Laparoscopic Nissen fundoplication: a stepwise standard approach

Authors

B Dallemagne, J Marescaux

Abstract

This video demonstrates all the important technical steps for a standard construction of a Nissen's fundoplication.

Classification

basic techniques

Keywords

laparoscopy, Nissen fundoplication, GERD, gastroesophageal reflux disease

Media type

Duration

13'10''

Publication

2008-09

Popular

Favorites

Audio

Subtitles

E-publication

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2376.htm

Laparoscopic Nissen fundoplication: a stepwise standard approach

1. Right crus dissection 00'10''

The procedure begins by applying traction to the cardio-esophageal junction, this maneuver is very important as it will allow to expose the hiatal orifice’s different structures. First, we open the lesser omentum’s pars condensa; in most cases, we try to preserve the vagus nerve’s hepatic branches. In specific conditions, these branches are divided, but our first intention is always to try and preserve them. The incision is continued on the anterior part of the hiatal orifice with the incision of the phreno-esophageal membrane. At this stage of the operation, we only incise the superficial layer of the membrane as we do not yet know the exact position of the esophagus, or the position of the anterior vagus nerve. The membrane’s incision is gradually continued towards the left diaphragmatic crus; this crus preparation is important because it will facilitate the posterior dissection of the esophagus. Following this first incision, the right diaphragmatic crus can be identified easily and the entry into the mediastinum is done by keeping in contact to the right crus, this is because we do not know the exact position of the different intra-mediastinal structures such as the esophagus or the vagus nerve. We mostly use an atraumatic dissection that allows us to identify the structures first, then divide them. We begin by the right crus, then gradually go up along the diaphragmatic muscle while separating the structures, especially the esophagus that is now clearly identified. We must remain careful at this stage as we still do not know where the anterior vagus nerve is located. Indeed, this one can be situated on the left crus and we can clearly see that a very precise dissection must be followed in order to avoid dividing it or injuring it through diathermy.

2. Left crus dissection 02'48''

Once the vagus nerve is pushed onto the esophagus, we can gradually continue the incision of the phreno-esophageal membrane on the left crus. Once again this step is important because we can see here how the traction applied by the assistant allows to expose the structures and facilitates the identification of the different dissection planes. Another important step is the dissection of the base of the left crus with incision of the peritoneal reflection, which allows to free the left border of the esophagus. We can see that this allows an immediately improved retro-esophageal passage. The surgeon’s left hand ensures that traction is placed on the cardio-esophageal junction. The esophagus should never be grasped using a forceps, it is much better to push it away using a forceps. We can see that the earlier preparation of the left crus allows to find the retro-esophageal passage easily. This retro-esophageal window must be enlarged by the incision of the cardia’s different posterior attachments. In order to avoid traumas linked to the instruments on the esophageal wall, we switch the grasper for an umbilical tape that will allow to apply sufficient and angulated traction on the lower part of the esophagus and on the cardio-esophageal junction. This tape is grasped by the assistant standing to the patient’s left.

3. Mobilization of intramediastinal esophagus 04'54''

The traction and the changes in angles of the grasper on the tape allows to expose different intra-mediastinal structures and permits the following step that is the mobilisation of the intra-mediastinal esophagus. This step of the procedure is very important as it will allow to obtain a sufficient sub-diaphragmatic esophageal segment. At the level of this segment is positioned a Z line, that is at the level of the junction between the esophageal and gastric mucosa. It is at the level of that Z line that the anti-reflux mechanism should be positioned. The intra-mediastinal mobilisation usually goes up to the level of the pulmonary veins. The right border is mobilised, followed by the left border; for this step, it is important to correctly visualise the anterior vagus nerve that goes up towards the patient’s left and into the mediastinum. When we free these lateral attachments, it is important to incline the anterior vagus. These structures are gradually incised and we can feel the gradual freeing of the esophagus with this sub-diaphragmatic segment that must be around 2 to 3cm in order to allow for the correct positioning of the fundoplication valve. If there are any doubts on the length of the esophagus, it is sometimes recommended to perform an intra-operative endoscopy. Here we can see the measuring of the sub-diaphragmatic segment; we observe a lengthening of 2 to 3cm sub-diaphragmatically tension-free.

4. Mobilization of gastric fundus 07'15''

The following step is the mobilisation of the gastric fundus. It begins at the top of the gastro-splenic ligament where a lipoma can be identified in all patients. This lipoma constitutes a landmark for the start of the division of the gastro-splenic ligament and vessels. The lesser sac is penetrated with the incision of this ligament and it is very important to mobilise all of the stomach’s posterior attachments as these fix the posterior surface of the fundus, which will be used to create the anti-reflux stump. This division is performed easily with the ultrasonic dissector. The surgeon’s left hand applies the adequate traction upon the gastric fundus in order to avoid injuries at the level of the splenic capsule. This dissection is usually finished with the incision of the gastrophrenic ligament and we can clearly see that the top of the gastric fundus is now completely free. The mobilisation usually ends when the left crus or even the right crus can be identified from this side of the esophagus.

5. Hiatal repair 09'00''

The following step is the reconstruction; it begins with the hiatal repair. We use non-absorbable sutures, 0 or 2/0, placed on the crus of the diaphragm. There is still controversy as to whether or not it is necessary to reinforce this crural repair with a prosthesis. This can be necessary in some patients but we remain very cautious about this; we only use them when the crus is in a very bad state, or if the hiatal orifice is really enlarged. Here we can see that this crural repair will close the hiatal orifice by being calibrated on the size of the esophagus. We recommend the use of a bougie when beginning this type of operation as it will allow to avoid stenosis during the crural repair. Calibration is ensured by releasing the traction on the esophagus, which allows to check the correct positioning of the esophagus at the level of the orifice.

6. Fundoplication 10'42''

We finally identify the portion of stomach that will be used for the fundoplication, the posterior surface of the gastric fundus is brought to the right of the esophagus while its anterior surface is identified at the level of the left body of the esophagus. This set-up is made possible by the mobilisation of the gastric fundus that has been described in a previous operative step. Here as well we apply non-absorbable sutures. The aim is to create a valve of less than 2cm, thus with a very short anterior part. The technique employed here allows to check the valve’s calibration, to make sure that there are no twists in the gastric fundus and ensure that the fundoplication’s valve is in a correct position in relation to the cardio-esophageal junction. When attaching the valve to the anterior border of the esophagus, care should be taken to avoid suturing the anterior vagus nerve. It must therefore be identified before the fixation stitch is placed. This fixation stitch allows to approximate the fundoplication stump and the esophagus and we can still check that the stump is not stenotic. Finally, an inferior and lateral left fixation stitch will attach the fundoplication stump to the phreno-esophageal membrane as it is a zone with higher resistance than the anterior wall of the esophagus: it therefore ensures that the valve is anchored in a satisfying way. At the end of the procedure, the whole mechanism is checked and the crural repair is also checked to ensure that there is no stenosis. All the different elements that have been introduced in the peritoneal cavity such as tape, sutures, or even gauze, are extracted, and a final check is performed before removing the trocars.

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