Hill repair posterior gastric wall fixation

This procedure is to repair the refractory esophagitis by a hole in the abdominal incision. Principle of surgery: 1. Restore the abdominal esophagus and maintain the length of the esophageal segment of the abdomen. 2. Increase the gastroesophageal angle (His angle). 3. Tightening the laryngeal fibers of the cardia to increase the intraluminal pressure of the lower esophageal sphincter. Treatment of diseases: reflux esophagitis Indication Hill repair posterior wall fixation is suitable for: 1. Refractory reflux esophagitis, systemic medical treatment is invalid. 2. Reflux esophagitis has caused esophageal ulcers, stenosis, hemorrhage and respiratory complications. 3. Reflux esophagitis caused by esophageal hiatal hernia, accompanied by intra-abdominal organ diseases, such as gastroduodenal ulcer or pyloric obstruction, requiring intra-abdominal surgery. 4. Larger esophageal hiatus hernia has oppressed the internal organs of the chest and developed cardiopulmonary dysfunction. 5. Barrett's esophagus. Contraindications 1. The patient is obese and the abdomen is difficult to show. 2. The nutritional status is low and no correction is obtained. 3. Serious adhesion around the esophagus. 4. Others are not suitable for surgery. Preoperative preparation 1. Epidural anesthesia or intravenous general anesthesia, endotracheal intubation. 2. In the supine position, the ribs in the left quarter are slightly raised (30°). Surgical procedure 1. Through the mid-abdominal incision, the xiphoid process is reached, down to the umbilicus. If the xiphoid is thick or bent into the abdomen, the surgical field can be removed. If the spleen adheres to the big curvature of the stomach and seriously affects the degree of freeness, it can also be removed together. 2. After entering the abdominal cavity, the left lobular ligament of the left lobe of the liver is first cut, and the left lobe of the liver is pulled to the right side, and the assistant assists in retracting the stomach to the left side. The esophageal membrane was dissected to reveal the hiatus of the esophageal tract, and the fibrous cellulite of the esophageal bundle formed by the gastroesophageal junction was maintained as much as possible. 3. Cut the small omentum to reveal the esophageal hiatus, free the lower part of the esophagus and gently pull the esophagus to the left side, and cut the appendage of the cardia and diaphragm. Separate the fibrous tissue around the esophageal hiatus. It is generally not necessary to cut off the short blood vessels of the stomach and, if necessary, cut off the uppermost one. The upper part of the esophageal ligament and the spleen and stomach ligament were cut off, the stomach bottom was released upward, and the stomach was pulled to the left to reveal the anatomical structure behind the stomach. The abdominal aorta and celiac artery can be accessed after the anterior fascia of the abdominal aorta. The median arcuate ligament is located just above the celiac trunk. Open the anterior fascia of the abdominal aorta, and extend the finger from the anterior fascia of the abdominal aorta to the celiac artery for blunt dissection. Gently push the celiac artery to separate the anterior fascia of the abdominal aorta from the abdominal aorta. , revealing the median arcuate ligament. The anterior fascia of the abdominal aorta is lifted with a Babcock forceps close to the finger, and the suture can directly pass through the anterior fascia of the abdominal aorta to avoid damage to the celiac artery. 4. The esophageal hiatus is loosely sutured at the back of the esophagus with a non-absorbent suture, so that the width of a fingertip is appropriate. Turn the stomach over and reveal the esophageal bundle before and after. The needle is inserted from the anterior iliac esophagus with a non-absorbable suture, and the posterior esophageal bundle and the aorta fascia are worn. Usually 4 to 5 stitches are stitched. First, the upper 3 needles are tied and then clamped with a long hemostatic forceps. At this time, the pressure of the gastroesophageal junction area should be measured, and a pressure measuring tube should be placed nasally at the gastroesophageal junction, and the tightness of the knot should be adjusted according to the pressure measurement result. If the pressure is greater than 5.33 kPa (40 mmHg), the knotted suture will be relaxed; if the pressure is less than 3.33 kPa (25 mmHg), the knot should be tightened. After the pressure adjustment is appropriate [3.33 ~ 4.67kPa (25 ~ 35mmHg)], first tighten the second knot of the above three needles, and then tie the remaining two sutures. At this time, the length of the esophagus in the abdomen is about 3 to 4 cm. Finally, the fundus and diaphragm were sutured and fixed by one needle. complication 1. vagus nerve injury. 2. Gastric paralysis or pyloric obstruction. 3. Postoperative pulmonary inflammation, atelectasis, and even abscess formation. 4. Incision infection, underarm abscess, peritonitis. 5. Late complications include recurrence of hiatal hernia, esophagitis and esophageal stricture.