Basso N, De Leo A, Genco A, Rosato P, Rea S, Spaziani E, Primavera A
II Clinica Chirurgica, Policlinico Umberto I, Università La Sapienza, Viale del Policlinico 155, 00161 Roma, Italy.
Surg Endosc. 2000 Feb;14(2):164-9. doi: 10.1007/s004649900092.
Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure has been widely employed for the treatment of symptomatic gastroesophageal reflux disease (GERD) and/or hiatal hernia. However, a relatively high incidence (7-11%) of intrathoracic Nissen valve migration/paraesophageal hernia following laparoscopic fundoplication has recently been reported.
Between November 1992 and August 1995, 65 consecutive patients with severe GERD and/or hiatal hernia underwent laparoscopic 360 degrees fundoplication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen valve migration had occurred within 4 months. Six of these patients were symptomatic and were again submitted to the laparoscopic intervention. Videotapes of both the first and second operation were reviewed. In all cases, it was apparent that, at the first operation, closure by stitches of the hiatus was under tension, and at the second operation, the muscle fibers of the right crus were disrupted, probably due to the tension between the suture margins during the inspiratory movements of the diaphragm. These findings prompted us to perform an effective tension-free closure of the hiatus. A polypropylene mesh (3 x 4 cm) was placed on the hiatus behind the esophagus and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 on the lateral sides of the right and left cruses).
Between August 1995 and February 1998, the technique, complete with 360 degrees fundoplication, was used for 67 patients with GERD. At mean follow-up of 22.5 months (range, 1-30), there was no evidence of postoperative paraesophageal hernia or complications related to the use of the mesh.
This tension-free hiatoplasty seems to be an effective solution to prevent postoperative paraesophageal hernia in patients undergoing antireflux laparoscopic surgery. However, longer follow-up is still needed.
自1989年库希耶里首次描述腹腔镜下尼森胃底折叠术以及1991年达勒马涅之后，该手术已被广泛用于治疗有症状的胃食管反流病（GERD）和/或食管裂孔疝。然而，最近有报道称腹腔镜胃底折叠术后胸内尼森瓣膜移位/食管旁疝的发生率相对较高（7 - 11%）。
1992年11月至1995年8月期间，65例连续的重度GERD和/或食管裂孔疝患者接受了腹腔镜360度胃底折叠术。在这65例患者中的9例（13.8%），胸内尼森瓣膜在4个月内发生了移位。其中6例患者有症状，并再次接受了腹腔镜干预。对第一次和第二次手术的录像进行了回顾。在所有病例中，很明显，在第一次手术时，食管裂孔的缝合关闭处于张力状态，而在第二次手术时，右膈脚的肌纤维被破坏，这可能是由于膈肌吸气运动期间缝合边缘之间的张力所致。这些发现促使我们进行有效的无张力食管裂孔关闭。将一块聚丙烯网片（3×4厘米）置于食管后方的食管裂孔处，并用8个金属夹固定（左右膈脚的上缘各2个 + 2个，两侧各2个 + 2个）。
1995年8月至1998年2月期间，该技术（包括360度胃底折叠术）用于67例GERD患者。平均随访22.5个月（范围1 - 30个月），没有证据表明有术后食管旁疝或与使用网片相关的并发症。
这种无张力食管裂孔成形术似乎是预防接受抗反流腹腔镜手术患者术后食管旁疝的有效解决方案。然而，仍需要更长时间的随访。
