Safe laparoscopic dissection of the gastroesophageal junction

The laparoscopic approach to surgical diseases of the foregut is rapidly gaining acceptance. These new approaches, however, pit the unwary surgeon against potentially devastating complications.

Based on a retrospective review of 153 consecutive laparoscopic foregut surgeries performed at a designated laparoscopic center between August 1990 and June 1994, plus analysis of the records of 6 patients referred from outside our institution, we determined that the majority (15 of 16) of these complications were the result of violating one of five technical precepts: (1) safe use of esophageal dilators; (2) atraumatic retraction; (3) systematic dissection of the esophageal hiatus; (4) dissection under direct vision; and (5) use of appropriate suturing techniques.

A retrospective review of our experience with laparoscopic gastroesophageal surgery shows an operative complication rate of 6.5%. The majority of these complications (7 of 10) were recognized at the time of occurrence and treated laparoscopically without subsequent complication. Two patients had delayed complications that required treatment. One patient developed adult respiratory distress syndrome, apparently not related to surgical technical error. The other patient required an additional laparoscopic surgery to correct a dissection error. This complication rate compares very favorably with those reported for open surgical techniques, that range from 14% to 22%.

This report outlines surgical precepts that, if violated, could lead to iatrogenic injury, which could result in severe morbidity if not recognized or properly treated.