Comparison between floppy Nissen and Nissen Rossetti fundoplication: the significance of short gastric vessels division

In this video, we present the surgical treatment of a typical gastroesophageal reflux disease in a young woman. She suffers from PPI tolerance, regurgitation with ENT symptoms, some asthma that usually is an indirect sign of very important regurgitation problems. That’s probably the best indication for anti-reflux surgery because everything can be controlled by medication. This is a very teaching video in which all technical details and all landmarks of the procedure are well illustrated.

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Comparison between floppy Nissen and Nissen Rossetti fundoplication: the significance of short gastric vessels division

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

In this video, we present the surgical treatment of a typical gastroesophageal reflux disease in a young woman. She suffers from PPI tolerance, regurgitation with ENT symptoms, some asthma that usually is an indirect sign of very important regurgitation problems. That’s probably the best indication for anti-reflux surgery because everything can be controlled by medication. This is a very teaching video in which all technical details and all landmarks of the procedure are well illustrated.

Classification

basic techniques

Keywords

Floppy Nissen, Nissen Rossetti fundoplication, short gastric vessels division

Media type

Surgical video

Duration

17'28''

Publication

2009-10

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Subtitles

E-publication

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2646.htm

Comparison between floppy Nissen and Nissen Rossetti fundoplication: the significance of short gastric vessels division

1. Clinical case presentation 00'20''

It is a typical gastroesophageal reflux disease in a young woman. She has problems with PPI tolerance, regurgitation with ENT symptoms, some asthma; that’s usually the indirect sign of very important regurgitation problems. That’s probably the best indication for anti-reflux surgery because everything can be controlled by medication. The strategy is to do a fundoplication and we are used to performing mostly total fundoplication, what we call the floppy Nissen. It means that we are doing a 360 degree valve after division of the short gastrics and mobilization of the gastric fundus.

2. Trocar placement and exposure of surgical field 01'22''

See the first trocar that is the optical trocar is passing a little bit above the umbilicus. Then you have on the right side of the patient, and my assistant is standing on the patient’s right side, you have one lateral port, which will accommodate the liver retractor and the liver retractor is already in place and you see my assistant is holding the liver retractor plus the camera. For this operation, we are using a 30 degree scope. First, I’m introducing the lateral grasper held by the assistant, left axillary line and we’re going to use this grasper to expose the GE junction. In this patient, it’s not very difficult because she’s so thin that you can recognize all of the anatomy and just look at that: it’s amazing to see this anatomy, because you see everything.

3. Opening of lesser omentum 02'25''

So what we’re going to do in this patient for teaching purposes is open the lesser omentum. Usually, I’m just opening the pars condensa preserving these little branches. But to have a clearer view for you, I’ll open this. See we are using this ultrasonic dissector, which is quite nice.

4. Right crus identification 02'53''

See very important is this landmark because in adipose patients sometimes you don’t know exactly where the junction is so you need landmarks and personally I like this right crus because it’s very easy to expose. Some people are using the left one. See the vena cava is there. So if you don’t identify the landmarks immediately, in a very fat patient, you can be in trouble when you are dissecting the vena cava instead of the esophagus so that’s a very basic rule. It is to have identified at least one landmark before starting or thinking to approach the esophagus. Again very superficial incision, and then I’ll try to find my cleavage plane between the muscle and the esophagus, the idea being that I want to know exactly where the esophagus is and where the major mediastinal structures (like the vagus trunk, etc.) are. So just blunt dissection. There’s probably some pleura there.

5. Blunt dissection of anterior esophagus 04'10''

In the anterior aspect of the esophagus, see I’m still using blunt dissection because sometimes you can have the vagus trunk, which is crossing in this area. So I like to clear a little bit the left crus before dividing the membrane. See when you don’t have a very clear view of the different cleavage planes, that’s very important to reposition the grasping forceps that gives you this very exact position of the cleavage planes. I think probably that’s something we have learnt from experience is that this traction on the GE junction is so important to help you clear the anatomy and to have a very nice view of the different cleavage planes. It also helps identify the vagus nerves because it puts them under tension and you can even feel them easily.

6. Identification of vagus trunk 05'17''

See the vagus trunk is there: we can see it quite clearly. I will mobilize en bloc the vagus trunk with the GE junction. See I’m just lifting up with my left hand. I’m not grabbing anything. I’m just lifting, dissecting. That 30 degree laparoscope gives you a very nice view. But I have to tell you that more and more I use a 30 degree with my assistant who knows exactly where I have to go. It’s very important when you’re working with a surgeon is that he/she’s anticipating all your movements. See from the start of the operation, we did not change anything. We’ve been working with the ultrasonic system all the time.

