar, MD Assistant Professor of Surgery Department of Surgery Weill Cornell Medical College New York, New York Tolulope Oyetunji, MD Pediatric Surgery Fellowship University of Missouri Columbia, Missouri Rodrigo Pedraza, MD Colorectal Surgical Associates, Ltd, LLP Minimally Invasive Colon and Rectal Surgery Fellowship The University of Texas Medical School at Houston Houston, Texas Alessio Pigazzi, MD, PhD

Chief Department of Surgery Division of Colorectal Surgery School of Medicine University of California, Irvine Orange, California Harsha Polavarapu, MD Florida Hospital Orlando, Florida Reese W. Randle, MD Department of Surgery Section of Surgical Oncology Wake Forest School of Medicine Winston-Salem, North Carolina Scott E. Regenbogen, MD, MPH Assistant Professor Department of Surgery Division of Colorectal Surgery University of Michigan Health System Ann Arbor, Michigan Feza H. Remzi, MD Chairman Department of Colorectal Surgery Cleveland Clinic Foundation Cleveland, Ohio Saul J. Rugeles, MD Chairman Department of Surgery Titular Professor of Surgery Gastrointestinal Surgeon Hospital Universitario San Ignacio Pontificia Universidad Javeriana Bogotá, Colombia Tarik Sammour, BHB, MBChB, PhD Surgical Registrar Department of General Surgery Middlemore Hospital Auckland, New Zealand William Sanchez, MD, FACS

Professor of Surgery Chair Department of Surgery Hospital Militar Central Universidad Militar Nueva Granada Bogotá, Colombia Shiva Seetahal, MD Minimally Invasive Surgery/Bariatric Surgery Fellowship Atlanta Medical Center Atlanta, Georgia Perry Shen, MD Department of Surgery Section of Surgical Oncology Wake Forest School of Medicine Winston-Salem, North Carolina Margaret V. Shields, BA Division of Colorectal Surgery Main Line Health Lankenau Medical Center Wynnewood, Pennsylvania Eric J. Silberfein, MD Ben Taub General Hospital Assistant Professor Michael E. DeBakey Department of Surgery Division of Surgical Oncology Baylor College of Medicine Houston, Texas Michael J. Solomon, MB ChB, BAO, MSc, FRACS Senior Colorectal Surgeon Department of Colorectal Surgery Head and Director Surgical Outcomes Research Centre Royal Prince Alfred Hospital Clinical Professor of Surgery Discipline of Surgery University of Sydney Sydney, New South Wales, Australia Andrew Stevenson, MBBS, FRACS Head of Unit and Colorectal Surgeon Colorectal Unit

Department of Surgery Royal Brisbane and Women's Hospital Senior Lecturer School of Medicine Faculty of Health Sciences University of Queensland Brisbane, Queensland, Australia John H. Stewart, IV MD, MBA Department of Surgery Wake Forest School of Medicine Winston-Salem, North Carolina James Suliburk, MD Attending Surgeon Ben Taub General Hospital Assistant Professor of Surgery Michael E. DeBakey VA Médical Center Department of Surgery Division of General Surgery Baylor College of Medicine Houston, Texas David Taylor, MBBS, FRACS Colorectal Surgeon Colorectal Unit Department of Surgery Royal Brisbane and Women's Hospital Senior Lecturer School of Medicine Faculty of Health Sciences University of Queensland Brisbane, Queensland, Australia Ryan M. Thomas, MD Assistant Professor Department of Surgery North Florida/South Georgia Veterans Health System Assistant Professor Department of Surgery University of Florida College of Medicine Gainesville, Florida Kathrin Mayer Troppmann, MD, FACS Professor of Surgery Department of Surgery Division of Gastrointestinal and Minimally Invasive Surgery University of California Davis School of Medicine

Sacramento, California Elsa B. Valsdottir, MD Department of General Surgery University Hospital of Iceland Associate Professor University of Iceland Medical School Reykjavik, Iceland P.viii Oliver Varban, MD Assistant Professor of Surgery Minimally Invasive Surgery and Bariatrics University of Michigan Health System Ann Arbor, Michigan Theodoros Voloyiannis, MD, FACS, FASCRS Clinical Assistant Professor in Surgery Medical Group Memorial Hermann Hospital Colon and Rectal Surgery University of Texas Health Science Center at Houston Houston, Texas Konstantinos I. Votanopoulos, MD, PhD, FACS Assistant Professor Department of General Surgery Comprehensive Cancer Center Wake Forest School of Medicine Winston-Salem, North Carolina Rebecca L. Wiatrek, MD Assistant Professor Department of Surgery University of Texas Health Science Center at Houston Houston, Texas Curtis J. Wray, MD Associate Professor Department of Surgery University of Texas Health Science Center at Houston Houston, Texas Y. Nancy You, MD, MHSc Assistant Professor Department of Surgical Oncology

The University of Texas MD Anderson Cancer Center Houston, Texas

2015 Lippincott Williams & Wilkins Philadelphia Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103 USA 978-1-4511-9017-5

