Laparoscopic fundoplication: New aspects in neural anatomy of the esophagogastric junction

Background:

In laparoscopic fundoplication the mobilisation of the distal esophagus and the proximal stomach are mandatory. In surgical literature and in most anatomic illustrations there are no nerves described between diaphragm and stomach. We intraoperatively observed small nerve branches penetrating the left crus of the diaphragm lateral of the hiatus, presumably going into the stomach. Their course (from lateral to medial) suggested that they could be branches of the splanchnic nerves or phrenic nerves rather than branches of the vagus. It was the aim of the study to find these nerves in cadavers and to describe their origin and their target organ.

Material and Methods:

53 cadavers (23 male 30 female, age range: 35 – 103 years) were dissected with special attention to the course of the nerves penetrating the left crus of the diaphragm. The whole course of the nerves was documented with drawings and photos.

Results:

In 17 out of 53 cadavers, one or two splanchnic nerves were found. Seen from below, they penetrated the left crus of the diaphragm in mean at the 4 o'clock (range: 2 – 5) position, in mean at a distance of 2 cm (range: 0 – 5) from the hiatus, all of them going into the stomach (cardia or fundus). Ten out of them had an additional branch going into the coeliac ganglion.

In 14 cadavers, a branch of the phrenic nerve was found, penetrating the left crus at a 4 o'clock position. These phrenic nerves mostly went into the stomach (fundus), but in two cases, additional branches going to the coeliac ganglion were found.

Conclusion:

Branches of the splanchnic nerves and of the phrenic nerve, penetrating the left crus of the diaphragm at the 3 – 5 o'clock position are regularly found. Most of them go to the stomach, and some also have branches to the coeliac ganglion.