A live case of laparoscopic floppy Nissen fundoplication for GERD: teaching the novice

Authors

Abstract

This video shows a live case of laparoscopic floppy Nissen fundoplication for GERD in which all surgical steps are accurately described. This is a perfect teaching case.

Keywords

Laparoscopy, floppy valve, floppy Nissen fundoplication, GERD

Media type

Duration

23'00''

Publication

2011-03

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Subtitles

E-publication

WeBSurg.com, Mar 2011;11(03).
URL: http://www.websurg.com/doi-vd01en3152.htm

A live case of laparoscopic floppy Nissen fundoplication for GERD: teaching the novice

1. Introduction 00'45''

We are going to start this reflux for GERD. I am standing between the patient’s legs, and that is the view you have from the legs.

2. Port placement 00'57''

We can see that in this patient we use the 10mm port inserted in the umbilicus because the patient has a BMI of 20, so it is a small woman. We try to mask this scar inside the umbilicus. Usually with male patients we work with this optical trocar a little bit higher on the midline. Then I move into the left side of the patient, so my right side, and you see that in the left subcostal area we have one lateral port which will be used by the assistant. On the right side of the patient we have another port, which is used for the liver retractor. Last two ports: this one, approximately in the clavicular line and this one, a little bit on the left of the midline. These two ports will be used by my two hands. It is quite a special position, but I like it because when I am working on the hiatus, I have a very short distance between the entrance inside the parietal cavity and my target, which is the GE junction, so I have to be very short in distance. We enter through the umbilicus. In this very thin woman, the port in the umbilicus does not create any problem of exposure of the GE junction. The is the assistant’s grasper coming from the left lateral trocar. We are going to grab a little bit below the GE junction to make some traction.

3. Intraoperative anatomy 03'00''

Anatomy: left liver lobe, pars flaccida of the lesser omentum, pars condensa. You see those little fibers and the hepatic branch of the vagus trunks. Maybe we will discuss afterwards if there is a need for preservation of these fibers. Our colleague from Korea was doing a pylorus-preserving gastrectomy to preserve those branches in order to keep a good function of the pylorus. I open this little window above the branches. Personally, I always start with this landmark. For this sort of patient it is not a big issue, but for fatty patients you always have to find your landmarks. If you don’t find them there because the patient is too fat, you go just below and you see this anatomy. This is the vena cava, the right crus, the phrenoesophageal ligament. Left crus is over there. I will cross the GE junction with the division of the phrenoesophageal membrane.

4. Start of dissection 04'30''

I cut very precisely at the tip, I think with the ultrasonic system, but it is quite OK. The difference with the Ligasure® is that it does not cut at the tip. I am looking just to make some opening, and you do not have that with the ultrasonic system. I have a very small amount of tissue within the jaws, and it is a little bit difficult to start, but once you have the plane, it is OK. I use this one. Once I have the opening of my membrane, I am OK, but it is really challenging to do the first cut with this system. I am just doing blunt because of the vagus trunk. That is why you need to go bluntly. That is very important, because if you go straight, you will do a vagotomy, so that is why we have to identify that till the junction between the left crus and the ligament. I am focusing a little bit on this crus, because I know that afterwards, when I do my posterior window, my retroesophageal passage, it will be easier if I clean my left crus. The passage is far more easy. We have to preserve as much as possible. I am not doing anything on the diaphragm, I am just trying to be very close and very gentle with the muscle. That is very important. Vagus trunk is there again. This is my left hand and I am reducing a little bit the junction. It helps me expose the lower mediastinum.

5. Retroesophageal passage 07'11''

When we do this posterior tunnel it is always very important to try to get your landmarks. You see the vagus trunk is with me. So I lift everything. And then I am free to cut it because I know the vagus trunk is in my hand. It is quite a clear anatomy in this patient. I always check that I am in the right plane. That is very important because we know that some problems may occur during this posterior tunnel, so I will divide this from this side. We are moving back. I am not doing any blind maneuver around the cardia, always under vision, that is very important. Now that I have my retroesophageal passage.

