Tips RGE
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Clínica Las Condes. Santiago. Chile
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Tratamiento Quirúrgico del RGETécnica y Trucos
Dr. Jorge Godoy L.
Departamento de Cirugía InfantilClínica Las Condes
Santiago - Chile
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RGE – Tratamiento Quiúrgico
• ¿A quienes opero?
• ¿Que técnica utilizó ?
• ¿Cuál es mi estrategia quirúrgica?
• ¿Cómo realizo la cirugía?
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El cirujano debe participar en la indicación
Sano Enfermo
Cirugía del RGE
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Grupos etarios (indicaciones)
• RN y Lactante• Apnea – ALTE
• Irritabilidad +++
• “” Alergia Prot. Leche Vaca””
• Pre- Escolar• RGE que no respondió a tratamiento
• IC por Otorrino
• Escolar• Cuadros Digestivos
• Cuadros Respiratorios
• Otorrino
• El niño pide consultar (esofagitis)
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Técnica Quirúrgica
Fundoplicatura de Nissen
Bufanda posterior de fondo gástrico de 360o
Cara anterior toma contacto con esófago.
Flopy
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Sin contraindicación por cateter peritonea(diálisis – Ventrículoperitoneal)
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Sin contraindicación por cirugía previa o ostomias y gastrostomías
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Sin contraindicación por anatomía
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Cirugía Laparoscópica RGE - Posición
xx x
1 IQ
x
x3 2
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Estrategia Quirúgica Posición de los trocares
• 4 trocares
• Pexia Hepática percutanea con 1 solo punto
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55
5x
5
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35
3x
5
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33
3x
5
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Pasos quirúrgicos. Estrategia
Sección vasos cortos
Rodear esófago
(sección membrana frenoesofágica)
Hiatoplastia posterior
Fundoplicatura
(Estabilización)
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Sección de vasos cortos
Monopolar
Armónico
Ligasure
Clip
Desde 1/3 medio estómago hacia arriba hasta pilar izquierdo
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Rodear Esófago
Abrir menbrana freno- esofágica
No sobre disecar por anterior.
Retirar membrana freno esofágica posterior
Rodear esófago
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Adecuada apertura de membrana freno-esofágica
anterior posterior
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Incluir nervio vago
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MEMBRANA FRENOESOFAGIC
A
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- Rodear esófago incluyendo nervio vago.
- Retirar “bandas posteriores”
- Facilita obtención de esófago intra-abdominal.
- Facilita identificación de pilares del diafragma.
- Facilita la hiatoplastía.
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Hiatoplastía posterior
• Observar V Hiatal.
• Conservar peritoneo de los pilares.
• Puntos sin tensión.
• Calibración.
• Esofago-cruropexia posterior.
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Hiatoplastia
Esofagocruropexia posterior
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Construcción fundoplicatura
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Fibras SlingFibras Sling
Fibras ClaspsFibras Clasps
- Liebermann-Meffert D, Gastroenterology 76: 31,1979- Liebermann-Meffert D, Gastroenterology 76: 31,1979
- Stein H.J. Surgery 117:692, 1995- Stein H.J. Surgery 117:692, 1995
Principios FisiopatológicosAnatomía
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M. Rossetti, D. Liebermann-Meffert.
Principios FisiopatológicosVector de presión
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Principios FisiopatológicosImportancia sección vasos cortos
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Esófago Intra-abdominal
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CalibraciónCalibración
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Esofago-cruropexiaEsofago-cruropexia
Previene Hernia HiatalPreviene Hernia Hiatal(esófago corto – hiato amplio)(esófago corto – hiato amplio)
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Punto de estabilización: Fundo-arcuatopexiaPunto de estabilización: Fundo-arcuatopexia
...Evita disrupción de la bufanda y torción de esófago (estómagos pequeños)
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Puntos de estabilización
Sólo si es necesario estabilizar
No confundir con insuficiente sección de vasos cortos
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Evitar torsión y tracción por vasos cortos
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Hernia hiatal post-operatoriaHernia hiatal post-operatoria
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DisrupciónDisrupción
DisfagiaDisfagia
Hernia hiatalHernia hiatal
Bufanda HolgadaBufanda Holgada
Nissen estableNissen estable(no rotación)(no rotación) AdecuadaAdecuadaHiatoplastíaHiatoplastía
Esófago IntraabdominalEsófago Intraabdominal
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Adecuada Indicación…..
Garantiza mejores resultados…..
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Ojo!!!!
Niño excesivamente vomitador
Con alergia a proteína leche de vaca
Con otras alteraciones anatómicas (RxEED)
Asociación a otros síntomas digestivos
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• Muchas gracias……
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