Laparoscopic Nissen fundoplication for GERD

This didactic video clearly demonstrates all the key steps of a laparoscopic Nissen's fundoplication for the surgical treatment of gastroesophageal reflux disease. All salient issues are discussed in reference to all the important operative tricks and techniques.

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Laparoscopic   Nissen   fundoplication   for   GERD

Authors
B Dallemagne
Abstract
This didactic video clearly demonstrates all the key steps of a laparoscopic Nissen's fundoplication for the surgical treatment of gastroesophageal reflux disease. All salient issues are discussed in reference to all the important operative tricks and techniques.
Keywords
hiatal hernia, treatment by laparoscopy, coelioscopie,cure RGO, GERD, hernie para-oesophagienne
Media type
Duration
17'50''
Publication
2006-05
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, May 2006;6(05).
URL: http://www.websurg.com/doi-vd01en1968.htm

Laparoscopic   Nissen   fundoplication   for   GERD

3. Start of procedure 01'00''
That’s why I recommend to do a barium swallow in all patients before anti-reflux procedures. Under X-rays it was an irreducible hiatal hernia and we’ll check how we can reduce that without any tension. The trocar placement is as usual with the liver retractor coming from the right side of the patient, I am working in the middle sector and on my right, the assistant is working laterally and holding the GE junction. Traction and counter-traction is very important in laparoscopic surgery because without traction, I can’t see the plane very well, with just gentle traction I can see clearly the different anatomical planes. Hepatic branches of the vagus trunks, I am trying to respect those branches starting on the pars condensa of the lesser omentum. We will divide opening this window, there is no risk in this area so it’s a good landmark to start with. Through this little window, we can already see our important landmarks with the right crus there and probably somewhere there the vena cava. So you see I am trying to work a little bit outside the sac, I have a big vein there. It’s the approach we use for giant hiatal hernias, so you can identify more easily the different anatomical structures. So we are moving progressively on the left side in a blunt fashion. We demonstrated that we use quite a lot of blunt dissection in order to avoid injuries to the main structures. I am working quite extensively on the left crus since the beginning of the operation, I prefer it because it prepares my posterior dissection of the esophagus. I clear as much as possible on this side, then move back on the right side of the esophagus and you see my assistant is moving the position of the grasper. This is a well-known structure here; of course on the left side here, you have to be careful with the pleura because sometimes in these middle-sized hernias you can have some adhesions with the pleura. We can see the vagus trunks quite well. If you opened the pleura, how would you manage it? First thing to do is tell the anesthesiologist so that he adapts the ventilation rate and he will put a little beep to counterbalance the pneumoperitoneum.
4. Mobilization of esophagus 05'10''
I have prepared my left crus from the other side and when I am dissecting bluntly I can easily find the correct plane behind the esophagus. We still see some surgeons doing this posterior channel blindly and that is the most horrible thing that we can do when working on the GE junction. We have seen graspers within the posterior aspect of the esophagus or the cardia, it’s a step that has to be done with a very clear view, precise dissection of the anatomical planes and this way it’s not dangerous. The pleura is still there. You see here quite well the direction of the vagus trunk, which is anterior to the left, you see it’s going to the left. If the surgeon accidentally injures the vagus, what would he do? The sequella of the division of the trunk is not usually that dramatic, I think it’s very important to try to keep it but if by accident you divide the trunk, then you just need to be aware of that, look at the emptying of the stomach in the postoperative period, it’s probably the only thing to look for. Usually when you are dealing with a patient with GERD, you have to check the symptoms of the patient in terms of problems of gastric emptying; in our preoperative workup quite frequently I use isotopic test to be sure there are no problems with the emptying as it can lead to very severe side-effects after anti-reflux surgery. You can get some bleeding from there, see this little branch there. We are taking our time to mobilize this esophagus within the chest. The final result is that we can get this good length of the esophagus back into the abdomen. That is really one of the most important points of the operation, to preserve those branches. When you want to get access posterior here of course, you have to respect those branches. If you keep this branch and you divide, this it is nonsense. I think we are good in that part of the operation.
5. Mobilization of fundus 08'30''
See the typical fat pad, lipoma that is a really good landmark because it’s at the top of the gastrosplenic ligament. My assistant comes to grab it; in a woman it is much easier, planes are different, the textures of tissues are different so it’s easier. I am trying to find the entrance of the rear cavity. We are coming to this posterior attachment so we change the position. This is the grasper for the assistant on the left side and what I am doing is just closing the grasper of course and just opening a little bit the rear cavity so I can get access to the posterior attachments. You see some people who are working from the front forget that there are vessels there and I think that they are very important. The vast majority of the surgeons here do not take the short gastrics. There is one very well described by Guy-Bernard Cadière because he showed that with the hook dissection: in this ligament, there are two layers, an anterior layer and a posterior one; if you open the anterior layer of the ligament here, you increase the distance between the spleen and the stomach, it is a very good trick. This is a posterior fundic branch that I usually divide because it fixes a little bit the posterior fundus and I saw yesterday that Lee Swanström also divides this branch. Everything is coming from the splenic artery and we are staying quite close to the stomach because the artery is down there. Sometimes you have loops with the artery and if you go too deep, you are dividing or trying to divide the splenic artery, that why we stay very close to the stomach. There are some attachments there, it’s part of the insertion of the phrenogastric ligament. We are coming on the left crus and a good landmark is when you are dividing your drain around the esophagus, you know that you have reached the right area. Usually when you do this, you find this mediastinum lipoma in this area on the back of the cardia.