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Laparoscopic floppy Nissen: a standard procedure

Authors

Abstract

This authoritative operative performance clearly demonstrates each important technical step in the construction of a "floppy wrap" Nissen's fundoplication.

Keywords

laparoscopy, floppy Nissen, standard approach

Media type

Duration

14'30''

Publication

2008-05

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E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2340.htm

Laparoscopic floppy Nissen: a standard procedure

1. Trocar positioning 00'29''

Here’s the typical positioning of the different ports. I’m using a zero degree scope as usual and you can see that the umbilicus is down there. I try to maintain some distance between the xiphoid process and this umbilical trocar in order to have some working space. I try to “divide” the patient into different sectors; on the right side of the patient, this is a sector for retraction of the liver. The middle sector is for the surgeon, with my left and right hands here on the mid-clavicular line and the external sector is used to retract also the GE junction and present all the different structures to the surgeon.

2. Exposure of operative field 01'14''

Regarding the anatomy, we’ve placed this atraumatic liver retractor. By experience, that’s probably the best type of retractor that we have on the market. You have the left liver lobe, segment 1 of the liver: these are important landmarks. We just check the gallbladder on the right side. The liver is normal. On the other side, we have the splenic flexure here, here’s the spleen. This is the pars flaccida of the lesser omentum; this is the pars condensa.

3. Operation commencement (initial dissection of pars flaccida and exposure of crura) 01'54''

So usually I’m trying to keep the hepatic branches of the vagus trunks for different reasons; sometimes we have an artery so I try to be as functional as possible. If you’re starting with this operation, maybe you can divide it to get a clear view. I’ll show this clear view. We’re looking for the 1st landmark and the very important landmark is the right crus; nothing can start without the view on the right crus. You see that we’re not that far from the vena cava. The right crus is here. You can divide this when you’re starting with this procedure because you have a very clear view on the crus. With this little trick, you can get the good landmark from below. I’m working directly on the phreno-esophageal membrane and you see that during this whole procedure, I’ll work only with this ultrasonic system. It’s quite comfortable to go straight ahead only with one instrument because it reduces the number of movements within the trocar and you know that each introduction of an instrument within a trocar carries some potential risk so I try to reduce the number of movements of the instrument in and out. I’ve opened the membrane and I make a little bit more space. I clear a little bit the right crus so the view is better and you see how I’m entering the mediastinum. You see the right crus here. And so I’ll go alongside the right crus because I know there are no risks for any major structures like the vagus trunk. I know that there is nothing there. And progressively by blunt dissection, I’ll find the esophagus, which is there. I’m trying to see the position and direction of the esophagus. It’s important to go on the lower part of the left crus because it’ll help you when you want to find the posterior channel behind the esophagus.

4. Circumferential exposure of distal esophagus 05'00''

We now move back to the right. I’ll try to lift up the esophagus. I’m doing a lot of blunt dissection. I’m not grabbing the esophagus. I’m trying just to retract it so the esophagus is on the side and I’m working a bit more alongside the right crus. Now I’m trying to find my plane and landmarks. This is the right crus and I guess that the left crus is there. That’s very important because if you’re going inside too high, you’re going to the left pleura. If you’re going too low, you’re going to be in the cardia. That’s why I try to establish first my landmarks and then I continue my dissection. And you see since I’ve been working on the left crus from the start, I can find my way very easily.

5. Taping of esophagus for retraction 06'17''

So I’m passing my umbilical tape in the hole, the channel, then move it to the other side and I grab it from there. So you see now we’ve a very safe and good traction on the GE junction without any grasper on it, I’ll move back to the chest. So you see we have a nice positioning of the different landmarks; one of the major problems in anti-reflux surgery is to properly evaluate the length and the tension we’re applying on the abdominal segment of the esophagus.

6. Mediastinal dissection and mobilization 07'22''

You see the pleura there. Progressively we’re working around the esophagus. The pulmonary vein is there and we can see quite clearly the vagus trunk. I can even clear more and in fact you can see very well the trunk. The idea of checking is that you have the position of the phreno-esophageal membrane, which was fixed like this initially. So you see that we’ve got quite a good length and I release the traction on the Penrose drain and probably my junction is staying in the abdomen.

7. Construction of floppy wrap (dissection of gastric fundus) 08'14''

We defend the idea of always doing the floppy Nissen, with gastric mobilization and I’m trying to find my landmarks. So this is the posterior cavity so I clear a bit the window. You see all these posterior attachments of the gastric fundus. When discussing the gastric mobilization, it has to be very precise because sometimes people are mobilizing from the lower part of the greater curvature, which is not necessary. So you see we’re coming on the gastrophrenic ligament so I’m joining my previous plane of dissection on the right side. We can see very clearly this ligament and we have to divide it to free the upper fundus.

8. Crural opposition 09'27''

When I’m closing the crura, I’m trying to include some peritoneal sheath in the suture to protect a little bit the muscle. You see we have respected the sheath there so I’ll include that in my suture. You see my grasper is there protecting the needle to the vena cava and the liver. Probably when I’ll stitch it, I’ll stop. But sometimes when you’re creating this posterior channel, you can have some problems with this posterior left crural artery. I’m just coming with a sponge within the abdominal cavity. If you come directly with the irrigation system, you’ll have a lot of water fluid within the field and you can’t see anything. And here the view is very clear. We complete the little stitch and we complete our crural repair. You see that the junction is staying in the abdominal cavity but if I release my traction, you see that the esophagus is just kissing the crura. This expression ”kissing the crura” comes from Dr. Swanström.

9. Construction of fundoplication 11'31''

I have the anterior fundus. This is the line of the gastric mobilization, the short gastrics and the posterior fixation and this is the back of the esophagus just orientating the gastric fundus and I’ll grab it from the other side. I don’t think I need a bougie because I know if I do that, I can pass down a 50 or 60 French bougie. That’s why I’m not using a bougie. Again I recommend that people starting with this operation use a bougie in the initial stage of their experience just to get used to the size. I know that I’m doing a very loose valve because in my opinion the most severe problem that you can get with this surgery is dysphagia because this cannot be treated in all patients. Sometimes you can do a dilation if it’s too tight. On the other hand, if you have some little recurrence because the valve is too loose, which is rare as a matter of fact, but you can imagine that getting one pill is much easier than getting through several endoscopic dilations or re-operations. It’s very difficult to predict dysphagia, isn’t it? With this kind of surgery, I’ve never had any patient needing some dilation. You see with these 2 last stitches, I’ve tried to fix the fundoplication on the esophagus because I think it’s an important factor: we need to have a good fixation of the valve at a proper place on the esophagus and thus avoid slippage. Again it’s the phreno-esophageal membrane. We’ve placed the fundoplication not below the phreno-esophageal membrane but on the real cardia. Now we’re done. I’ll show you the final results. Everything is well respected with this kind of fundoplication.

10. Completed procedure 14'00''

There’s no twisting like the one you can get with the Nissen-Rossetti fundoplication, only the upper part of the gastric fundus. You see that the valve is very smooth, there’s no traction, no blue tissues, the repair is not too tight.

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