Laparoscopic Nissen-Rossetti fundoplication

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Laparoscopic Nissen-Rossetti fundoplication

Authors

D Mutter, J Marescaux

Keywords

stomach,operation,gerd,gastroesophageal reflux disease,hiatal hernia,Nissen,Rossetti

Media type

Surgical video

Duration

19'00''

Publication

2002-10

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E-publication

WeBSurg.com, Oct 2002;2(10).
URL: http://www.websurg.com/doi-vd01en1359e.htm

Laparoscopic Nissen-Rossetti fundoplication

1. Trocar placement 00'17''

This is a 35-year-old patient who presented with sever gastroesophageal reflux disease. Preoperative studies showed presence of a small hiatal hernia. We usually insert 4 ports. The 1st port for the camera is placed at mid-distance between the xiphoid and the umbilicus. It is a 12mm port inserted using an open technique. And there will be 2 retracting ports and 2 operating ports. The operating ports are placed, one 5mm trocar below the right costal margin 2cm medial to the anterior axillary line, and on the left side another 5mm trocar is placed at mid-distance between the retracting port and the midline. One 5mm retracting port is placed very high just lateral to the xiphoid process and will be used to insert a liver retractor. The other retracting port is placed as lateral as possible below the left costal margin and will be used by the assistant. The right hand operating port is placed at mid-distance between this retracting port and the camera.

2. Crural dissection 02'06''

This initial image displays the initial dissection. The initial dissection starts with the opening of the pars flaccida using coagulation and section. Here is the accessory hepatic pedicle. We will open the pars condensa just superior to the pars flaccida and the pedicle. We usually always clip this vessel to avoid any intra- or post-operative bleeding. The same thing can be achieved by the use of monopolar or bipolar coagulation. The vessel is sharply divided. The right crus has been identified here. When dissecting the peritoneal layer here, there is a risk of injury to a branch of the phrenic vein, and this vein can be controlled with clips or bipolar coagulation. In this thin patient, this vein is very easily seen. In the case of an overweight or obese patient, this vein is more difficult to see and bleeding may occur during the dissection of adipose tissue at the superior part of the right crus. This vessel here is particularly large and exceptionally we will clip it in order to avoid bleeding. We divide this vessel. This is the origin of the right crus. My strategy for the moment is to continue to open the superficial layer of the peritoneum and this will help to identify the left crus behind and to the left of the stomach. The phrenogastric ligament is opened using monopolar coagulation. If exposure of the field is well done, the identification of the left crus is possible from the side with minimal dissection. The retroesophageal window will be performed much more easily because the correct space will already have been dissected. The dissection here should proceed slowly because of a risk of injury to a phrenic vessel coming from the splenic artery towards the stomach. Now we open the 2nd peritoneal layer. Dissection here on the left crus is complete and we return to the right crus. Here is the left gastric artery, the crus, and the esophagus. The aim of the dissection is not to search for the esophagus but to look for the anatomical landmarks of the right crus. Our goal now is to free the crus. There is a risk to open in this direction and in fact when the anatomy is not perfectly demonstrated, there is a risk to dissect inside the crus, which causes bleeding, and the presence of blood in the field makes the procedure more arduous. The hiatus is progressively dissected and the crus is dissected caudad until the inferior portion of the crus is reached. The next landmark to look for is the junction between the left and the right crura. We will change the position of the assistant’s grasper to put it in the small opening, which will expose the field better. Now we can identify the gastric vein, the gastric artery coming from the celiac trunk and here we can see some muscle fibers. The goal is now to identify the origin of the left crus. Very gently, the small fibers here are dissected free, and the dissection is now going into the left direction. Here is the origin of the left crus. We will change the exposure and present the esophagus to the assistant. While the assistant retracts the esophagus anteriorly, we can cut this thin attachment to better expose the fibers of the left crus. The dissection will now proceed just lateral to the left crus. This peritoneal layer is gently and slowly dissected to achieve perfect hemostasis. Without blind and blunt dissection, we will easily go towards the left side of the stomach. It is very important to proceed laterally to the left crus and not medially to avoid going into the mediastinum. Now the 2 dissection planes will join to form the posterior window.