Laparoscopic Nissen-Rossetti with minimal dissection

Compared with other anti-reflux procedures, the Nissen-Rossetti procedure does not require the resection of the short gastric vessels; thus, it consists in a safer procedure with decreased bleeding. In this video, Prof. Jacques Marescaux demonstrates the laparoscopic procedure in a stepwise fashion.

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Laparoscopic   Nissen-Rossetti   with   minimal   dissection

Authors
J Marescaux
Abstract
Compared with other anti-reflux procedures, the Nissen-Rossetti procedure does not require the resection of the short gastric vessels; thus, it consists in a safer procedure with decreased bleeding.
In this video, Prof. Jacques Marescaux demonstrates the laparoscopic procedure in a stepwise fashion.
Keywords
stomach,operation,gerd,gastroesophageal reflux disease,hiatal hernia
Media type
Duration
14'00''
Publication
2004-11
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1285e.htm

Laparoscopic   Nissen-Rossetti   with   minimal   dissection

2. Trocar placement 00'28''
The 1st trocar, trocar A, is placed at mid-distance on a line going from the xiphoid and the umbilicus and that’s the optical trocar. The 2nd trocar, trocar B, is placed below the costal margin at the left mid-clavicular line. It is an operating trocar. The 3rd trocar through which a retracting grasper will be inserted, is trocar C placed on the left anterior axillary line. Trocar D is positioned just below the xiphoid process and will be used to insert the liver retractor. The last trocar, trocar E, is an operating trocar placed just between the 2 others on the left mid-clavicular line 2cm below the costal margin. The liver is well retracted. We will go right on the pars flaccida of the lesser omentum. The nerve of Latarget serves as a landmark and should be preserved. We can also identify a small accessory hepatic pedicle, which we will probably divide. We will stay at distance from the nerve of Latarget and will go towards the right crus and dissect along it in a caudad to cephalad movement until we reach the esophageal phrenic ligament. The accessory hepatic pedicle will be divided to have better access to the target, which is just superior to this pedicle as we show here. The lesser omentum is divided sharply with scissors and coagulation. The hepatic pedicle is divided between clips. It could also be divided with monopolar or bipolar cautery. We retract the liver a little bit more to improve exposure of the right crus. The strategy will be to go cephalad towards the esophageal phrenic ligament and to dissect the entire length of the medial side of the right crus. The present target is not the esophagus but the structures, anatomical landmarks around it. The esophageal phrenic ligament is divided with the hook and monopolar coagulation and the gastrophrenic ligament is divided as well as it is presently well exposed.
3. Esophageal dissection 03'41''
The medial border of the right crus is dissected in a cephalad to caudad movement and all dissection around the esophagus including that of the left crus will be performed from this angle without moving the camera. Either a hook or scissors can be used to perform this dissection. Dissection is kept in the avascular plane and absence of blood shows that we keep away from the muscular structures. The right crus is now completely dissected. A small fat pad is divided. Dissection is continued on the lateral border of the left crus as soon the V-shaped intersection of both crura can be seen. The delicate step will be the creation of the posterior window on the left side of the left crus. The window will be created on this lateral side just here. Grasper B is passed posterior to the esophagus and the esophagus is retracted ventrally and to the left. Creation of the window is completed with use of the hook and monopolar coagulation on the lateral side of the left crus. As it is a simple reflux disease without presence of a hiatal hernia, the posterior gastrophrenic ligament will not be divided contrary to what was classically described in the original technique. This is the retroesophageal window, which is almost completely divided. This is the right crus. Minimal dissection into the posterior mediastinum and this is the posterior vagus nerve. This nerve could have been injured by dissection performed into the mediastinum posteriorly. The dissection along the left border of the left crus is performed and finished here, which will conclude the dissection. Anterior dissection is now completed. We can see that the esophagus has been mobilized sufficiently and brought down into the abdomen. The nasogastric tube is pulled out by the anesthesiologist. This will help to create the wrap. We will not use a bougie to calibrate the wrap.
4. Fundoplication 08'09''
The other delicate step in this procedure is the choice of the optimal part of stomach to create the valve. It has been well demonstrated that the fundus of the stomach is the only part of stomach to relax during swallowing. The best area is located 3cm inferior to the cardia and at mid-distance from that point and the point on the dome of the fundus; this portion is thus identified and grasped by the assistant. The left hand instrument is then passed posterior to the esophagus and grasped this portion of stomach. The posterior side of the wrap is then passed through the retroesophageal window as the right hand instruments retracts the esophagus to the left. The wrap passes easily without tension even though the short gastric vessels have not been divided. The anterior part of the wrap has now been well chosen. The most common error is to take this part, which is too high; that would create a stricture and a twist. This part is the right one and will not create tension or twist. The first suture includes the small portion of the anterior wall of the esophagus. The knots are tied extracorporeally. The other sutures will only be stomach to stomach without including a portion of the esophagus. The aim is to create a wrap that is 1.5 to 2cm long compared to the 4cm classically described. This knot is again tied extracorporeally and the 3rd suture will be performed. The fundoplication is now completed. The wrap is floppy without stricture and without twist. We will now decide if the closure of the crura is necessary. If more than a fingerbreadth between the V intersection of the crura and the esophagus is present, a suture must be performed though with an open grasper corresponds to the breadth of a finger. So one stitch must be made. We will re-approximate the crura and leave a width of an open grasper and not less between the crura and the esophagus in order to avoid postoperative dysphagia. This concludes the intervention. The nasogastric tube will not be reinserted. A liquid diet is allowed on the operative evening, a solid diet on the postop day 1 and the patient is discharged on the morning of postop day 2.