Laparoscopic redo Nissen for recurrent GERD not responding to PPIs

This video demonstrates a redo laparoscopic Nissen fundoplication in a 34-year-old man with recurrent gastroesophageal reflux symptoms. A first laparoscopic Nissen-Rossetti procedure was performed ten years ago, and was taken down 2 months after surgery for severe dysphagia and important weight loss. The success rate of laparoscopic Nissen fundoplication depends on the proper creation of a floppy and symmetric wrap together with a suitable crural repair. Most failures and complications due to technical mistakes during antireflux surgeries are related to an incomplete or inadequate intraoperative evaluation of the wrap and crural repair. Development or persistence of dysphagia after fundoplication is among the most common complications occurring in up to 30% of patients. Surgical factors responsible for de novo dysphagia are mainly related to the degree, tightness, length of the fundoplication and technical errors leading to wrap misconstruction -below the anatomical gastroesophageal junction or by a distortion of the esophageal diameter and orientation at the level of the crural repair.

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Laparoscopic   redo   Nissen   for   recurrent   GERD   not   responding   to   PPIs

Authors
B Dallemagne, S Perretta, J Marescaux
Abstract
This video demonstrates a redo laparoscopic Nissen fundoplication in a 34-year-old man with recurrent gastroesophageal reflux symptoms. A first laparoscopic Nissen-Rossetti procedure was performed ten years ago, and was taken down 2 months after surgery for severe dysphagia and important weight loss.
The success rate of laparoscopic Nissen fundoplication depends on the proper creation of a floppy and symmetric wrap together with a suitable crural repair. Most failures and complications due to technical mistakes during antireflux surgeries are related to an incomplete or inadequate intraoperative evaluation of the wrap and crural repair. Development or persistence of dysphagia after fundoplication is among the most common complications occurring in up to 30% of patients. Surgical factors responsible for de novo dysphagia are mainly related to the degree, tightness, length of the fundoplication and technical errors leading to wrap misconstruction -below the anatomical gastroesophageal junction or by a distortion of the esophageal diameter and orientation at the level of the crural repair.
Keywords
Laparoscopy, redo Nissen, recurrent GERD symptoms
Media type
Duration
09'24''
Publication
2010-12
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Audio
en
Subtitles
en tw
E-publication
WeBSurg.com, Dec 2010;10(12).
URL: http://www.websurg.com/doi-vd01en3133.htm

Laparoscopic   redo   Nissen   for   recurrent   GERD   not   responding   to   PPIs

5. Mediastinal dissection 01'48''
Next, mediastinal dissection up to the level of the inferior pulmonary veins is routinely carried out. In order to do this, an umbilical tape is placed around the gastroesophageal junction, which should rest without traction for at least 2-3cm below the diaphragmatic hiatus. In this patient, no mediastinal dissection was obviously performed at the first operation since we soon encounter a virgin plane of dissection. The success rate of laparoscopic Nissen fundoplication (LNF) depends on the proper creation of a floppy and symmetric wrap together with a suitable crural repair. Most failures and complications due to technical mistakes during antireflux surgeries are related to an incomplete or inadequate intraoperative evaluation of the wrap and crural repair. Dysphagia is among the most common complications. Immediate postoperative dysphagia occurs to some degree in all patients after antireflux operations and usually runs a self-limiting course resolving within the first 6 to 8 weeks after surgery. This dysphagia is thought to result from edema of the fundoplication related to surgery. However, a subset of patients report long-term dysphagia, which will eventually require dilatation or re-operation. Development or persistence of dysphagia after fundoplication occurring in 3 to 30% of patients can be related to a variety of factors. Broadly, this factors can be divided into surgery-related causes and preoperative patients’ characteristics. Surgical factors are mainly related to the degree, tightness, length of the fundoplication and technical errors leading to wrap misconstruction —below the anatomical gastroesophageal junction or by a distortion of the esophageal diameter and orientation at the level of the crural repair.
7. Creation of Nissen fundoplication 06'21''
The crura are re-approximated with two non-absorbable sutures, taking care not to overtighten the hiatus. The fundus of the stomach is passed behind the esophagus in the newly created retroesophageal window. A short floppy fundoplication is fashioned using 2 anterior sutures to secure the wrap. One extra suture is placed distally to secure the inferior left border of the fundoplication to the esophagus at the level of the phreno-esophageal membrane. Troublesome persisting dysphagia is a common indication for redo antireflux surgery such as in this patient. In this case, the first operation was a Nissen-Rossetti, which differs from the floppy Nissen technique in that there is no division of the short gastric vessels. In 1986, DeMeester identified the ligation of short gastric vessels among the measures that improved the outcome of fundoplication. Several studies compared outcomes of division versus non-division of short gastric vessels, showing that in experienced hands, equally good outcomes are possible with both techniques at short- and long-term follow-up. The promoters of short gastric vessels preservation blame longer operative time, increased complications, higher recurrence rate and gas bloating syndrome on systematic ligation. However, an interesting point to consider is that a floppy wrap cannot be performed in up to 33% of the cases, even when preservation of short gastric vessels is intended. We believe that systematic division of short gastric vessels is mandatory in the learning curve and recommended thereafter. In addition, in the past, one of the main drawbacks of short gastric vessels division was related to the technical difficulties of such a maneuver, due to the lack of adequate instrumentation. The ligation performed with clips and cautery was cumbersome and time-consuming. Today, with the introduction of new energy sources such as the Ligasure® used in this case, this maneuver became faster and simpler and no longer represents a challenge. The wrap is floppy, 2cm long without tension nor rotation.