Laparoscopic Nissen fundoplication

This video demonstrates a standard laparoscopic Nissen fundoplication with full mobilization of the esophagus through the hiatus, division of short gastric vessels, posterior repair of crural defect, creation of 360 degree floppy Nissen fundoplication. The patient had an accessory left hepatic artery, which was preserved. This video is a good demonstration of anatomy and surgical approach for performing a standard Nissen fundoplication.

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Laparoscopic Nissen fundoplication

Authors

Abstract

This video demonstrates a standard laparoscopic Nissen fundoplication with full mobilization of the esophagus through the hiatus, division of short gastric vessels, posterior repair of crural defect, creation of 360 degree floppy Nissen fundoplication. The patient had an accessory left hepatic artery, which was preserved.
This video is a good demonstration of anatomy and surgical approach for performing a standard Nissen fundoplication.

Classification

basic techniques

Keywords

Laparoscopic, Nissen Fundoplication,GERD, Accessory left hepatic artery

Media type

Surgical video

Duration

14'00''

Publication

2002-11

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E-publication

WeBSurg.com, Nov 2002;2(11).
URL: http://www.websurg.com/doi-vd01en1378e.htm

Laparoscopic Nissen fundoplication

1. Trocar placement 00'07''

2. Approach of hiatus 00'19''

We use a total of 5 trocars positioned in the configuration shown here, all 5 above the umbilicus and the camera is in the midline. The principle is to start knowing the landmarks of this operation. Here it’s easy since we have this sliding hiatal hernia so we can see easily the crura. It’s probably the 1st landmark that we have to look for when doing this type of operation. There are 2 options to start with. The 1st one described by Dr. Cadiere is to go straight ahead on the lesser omentum dividing also the left hepatic artery that we see here. I’m dividing the lesser omentum there. You see the right crus is there so I’m continuing on the phreno-esophageal membrane. You see with the pneumodissection, it’s quite easy to find a plane: phrenogastric ligament, back on the right crus, small fat pad usual in this area. If you have difficulty in finding it, go this way, and you’ll see that you can also find the right crus there. You can use both approaches. Now we’re trying to find a plane between the crus and what we think that the esophagus should be. So I clean the crus and we find the access to the esophagus immediately. Here you have to be careful because sometimes the anterior vagus trunk has this route so just use first blunt dissection to clean the crus and be sure that the vagus trunk is not there. I don’t like to have a gastric tube inside because it’s a little bit too rigid for the dissection of the esophagus. This is different for the huge type of hernias. I know that the vagus trunk is not here. It’s just the membrane here.

3. Mobilization of esophagus 03'34''

I’m continuing to clean the crus. Now back on the right side. You see the pleura. Probably we’re going up 5 to 10cm inside the mediastinum. I think it’s easy because doing this way you can have a clear view on the crura and the anatomy of this area. I like to have a good length of the esophagus. I’m looking for the left crus so you see that I don’t grab the esophagus. I’m just retracting it. This is the left crus there. You see that even without this sophisticated instrument, if we’re in the right plane, it doesn’t bleed too much. As I’m using Ultracision, I’m not using any clips so again to avoid any instrument on the esophagus, I’m leaving this drain and as compared to the Penrose drain, this one is very flexible and too rigid. This reproduces what we could do with a finger in open surgery. You see that just mobilizing the Penrose drain, we can change the direction of the esophagus and then get access there. I think that we have a good mobilization there. We have a very big left artery. As we’re dealing with a functional disease, we try as much as possible to preserve what can be preserved. I agree that I’m dividing the short gastrics.

4. Mobilization of fundus 06'35''

And it’s the other way but those fibres of the vagal trunk, I prefer to keep it. You see the omentum is here. You have the arcade here and I’m going up towards it. The left gastroepiploic artery should be somewhere here and in the end, you don’t have fatty tissue any more. This is a little fat pad at the top and this is the point where I’m starting with the gastric mobilization. You find it in all patients, more or less fatty but always at the same place. These are not vessels but just adhesions. We see the posterior attachments of the fundus and we’ll see that these attachments are going up to the gastrophrenic ligament. Postoperatively, what instructions do you give to your patients? They can drink a little bit of water on the first evening. On the next morning, they can start with easy food. On the 2nd postoperative day, I perform a barium swallow to check that the wrap is in a proper position and then patients are discharged. You see the fundus, which is mobilized. In the Nissen-Rossetti, you’re constricting the valve with 2 parts of the anterior wall like this. This is the posterior wall of the fundus and if you do a Nissen-Rossetti, you use this part here and this one.

5. Cruroplasty 09'12''

The difference with the floppy Nissen is you leave the gastric fundus and then you’re going to grab the posterior aspect of the fundus. This is anterior and that is posterior. We can reduce the size of the ports because we know that in children, we can do it with very small ports. The 10mm camera is too large. In adults, I don’t know any advantages in using shorter ports. What is the most difficult case for you, obese patients or thin patients with a small xiphoid process? The thin patient is more difficult because the space is very narrow and this makes it difficult to know where the instruments are. When we keep these branches, it’s a little bit more difficult to do the crura repair; by moving the esophagus in different directions, you can avoid problems when doing this crural repair. At the beginning of my experience, I used a bougie. Now I don’t use it routinely. Sometimes in specific cases, we can still use bougies, in cases of redos, or dysphagia. I don’t think the bougie is very helpful because you can do a very tight wrap on a bougie. I’m using quite a good length because I’m used to a suture that is fixed with the 1st stitch and then you can use smaller branches of the sutures. I think I’ll put another stitch on the anterior part of the hiatus. We have to prevent common complications such as intrathoracic migration and that explains why I’m closing that much. From the beginning of my experience, I close the crura.

6. Fundoplication 11'58''

Dr. Cadiere did not close it and he had a 45% rate of migrations. Just imagine what we were used to doing in open surgery, putting your finger. You see that I can easily put my finger here. We now do the valve. Here’s the posterior wall still in place, then the anterior wall. That will be the valve. To be sure that you’re not tightening too much, you can put the 1st stitch without any stitch in the esophagus so you can check the shape of your valve. I’d recommend it at the beginning of your experience. I don’t believe that you need a bougie to be sure that you’re large enough. Most of the time, this is the 1st stitch that gives the dysphagia. Be sure that your valve is in a good shape and then you put the other stitch. And then, you can fix the other stitch on the esophagus. I finally put a last stitch, which is not really the Rossetti stitch, so you see the valve is quite large. I think that we could pass down a 60 French bougie without any problems. You see here is the junction. The phreno-esophageal membrane is just down there and I’m using a stitch only on the left part of the valve to fix it on this part of the junction, which is a little bit stronger than the anterior wall of the esophagus. I don’t know if it helps but I’m pleased with that.