Acquisitions Editor: Keith Donnellan Product Development Editor: Brendan Huffman Production Project Manager: David Saltzberg Design Coordinator: Doug Smock Senior Manufacturing Manager: Beth Welsh Marketing Manager: Daniel Dressler Prepress Vendor: Absolute Service, Inc. Copyright © 2015 Wolters Kluwer Health All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer Health at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Operative techniques in foregut surgery/editor, Mary Hawn ; editor-in-chief, Michael W. Mulholland. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-9017-5 (hardback: alk. paper) I. Hawn, Mary T., editor. II. Mulholland, Michael W., editor. III. Operative techniques in surgery. Contained in (work): [DNLM: 1. Digestive System Surgical Procedures. 2. Gastrointestinal Diseases—surgery. 3. Upper Gastrointestinal Tract—surgery. WI 900] RD32 617.9—dc23 2015004604 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals' examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer's package insert) accompanying each drug to verify, among other things, conditions of use, warnings, and side effects and identify any changes in dosage schedule or contradictions, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com

Dedication To my husband, Eben Rosenthal, who inspires me and has not wavered in his support of my career. Mary T. Hawn

Series Preface Operative therapy is complex, technically demanding, and rapidly evolving. Although there are a number of standard textbooks that cover aspects of general, thoracic, vascular, or transplant surgery, Operative Techniques in Surgery is unique in offering a comprehensive treatment of contemporary procedures. Open operations, laparoscopic procedures, and newly described robotic approaches are all included. Where alternative or complementary approaches exist, all are provided. The scope and ambition of the project is one of a kind. The series is organized anatomically in sections covering thoracic surgery, upper gastrointestinal surgery, hepatopancreatico-biliary surgery, and colorectal surgery. Breast surgery, endocrine surgery, and topics related to surgical oncology are included in a separate volume. Modern approaches to vascular surgery and transplantation surgery are also covered in separate volumes. The series editors are renowned surgeons with expertise in their respective fields. Each is a leader in the discipline of surgery, each recognized for superb surgical judgment and outstanding operative skill. Breast surgery, endocrine procedures, and surgical oncology topics were edited by Dr. Michael Sabel of the University of Michigan. Thoracic and upper gastrointestinal surgery topics were edited by Dr. Mary Hawn of the University of Alabama at Birmingham, with Dr. Steven Hughes of the University of Florida directing the volume on hepatopancreatico-biliary surgery. Dr. Daniel Albo of Baylor College of Medicine directed the volume dedicated to colorectal surgery. Dr. Ronald Dalman of Stanford University edited topics related to vascular surgery, including both open and endovascular approaches. The discipline of transplantation surgery is represented by Dr. Michael Englesbe of the University of Michigan. In turn, the editors have recruited contributors that are world-renowned; the resulting volumes have a distinctly international flavor. Surgery is a visual discipline. Operative Techniques in Surgery is lavishly illustrated with a compelling combination of line art and intraoperative photography. The illustrated material was all executed by a single source, Body Scientific International, to provide a uniform style emphasizing clarity and strong, clean lines. Intraoperative photographs are taken from the perspective of the operating surgeon so that operations might be visualized as they would be performed. The result is visually striking, often beautiful. The accompanying text is intentionally spare, with a focus on crucial operative details and important aspects of postoperative management. The series is designed for surgeons at all levels of practice, from surgical residents to advanced practice fellows to surgeons of wide experience. The incredible pace at which surgical technique evolves means that the volumes will offer new insights and novel approaches to all surgeons.

Operative Techniques in Surgery would be possible only at Wolters Kluwer Health, an organization of unique vision, organization, and talent. Brian Brown, executive editor, Keith Donnellan, acquisitions editor, and Brendan Huffman, product development editor, deserve special recognition for vision and perseverance. Michael W. Mulholland, MD, PhD

Preface As part of the series Operative Techniques in Surgery, this volume focuses on the detailed technical aspects of esophageal and gastric surgery. This book will serve as a guide to surgeons and trainees with an interest in foregut surgery. The unique aspects of this book are the provision of multiple approaches to a surgical problem with step-by-step instructions complemented by detailed illustrations and photos. The contributors to this book are surgeons well known for their technical expertise, with a specific focus on innovative approaches to the challenging practice of surgery. The goal of the textbook is to provide not only the technical steps of an operation but also the tips and pearls from master surgeons on how they approach the procedure. The book succinctly describes preoperative, intraoperative, and postoperative clinical decision making as well as potential pitfalls and how to mitigate them. This book was a major undertaking and could not have been accomplished without the superb work of the authors and illustrators. I would like to thank Dr. Michael W. Mulholland, Brendan Huffman, and Keith Donnellan for their mentorship and guidance in bringing the project together. My hope is that this book will inspire surgeons to perfect their technical skills and bring the best care to their patients. Mary T. Hawn, MD, MPH

Chapter 1 Paraesophageal Hernia Repair: Laparoscopic Technique John G. Hunter Mark J. Eichler

