EndoStim® Stimulation Therapy of the Lower Esophageal Sphincter

After a short incision in the left lateral mid-abdomen, access to the abdomen is achieved under visual control using a 12mm disposable trocar with optical function.
Subsequently, three 5mm trocars are inserted in an arc shape above the umbilical level into the upper or mid-abdomen. An additional 5mm trocar (as in the example) can optionally be placed high epigastrically.

With a fan-shaped retractor, the left liver lobe is elevated, making the gastroesophageal junction accessible.

The preparation phase begins with the incision of the lesser omentum in the area of the pars flaccida up to the free edge of the right diaphragmatic crus. The dissection of the right diaphragmatic crus is performed, with the gastroesophageal junction being exposed while preserving the posterior vagal branch. The preparation of the esophagus proceeds along the anterior commissure to the left side. Here, the left diaphragmatic crus is also exposed.

Note:
A rectangular longitudinal area of the anterior right distal esophagus about 3 × 1 cm is needed for electrode implantation. If a hiatus repair is omitted, only minimal dissection of the phreno-esophageal attachment should be performed; otherwise, transhiatal mobilization of the distal esophagus is performed.

The bifurcating lead carries a small needle electrode at each end, which is connected to a nylon thread and a needle (Schi needle).
The entire assembly is now introduced into the abdominal cavity through the 12mm trocar.

The implantation of the electrode is performed through a longitudinal incision in the esophageal wall, with the electrode being introduced into the incision channel by gentle traction on the thread. Subsequently, the electrode is secured in the area of the nylon thread with 2 clips.

Tip:
It is advisable to perform an intraoperative gastroscopy at this time (during the insertion of the electrodes). On one hand, the height of the Z-line (gastroesophageal junction) can be precisely located, and on the other hand, it can be checked during endoscopy whether the electrodes have not been inadvertently inserted through the mucosa (intraluminally).

Note:
To preserve the anterior vagus nerve, the electrode placement is on the anterior right side of the distal esophagus.

Next, the proximal end of the electrode is fixed to the esophageal wall with a "butterfly" using 2 sutures.