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Laparoscopic Nissen fundoplication

Authors

Abstract

This video demonstrates a routine laparoscopic Nissen fundoplication with division of short gastric vessels, crural repair and mobilization of the esophagus through the hiatus to achieve adequate intra-abdominal length.

Classification

routine cases

Keywords

GERD,extensive dissection,Nissen

Media type

Duration

20'00''

Publication

2004-12

Popular

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Audio

Subtitles

E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1693.htm

Laparoscopic Nissen fundoplication

1. Trocar placement 00'09''

This is the camera port, the umbilical is here, there is a scar here from a previous hysterectomy. What is important to start with is that the camera port is not at the level of the umbilicus, it is on the midline quite above the umbilicus. It is important to know that in female patients, you can put this port quite low on the median line, but in men you have to put it higher on this line because the subcostal margin is higher in men and the GE junction is very high in men. I am using a 0 degree, if you are using an angulated scope, you can use a different position for this first port but it is important to put it very high on the abdomen. If you are very high, you won’t have any problems; if you are very low, you can run into trouble with that; so you want to be very high on this median line. Position of the other ports, laterally on the right side of the patient is the liver retractor; on the left side there is a retraction grasper held by the assistant. I am working with 2 ports, one under the left costal margin, one under the xiphoid process and these are the 2 ports I am working with. This is my dissector; this is for retraction and this is for retraction of the liver. You can see that the traction is coming from the left side of the patient. It is very important to play on these tractions, you’ll see during the operation, we use a lot of these tractions.

2. Hiatus approach 02'10''

I am starting above the branches of the vagus nerve, and I am using the ultrasonics system that I like because it keeps the operative field very clean. You have different systems, you have this system, which is a disposable one, you have re-usable ones. Working here can give you the access to this 1st landmark, which is the right crus, this is the right crus, it is a very important landmark. If you are not very confident with this approach, what you can do is to come from the lower part of the lesser omentum and you can also get this first landmark, which is important. This crus is the beginning of everything, it is crucial for any kind of surgery of the GE junction.

3. Esophageal mobilization 03'23''

We start on the inner side of the right crus, on the inner side of this crus is the esophagus. Gentle, blunt dissection and then we enter the mediastinum. I identify the esophagus, which is very important, then I can work on the ring of the hiatus. On this side you have to be careful because sometimes the vagus trunk runs on the left crus, so I clean it a little bit before. This is muscle, so you see I clean this left crus, I know that there are no vagus trunks there and I can cut. I am working on this left crus, see the difference without and with traction? In laparoscopy, not just for the GE junction but for all the different types of procedure, traction is crucial for the different steps of the operation because we have no hands. I am working on this left crus preparing for the next part of the operation. You see, not too much coagulation or cutting or anything within the mediastinum. I am identifying the posterior vagus trunk, I load it on the grasper and then, important step: I have the vagus trunk there so I can clean a little bit the lower part of the crura. I am trying to identify the right and the left crus, which is really important, then I start the posterior dissection. I am safe because the vagus trunk is there, the esophagus is there, so I have all my important landmarks. Then by lifting progressively the esophagus, I am trying to find my way using blunt dissection and as I have prepared my left crus, it is quite easy to find my way behind the esophagus. I am introducing this tape and it will help me to place traction on the GE junction without any grasper. We know that grasping this area can be dangerous so this is a little trick. What I know is that by cleaning my mediastinum from above, I know that the vagus trunk should be somewhere here. I take no risks there, we will try to find it in a different step somewhere here, but we will see it. You see that when I move the esophagus, it is quite rigid, it is because of the nasogastric tube and I don’t like that so I just asked to have this tube removed. I clean this part of the esophagus within the mediastinum. The aim is to get as much length as possible of the lower esophagus back into the abdomen. You see the nasogastric tube has been removed. Here we don’t have that many adhesions, causing quite severe esophagitis; you can have very strong adhesions within the mediastinum. To get this esophagus back into the abdomen, you need to mobilize this segment of the esophagus. So just by mobilizing this traction system, you can prepare and present the different sides of the esophagus. Here this mobilization is probably not very necessary but it is just in order to show you what we are doing. So we see a lot of blunt dissection, what we would do with the finger in open surgery a lot time ago. I am testing these attachments to see if they fix the esophagus; if not, I won’t cut them. I can feel the vagus trunk, but it’s here as you see. The same way as we did with the finger, we feel with the instrument the vagus trunk, which is here. To mobilize the esophagus, you have to be always very careful not to injure it here when you detach the esophagus because the vagus trunk is going in this direction. If you have some fixations there, don’t cut them before knowing exactly where the vagus trunk is. Now we continue to clean the hiatal orifice in order to prepare for the repair. Here in this area, I am free because everything is under control with the vagus trunk, the esophagus and the drain. Now we will prepare the posterior window; it is important to have a quite large posterior window because the stomach has to go through this window and if you have a very small window, there is a compression through the stomach on the esophagus and we can imagine that some dysphagia might come from this very small posterior window. We will clean it from the other side as well. So you see the left crus. A very good view there, it is interesting how some people talk about not doing a minimalist dissection, but I agree that it is important to have a big window. You see that these branches are sometimes annoying. If you are starting this operation and you have nerve branches on this part, maybe you can cut it because it is easier. But after a while, when you get used to this operation, I recommend to try and keep it as much as possible because sometimes when you have a very large left hepatic artery, I prefer to preserve it. I’ve finished the dissection, I’m just checking the length of the esophagus that we’ve got back into the abdomen, so you see that without any traction, we can have a quite good 2 to 3cm of the esophagus back into the abdomen, so we have no problem with the length of the esophagus. For me, the Z line should be somewhere here, because the phrenoesophageal membrane is here, so I think it should be somewhere there. I gauge it with the open jaws of the grasper, is that how you estimate its length?