6. Umbilical tape insertion and mediastinal dissection 08'24''

I will insert this umbilical tape. I am relying only on the energy and stitching. That is why I am just knotting my umbilical tape. Now the assistant will grab the knots of this tape. It is totally atraumatic. We are inside the chest. This is a nice view on the pleural adhesions. When you look at this mediastinum, which is a little bit inflamed, and at these adhesions between the pleura and the esophagus, you know that is probably a true reflux disease with some periesophagitis. You can understand a little bit more about the severity of the disease. You see that systematically, we are mobilizing quite high in the chest. How do you routinely dissect? I will show you. Usually it is up to the pulmonary vein, because it is not a big challenge. It takes a little bit of time, sometimes, but, on the other hand, we know that this length of the esophagus below the diaphragm is so important, so we have to focus absolutely on that. I do not remember exactly how people name this, but I think it is a mediastinal type II dissection or something like that. Usually on the left border of the esophagus you have strong adhesions. I use a lot of blunt. That is why I do not like the Ligasure® with the blade, because if you do that, you can have some problems. Question from the audience about whether the patient was treated with PPIs before surgery and for how long. You see the vagus trunk there. It was a 5-year medical treatment, but despite that she still had some problems, coughing, etc. I think it is quite a severe reflux. It is not rare to observe this sort of important reflux with extraesophageal symptoms in this shape of women, I would say. That is not rare. OK, so we’ll check. What we do is to go back in the abdomen and look at the position of the GE junction. So you see it’s limit. So I’ll just work a little bit more because I want to have this 2cm at least free without any tension. So you see that even without any hiatal hernias or things like that, the esophagus tends to go back inside the chest. I don’t know Lee if you want to comment on this problem of the length of the esophagus. The difference today is that we can see what we’re doing but in fact even in open surgery, I’m pretty sure that we were mobilizing a little bit of the low esophagus. Just to remind you that there was still a lot of discussion between the proponents of the chest approach and the proponents of the abdominal approach at the time of open surgery. Because the chest surgeons were saying that they could get a better esophageal mobilization as compared to the abdominal surgeons so probably the difference is that we can see. Also one important thing is that even in open surgery, we had a lot of failure with intra-thoracic migration or recurrent hiatal hernia, etc. so open surgery maybe was not done in a proper way. See the difference now. I have my 2cm there so I’m OK. So I’ll focus on the mobilization of the GE junction that’s what I’m doing in all the patients. So we start very high. So this is may landmark here. See this little pad just above at the top of the gastrosplenic ligament. So I’m opening this ligament. I will enter the lesser sac. It’s easier to do in obese patients or in adipose patients. So now you see that with this maneuver of opening the back of the stomach, we have a very nice view on all the posterior attachments of the fundus and we know which one we have to take down to get a good fundic mobilization. And now with this energy, you see that we just identify the structure and then we go straight ahead, so it’s far easier. So I think that we don’t have a justification to avoid this important step any more. This is the phrenogastric part. And usually if I can see the crus there, I’m OK with the fundic mobilization.

7. Crura repair 15'13''

So the first step for us is to do the crura repair so again the basic rule is to do the crura repair in all the patients. That’s very important. To use silk in this surgery is no good because that will disappear so it’s not a permanent suture but you can use the material that you want. It’s not that important. The literature says that we should use mesh and really now the data that we are collecting progressively show that it’s not so true so we’ll have a discussion with Lee tomorrow about that. Very interesting point. And we’ve got very interesting results with the pledgets. And really the use of mesh is when we have no choice at all or because there is no musculature any more. Lee, I know that you have some good experience with that. I think that you’re right. It turns out that the mesh helps in the short term but not in the long term. That’s right. For most prostheses within the esophagus. And when you think that once you’re really reluctant with using another mesh but really to treat this sort of prosthetic problems, probably in this patient we’ll have to do an esophagectomy or a Merendino procedure I don’t know yet but they’re not so important in this sort of repair. So now we’ll check the size of the hiatus and usually we size our repair on the size of the esophagus. And Lee has a very good expression for that. The crura are kissing the esophagus.

8. Floppy valve creation 17'33''

We have used bougies in the past in the early experience. You see that I’ve passed the fundus around the esophagus and this is the anterior fundic wall that is going on the right side of the esophagus and here you see this is the posterior fundic wall. So this is the base of a floppy fundoplication because you see I can adjust exactly what I want. I can make it very tight. I can make it very loose. And so this is the biggest advantage of this fundic mobilization: you can do what you want. As you see, I’m doing the valve. I put my first stitch, then I can evaluate a little bit. I know that if I’m doing this, I can insert a 70 French bougie, no problem. So I’m just adjusting a little bit the size of my valve. What I’m doing now is to put a second stitch on my valve just to get my 2cm length and then I will fix the valve on the strongest structure that I can find in this area, which is the insertion of the phrenoesophageal ligament, and I’ll show you that afterwards. I think that during the dissection, I have a perfect position of my instrument to dissect the mediastinum. So this is my valve. It’s done. I’ll check again how it is. So you see, we can’t say that it’s too tight. I’m just checking the position so the phrenoesophageal ligament is there. This is the sign of my first try to open the ligament with the Ligasure®. So my Z-line is here, probably 1.5cm above. You can see the vagus trunk there. So my valve is well placed on the GE junction. Now I’ll try to stabilize all the mechanism by anchoring my valve. So that’s where I will fix laterally my valve. See this strong tissue there, a little bit burnt by my dissection. That’s really the insertion of the phrenoesophageal ligament and that’s strong. The other advantage is that I’m closing the angle there where we’ve seen sometimes herniation through the valve. Mostly in adipose patients, when you have this very important fat pad, you can have herniation of the fat pad through this corner so with this stitch, I’m blocking this corner. And it’s strong, stronger than the esophagus. So what you can do if you’re not comfortable with one stitch is to put another one on the other side. I did this one with a lot of patients so with very good results so I think that probably one is enough but as people want a little bit more, you can of course without fixing your umbilical tape, you can fix it on the other side but this is something that I’m not doing regularly. It’s just to show that you can do what we want but I like this lateral fixation compared to the anterior one. And interestingly, when we were used to doing both, when I have a postoperative upper GI series with anterior fixation or lateral fixation in the early postop it’s different. The esophagus is more stenotic with the anterior fixation compared to this lateral fixation. I don’t know if it probably doesn’t have any incidence on the long-term outcome but in the early postoperative period, there is some. See, it’s very floppy. Good position, good repair. It’s been a very nice example of dissection and creation of a nice antireflux valve. Perfect case to learn the anatomy.

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