Lesson 4. Toupet Posterior Partial Fundoplication

1. Know myotomy technique from Exercise #3.
2. Know why a partial wrap (fundoplication) is indicated in the setting of an esophagogastric
   myotomy for Achalasia.
3. Know the technique for posterior fundoplication (Toupet procedure).

• Goat mediastinal and gastric tissue block. Consists of heart, lungs, esophagus, trachea, diaphragm, thoracic aorta and esophagogastric junction with attached proximal one third of stomach.
• Maloney tapered bougie -¬‐ Size 54 French for human adult. Size 45 French for goat model.
• 17-¬‐ inch x 24-¬‐ inch plastic cutting board with single screw placed in center edge of each end
  of longest dimension.
• Lubricant-¬‐ tube of K=Y jelly or Lubriderm.
• One pair of Metzenbaum scissors.
• Surgical forceps.
• 2-¬‐ 0 Ethibon or silk sutures.
• 3-¬‐ 0 silk sutures on an atraumatic needle.
• Suture scissors.
• Curved hemostat.
• Babcock clamp.
• Needle holder.

1. Attach the mediastinal and gastric tissue block to the cutting board with a heavy suture passed through the proximal esophagus and trachea. Do not obstruct the esophageal lumen with this suture. Tie this suture around the end of the cutting board. Place a second heavy suture through the distal diaphragmatic crura and tie around the screw at the distal end of the cutting board.
2. See Lesson #2, Step 2, for preparation of the goat stomach to simulate the human stomach.
3. Pass a lubricated esophageal bougie the full length of the esophagus.

1. Pass an esophageal bougie through the esophagus from its proximal lumen through the esophagus into the lumen of the stomach segment.

2. Describe the location and the rationale for dividing the vasa brevia between the human gastric antrum and the spleen and for making an opening in the human gastrohepatic ligament. These anatomic structures are not available in this goat model.

3. Identify the left and right crura of the diaphragm.

4. Performance of an esophagogastric myotomy: make a 4 cm longitudinal incision through the muscular layers of the bougie distended distal esophagus using the “belly” of a scalpel with a #10 blade. Carefully carry this incision across the esophagogastric junction through the muscle layer of the stomach for a distance of 1.5 cm. Take care not to incise the underlying submucosal/mucosal layer of the stomach.

5. Using a curved hemostat, Metzenbaum scissors and surgical forceps, elevate the esophageal muscular layers off of the submucosal layer of the esophagus for 1 cm lateral and medial to the myotomy. This will reduce the likelihood of the myotomy closing again.

6. Toupet posterior fundoplication. Grasp the gastric antral tissue with a Babcock clamp and pass it posterior to the esophagus (see below Figure  4-1).

Figure 4-1: Blue Stay Suture Marks the Leading Edge of the Posterior Wrap

7. Place multiple 3-0 sutures attached to an atraumatic needle between the muscle layer of each side of the full length of the esophagogastric myotomy approximating each suture to the adjacent posterior fundic wrap (see below Figure  4-2). Tie in place (Figure 4.3).

Figure 4-2: Initial Sutures

Figure 4-3: Completed Approximating Sutures

8. Final step. Place 2-0 sutures between the posterior gastric wrap and the adjacent underlying right crus of the diaphragm to anchor the wrap below the diaphragm
(see below Figure  4-4).

Figure 4-4: Sutures Anchoring Posterior Wrap to Right Crus of Diaphragm