4. Gastric fundus mobilization 12'55''

We move in to the gastric fundus because I am used to doing a floppy Nissen fundoplication, and then I am trying to find the starting point of my mobilization. If we look at this, I don’t know if it has a name, but this fat pad here can be found in all patients and this is my landmark to start the gastric mobilization. I call it the Dallemagne piece of fat now, since I have been watching you do these so many times, and yes it is always there as you say and a good place to start. Then you don’t do a full gastric mobilization but you just mobilize what you need to to do a good floppy Nissen. Maybe the upper third of the fundus do you think? I don’t know, it’s always the same anatomy I would say in different patients, even in slim patients you find this little fatty tissue. I am used to working from the posterior aspect of the gastric fundus. I like this way because first I am not using an angulated scope, so it is difficult to work in this front of the gastric fundus, and the second reason is that from the back, you can see all the attachments very easily. My left assistant is grabbing progressively the gastrosplenic ligament because these are not the short gastrics of course, it’s only the gastrosplenic ligament. Here you have to be careful because the spleen is just there. Here you have to be careful because the spleen is just there. During this step, I am using the left retractor to open this retrogastric space. Sometimes there are some fatty tissues there. We can see these attachments with these fatty tissues there, but there is another trick I will show you. I am using this to hold the fat; so you see, that holds the gastrosplenic ligament and then we can see the posterior attachments very clearly. It is very important to get this posterior part because that is really the part of the stomach that you will use to create the fundoplication, so we need to take it down. You see that the posterior fundus is gradually coming. All the posterior aspect of the gastric fundus is freed. We check the spleen and short gastrics to make sure there are no bleedings. We don’t mobilize all the short gastrics, now we have this posterior fundus, which is totally freed and that is very important for the type of fundoplication we are creating.

5. Hiatus repair 18'38''

Now we are going to the repair, the first step is the crura repair, I think it’s important and that in all patients we probably have to do that. We can start from the back here, it is important to remember that the aorta is not that far. There have been descriptions of injuries to the aorta so be careful and do it with a perfect view. Clean the field for the view before starting anything because here is another important thing, the vena cava. This is quite a dangerous area, so it is very important to work progressively and not do anything without a very good view. The left crus is there, a take a good bite. This crus is quite fragile. Do you do anything bigger for larger hiatal defects, do you use pledgets? Yes I use pledgets, or this new material Surgisis that I try sometimes, what do you think of it? I think it is safer than synthetic mesh, it is still not perfect. Sometimes it does not incorporate and just falls off. Most of the time I use Teflon pledgets to reinforce the sutures. One stitch, we check and there is still a large hole so I need another stitch. I would say that in 75% of the people, we use just one figure of eight stitch (X) and one normal stitch. I agree that the average size of the crura repair is usually two or even three stitches. We were talking about calibrating the closure to not make it too tight or too loose, I tend to make it more tight, then loose. That is right because of our experience of early postoperative migration, it is important. That never seemed to be a problem in open Nissen, but there are no adhesions I think.

6. Fundoplication 22'55''

We will make the valve. This is the gastric fundus, the main difference between the two Nissen types of operation is that for the Nissen-Rossetti, you don’t mobilize this posterior gastric fundus and you use only the anterior wall of the stomach, these 2 pieces to create the fundoplication. On the contrary, the floppy Nissen uses both sides (posterior and anterior) of the gastric fundus to create the fundoplication. So now I am just placing this posterior fundus in this position there and I will grab it from behind the esophagus. You see this posterior fundus is coming because we have mobilized it. There is part of the anterior fundus but mostly its posterior aspect of the gastric fundus and then you see that we can create what we want. We have a lot of tissue so we can calibrate, make it loose, tighter, it is very easy. That is something you can do only if you mobilize. I don’t fix the first stitch to the esophagus because I want to see the general shape of the valve before fixing it. You see this valve is very floppy so I’m just checking its shape, that there is no torsion; I am checking everything and it looks quite good, I will fix again this valve. I have created this valve that is about 2cm, we measure with the grasper. What I like is to fix it a little more with just one stitch comparable to the Rossetti stitch.

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