DEFINITION For millennia, the existence of hiatal hernias was well known. First described by Henry Bowditch in 1853, and later in 1951 officially by Philip Allison, the paraesophageal hernia (PEH) presents a physiologic link to reflux esophagitis, ulceration, stricture, and other esophageal pathology.1,2 Of the four types of hiatal hernias known today, 95% of incidence resides with the type I or sliding hiatal hernia, which typically can be managed medically with gastric acid suppression. The remaining three types are lumped as “paraesophageal hernias.” These include the true PEH (type II), combined sliding and paraesophageal (type III), and extragastric (type IV) (FIG 1). With the advent of modern antireflux surgery, failed fundoplication overlaps with this classification (FIG 2). Furthermore, disruption of the esophageal hiatus for other disease processes, such as esophagectomy, potentiates the PEH, especially type IV. This chapter, in concert with other procedures such as fundoplication and esophageal lengthening (Collis gastroplasty), will deal with the surgical management of PEH types II to IV, which anatomically may also encompass redo fundoplication. Principles of repair include definition of anatomy and symptoms, safe reduction of abdominal organs back to the peritoneal cavity, excision of the hernia sac, closure of crura (with or without mesh repair), evaluation of intraabdominal esophageal length, and an antireflux procedure.3,4

PATIENT HISTORY AND PHYSICAL FINDINGS Necessity for PEH repair lies with the patient symptomatology, medical status, and chance of obstruction or strangulation. PEHs can encompass symptoms of gastroesophageal reflux disease (GERD), which includes typical symptoms of heartburn, acid reflux, and dyspepsia. In contrast, atypical GERD symptoms manifest as laryngeal and pulmonary complaints of noncardiac chest pain, dyspnea, poor dentition, sinusitis, asthma, chronic cough, pneumonia, and halitosis. PEH-specific complications include gastric volvulus, incarceration, gastric outlet obstruction, and higher mortality when performed emergently. Early studies on mortality in the 1960s demonstrated mortality rates over 50% for PEHs with associated gastric volvulus, although more recent analysis suggests that number to be overestimated and is actually more likely to be under 20% for such patients in duress from PEH.5,6 For all PEH patients, overall mortality is under 1% and can safely be performed with a laparoscopic approach even in the face of obstruction, gangrene, and so forth.7 Indications for PEH repair therefore should be tailored to patients who are symptomatic and medically likely to survive an operation. Ultimately, most patients who have a PEH will become symptomatic.3,5,6

IMAGING AND OTHER DIAGNOSTIC STUDIES Preoperative diagnostic studies help dictate the range of elective, urgent, and emergent nature of a symptomatic patient with a PEH. In those patients who are in extremis, the minimum workup needed for urgent

or emergent PEH repair is radiographic evidence of incarceration, perforation, obstruction, or failed antireflux surgery. However, the majority of patients present in an elective manner, and we therefore advocate for a complete workup to assist preoperative planning of the symptomatic patient with PEH by the addition of manometry, pH testing, and endoscopy to rule out pseudoobstruction or esophageal motility disorders. Chest x-ray: At presentation, whether to an emergency department or a primary care physician's office, the chest x-ray gives quick and cost-effective information to the severity of the PEH. Mediastinal gas bubble can be seen on plain film radiography as well as the presence of pneumoperitoneum or pneumomediastinum. Esophagram: The supine and upright plain film esophagram demonstrates static anatomy and can often locate the gastroesophageal junction (GEJ) in relation to the diaphragm as well as deduce the presence of reflux on delayed films. Mucosal abnormalities can be seen with this modality as well (FIG 3A,B). Computed tomography (CT): Indications for obtaining CT scans include the emergent presentation, inconclusive but worrisome findings on two-dimensional radiography, and PEH type IV (FIG 4). CT aids the preoperative planning by alerting the surgeon to the extent of skin preparation and positioning for operative repair but is not necessary. Upper endoscopy: All preoperative patients should undergo upper endoscopy if possible. By visualization of the esophageal and gastric lumen, neoplasm, Barrett's esophagus, and esophagitis can be biopsied, and, in case esophagectomy is warranted, provide histologic diagnosis. Furthermore, anatomic landmarks can be seen such as the distance between the hiatus and the GEJ as well as the size of the hiatal hernia. Manometry: Several studies of benign esophageal disorders confirm the use of preoperative manometry.3,8 Distal esophageal pressures greater than 30 mmHg indicate favorable outcome of response to fundoplication, which, according to some surgeons, is a threshold for performing a complete versus partial wrap for the antireflux component of the PEH repair. Manometry also rules out primary esophageal dysmotility including achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter (LES), and ineffective esophageal motility. We do not advocate performing a complete fundoplication for patients with esophageal dysmotility or low distal esophageal pressures. pH study: Although the previous modalities of the PEH workup provide a robust description of the PEH patient, pH studies provide data for the decision in failed antireflux P.2 surgery to dissect and redo a previous fundoplication. In the setting of a negative pH study (by way of DeMeester score