Surgery of the Esophagus & Stomach

Question 1

what are the 4 layers of the esophagus and which layer is the esophagus missing that the stomach has?

bonus: which layer is the holding layer

Answer 1

1. Adventitia
2. Muscularis
3. Submucosa
4. Mucosa

missing serosa
holding layer is still the submucosa

Question 2

what surgical approach would you take for each of the following surgical locations?

A. Cervical
B. Thoracic
C. Abdominal

Answer 2

A. Cervical – ventral midline
B. Thoracic – thoracotomy
C. Abdominal – ventral midline celiotomy

sometimes you may need a combined approach

Question 3

What are the surgical principles that should be applied for surgery of the esophagus and the stomach?

Answer 3

1. gentle tissue handling
2. minimize contamination
3. appropriate use of suture material
4. judicious use of electrocautery
5. accurate apposition of tissues

Question 4

T/F: There is a higher instance of complications (esp. dehiscence) with esophageal surgery. This is directly related to the lack of serosa, segmental blood supply, and lack of omentum presence.

Answer 4

true

Question 5

What type of suture is the best choice for esophageal procedures?

Answer 5

monofilament, slow absorbing suture
Ideally PDS.

Question 6

what are the 3 types of esophageal surgeries?

Answer 6

1. esophagotomy (create an opening)
2. esophagectomy (R&A essentially)
3. esophagostomy (create temp/perm opening)

Question 7

what are the 4 types of hiatal hernias?

Answer 7

1. Type I – sliding (the stomach intermittently slides up into the chest through a small opening in the diaphragm –> changes pressure that exists on the gastroesophageal junction which creates the clinical signs we see)
2. Type II – portion of the gastric fundus located above the esophageal hiatus adjacent to the esophagus while the gastroesophageal junction (GEJ) remains fixed below the esophageal hiatus.
3. Type III – type I + type II (progressive enlargement of the hernia through the hiatus causes the membrane to stretch, displacing the gastroesophageal junction above the diaphragm, thereby adding a sliding element to the type II hernia.)
4. Type IV –gastroesophageal junction stays in abdomen, but other organs herniate.

Question 8

what is the surgical treatment options for hiatal hernias?

Answer 8

1. phrenoplasty (makes hiatus smaller so things that are supposed to pass can, but things that are not supposed to pass do not.
2. Esophagopexy (esophagus to diaphragm)
3. Left gastropexy (fundus to left body wall)

Question 9

what are the potential complications of surgical treatment of hiatal hernias?

Answer 9

1. persistent regurgitation
2. esophagitis/megaesophagus
3. re-herniation
4. hiatus over-reduction
5. nerve damage
6. esophagus made too narrow

Question 10

What artery runs along the greater curvature of the stomach?

Answer 10

left gastroepiploic artery

Question 11

what artery runs along the lesser curvature of the stomach?

Answer 11

right gastric artery

Question 12

what artery connects the cranial edge of the spleen to the fundus of the stomach?

Answer 12

short gastric arteries

Question 13

what are the 4 surgical options for the stomach?

Answer 13

1. gastrotomy
2. partial gastrectomy
3. gastropexy
4. gastrostomy tube placement

Question 14

Describe the orientation/movement of the stomach of a GDV

Answer 14

the pylorus rotates clockwise
then the stomach distends with gas

Question 15

why do you need to perform a CBC/Chem and lactate prior to and after going to surgery for a GDV?

Answer 15

gives you prognostic indicator
if it is serially high, then this is bad.

Question 16

Describe derotation of a GDV

Answer 16

With one hand (usually your right) reach down the left abdominal wall and firmly grab the stomach (pyloric region) where the spleen normally resides and then pull towards you. At the same time, use your other hand to apply downward pressure on the right side of the stomach (fundic region)

Question 17

In what area of the stomach do you place the stay sutures during a gastropexy?

Answer 17

pyloric antrum

Question 18

Describe the initial incision made into the pyloric antrum during an incisional gastropexy. (Location, thickness, etc.)

Answer 18

The incision is made half way in between the lesser and greater curvatures of the stomach.
The incision should NOT be full thickness, it should only go through the serosa and muscularis.

Question 19

how are gastric tubes removed?

Answer 19

traction

itll heal by second intention

Question 20

What technique is used to secure a gastrotomy tube into the stomach?

Answer 20

once a hole is made into both the body wall and the fundus of the stomach, the gastrotomy tube is pushed into the incision you made into the stomach.
Then, the tube is secured via purse string suture around the tube.
In addition to this, the tube is secured to the body wall via pexy.