7. Insertion of umbilical tape for traction on GE junction 06'16''

Now I’ll come with an umbilical tape that I’ll tie around the GE junction so again in order to avoid any instruments or any grabbing with graspers on the esophageal wall. We’ll use to grab the junction so you see there’s no risk of esophageal trauma using this system. It’s very useful because you can orientate the dissection just by moving the retracting forceps. See we’ve just mobilized the junction on the side to continue the dissection on the left side, and probably most of you are wondering why I’m using this intramediastinal dissection. It’s because with experience we know that probably most of the complications related to anti-reflux surgery are due to short segments of the esophagus below the diaphragm and that can explain some of the early intrathoracic herniation, that can also explain some slippage. It means that the valve is sliding down on the stomach and does not work as an anti-reflux barrier so that’s why I think today most of the operators feel that this parameter of the length of the esophagus below the diaphragm is a very important one. So if we release the traction now, you can see that I have a good segment of the esophagus back. Because initially just remember that the position was like that so now as I mentioned we’re doing a floppy Nissen.

8. Mobilization of gastric fundus 08'13''

It means that we will mobilize the upper part of the gastric fundus. The idea of the Nissen Rossetti is to use only the anterior wall of the stomach so this is the part that should go on the right side of the esophagus and this is the part that should go on the left side. Then I’m coming with my grasper and I grab the anterior wall and I will pass the anterior wall behind the esophagus trying to get it. See problems are starting. I have a lot of traction on it so I can do it. I will grab this and if I want, I can tie it. This is the Nissen Rossetti, just the anterior wall but you will see that as soon as I release the traction, everything is passing on the other side. Do you have a landmark for this? I think we look for this now as well but we try never to go below the lower margins. Do any of you do the Nissen Rossetti operation? Personally I feel that doing this mobilization is far safer than doing a Nissen Rossetti because we’ve seen that the patient that we are redoing for dysphagia mostly, the vast majority of such patients have had a Nissen Rossetti. This means that a technical error of the surgeon while performing the Nissen Rossetti because the surgeon cannot find exactly the good landmarks, the part of the stomach to be used to construct the fundoplication and the surgeon is creating a tight system or creating a gastric valve.

9. Creation of floppy valve 10'25''

So you see, we have divided the posterior attachments of this gastric fundus and you can imagine what will happen when we will compare with the Nissen Rossetti’s, we will have a very floppy valve. Very short mobilization, I will grab the posterior aspect of the gastric fundus on the right side, and you see the difference is that I have no tension at all on my right valve, everything is staying in place. That is probably one of the safety reasons why we find that this fundic mobilization is very safe. The other thing is that you can imagine that when you have a more flexible system, relaxation properties are better with this system than with the Nissen Rossetti, and that is something that was shown is some of those randomized trials, the relaxation was a little bit different for the floppy than for the Nissen Rossetti. If your sphincter is relaxing, it means that you have less side-effects than with the Nissen Rossetti, that is our experience at least. This is the left crus, you see that the aorta is not that far, so if you are going this way, you will puncture the aorta. It is very important to have this clear view that we have today. I am always checking the position of the vena cava on the side. You see that we have respected the peritoneal coverage of the crus, and I think that it increases the strength of the repair. I think that is why I insist on the landmarks when I start because if you identify easily your right crus, you can respect this peritoneal protection on the crus. This patient is very thin, the position of the esophagus is very high but if I am closing there, I will create some angulation. So if you make too much of a posterior repair, you have this angulation. Moreover, you will put a fundoplication there. I prefer to leave it quite open there to avoid this angulation of the GE junction, and maybe that after creating the fundoplication, I will come back with one more stitch. This is my bougie; I am not fixing the first stitch, so I can see the tightness of the valve. For example, you can see that I am very floppy and I could use a 50 French bougie without any problems. This is why I like to fix the first stitch to get the aspect of the tissues, be sure that I’m not twisting any part of the gastric fundus, then when you have this aspect, you can place the valve in the right position and be sure that you are not tightening the second stitch. That is quite helpful when working in this way. Sometimes when you suture along the greater curvature like that, you get a hematoma of the wrap, do you think that is important or is there a way to avoid it? I’ve had some of course, but never seen any consequences because I am used to performing a swallow on the first day after surgery because I like to see the position of the valve and the tightness of the valve. With or without hematoma, I can’t see the difference in terms of esophageal emptying so I don’t think it is a big issue. All the mechanisms should be able to work together, the esophagus is moving because of the peristalsis, you have more than 2,000 movements a day when people are swallowing, and I like to have this mechanism. What I like is not to fix on the esophagus because it is quite fragile, but just here on the insertion of the phrenoesophageal ligament, so it’s a little bit stronger than the esophageal wall, so I like to fix my valve in this position. I still put a posterior suture, but I think you are right. Moving together with the esophagus, that’s why I personally don’t like to fix the valve on the diaphragm because I have one sort of fixed part, and the other, which is moving inside. What I was telling you is that for this sort of anatomy, you have the esophagus coming down, and then you have this angle, and if you put another stitch there, you increase the angle, so I will probably leave it like this. You have only two stitches in your wrap there? Yes that’s right. Another advantage of having a very floppy valve is that we have no tension at all on these sutures so I don’t think it is necessary to put three or four sutures. But again it is surgeon-dependent; OK here is the stitch for Michael.