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Laparoscopic redo for dysphagia after Nissen fundoplication induced by fibrosis at the hiatal orifice

Authors

Abstract

This video demonstrates the performance of a difficult redo operation following a previous laparoscopic Nissen fundoplication complicated by severe fibrosis at the hiatal orifice.

Keywords

laparoscopy, redo, dysphagia, Nissen fundoplication, fibrosis, hiatal orifice

Media type

Duration

28'25''

Publication

2008-05

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E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2337.htm

Laparoscopic redo for dysphagia after Nissen fundoplication induced by fibrosis at the hiatal orifice

1. Case background 00'18''

On the right side, you can see that there is esophageal peristalsis, but just before the peristalsis on the right side, which is in red, you see some change in the colours, and in manometry, it can be explained by the increased pressure in the esophagus. When the patient is opening the upper sphincter, the lower sphincter relaxes, you see the red line on the right side. The sphincter opens, so it is not a problem with the fundoplication and the high pressure zone. As soon as the patient swallows, there is a column of high pressure within the esophagus, which corroborates the idea that it’s not a problem with the fundoplication but maybe a problem at the level of the diaphragm. There is a small increasing pressure just above the high pressure zone. So we have the feeling that there is some outlet problem not at the level of the fundoplication and the high pressure zone but maybe a little bit above this zone. This patient has real symptoms. He is complaining of solid food blockage that entails vomiting from the esophagus and not from the stomach. That’s why we decide to go further with the exploration and use surgery to resolve this problem. This patient has lost a lot of weight in the beginning, that is 8 kilograms but now he’s quite stable. But as soon as he’s sitting at a table, he’s suffering from food blockage and has to drink water. With the X-rays, we have some print on the back side of the esophagus and the endoscopy is normal and the fundoplication through the endoscope looks normal. Always listen to the complaints of the patient.

2. Trocar placement 02'48''

When we enter the peritoneal cavity, you’ll see that there are no adhesions at all. Here’s the aspect of the peritoneal cavity.

3. Initial laparoscopy and exposure of operative field 03'00''

Then we’ll retract the left liver lobe. You see that the stomach is perfectly intact so we just use the upper part of the stomach and this is the site of the fundoplication. First we need to get access to the hiatus. This is the lower part of the fundoplication, which is lying here. It’s not very stenotic, it’s quite floppy but we don’t know where the fundoplication is so we have to open these adhesions and get access to the diaphragm to start with. Then as soon as we have a clear view on this side, we’ll come and test the passage through the esophagus with a bougie and try to understand where the outlet problem is. Regarding the anatomy, you see that we have preserved the branches there so this is the lesser omentum with the pars flaccida and the pars condensa. So I know that I have opened the pars condensa only; so I’ll work there and get these adhesions.

4. Initial dissection and adhesiolysis 04'08''

Very rarely I had problems with the fundoplication itself, but problems sometimes come from the crura or the diaphragm. I suspect that it may be the case in this patient. Technically speaking, in that kind of redo, you see that I use normal scissors because the goal is to find exactly the plane and usually with the ultrasonic system, it’s not so easy. Typical findings you see in these redoes with these adhesions to the left lobe, which are sometimes quite dense. Usually when you have performed the first operation, it’s far easier since you know exactly where you have to go. When you’re dealing with redoes coming from outside, the first part of the operation is to try and understand what’s happened and what the surgeon’s done before. But always remember that you have to listen to the patient’s complaints. Here are the edge of the left liver lobe and the diaphragm. In this patient preoperatively, we didn’t get any information. They couldn’t do the manometry but here with the tests that have been made, I can say that I’ve never seen people who can’t accept the probe. I have to find my way here. I’m trying to respect all the planes because otherwise it starts to bleed. Here’s the dissection is very progressive. I’ll check from below. This is the ligament. I’m trying to approach the crura repair very gently. This is the crura repair and the fundoplication is there. I think that you have to totally mobilize. Recurrent reflux is the number one problem we encounter in these patients. I’m always amazed at seeing these patients coming back for a redo fundoplication for recurrence. For me, it’s a good sign that the functional results and the quality of life are very good with a good Nissen when compared to medication use. This might be a little hernia sac. This is what you may suspect with this posterior herniation there. I’ll go on the left side. Regarding the valve, one of the causes of dysphagia, but it’s related mostly to the Nissen-Rossetti, it’s that you have this axial torsion of the esophagus. We don’t have this here because the valve is in the right position there. You see the right side of the valve and I don’t think that there is a big problem there. Now we’re going to try to pass down the bougie and see if the bougie is coming through.

5. First intraoperative passage of bougie 09'43''

The anesthesiologist says that it’s blocked and we don’t see the bougie here. The problem doesn’t come from the wrap apparently. Did you do the endoscopy as a surgeon? Yes we did it. If you ask a gastroscopist who is unaware of the operation, he/she has not the same vision as a surgeon. The problem is very specific here. What’s your opinion regarding the position of the valve? It’s always very difficult to tell because the landmark has gone. I think it would be good to do endoscopy. It’s very suspicious that the bougie wouldn’t go through. It looks like the esophagus there. If we have a valve, which is placed on the stomach just half a centimetre below the good position, it doesn’t give dysphagia. Usually it’s recurrent heartburn. When the valve is really placed on the body of the stomach, then you have dysphagia, that’s why I’m not convinced by the question about the position of the fundoplication. We’ll ask an endoscopist to come over and have a look.

6. Second passage of the bougie 12'53''

We’ll check again with the bougie.

7. Further dissection of hiatus and entry in mediastinum 13'13''

So it’s not really the fundoplication that creates problems. There’s a small herniation there. It’s rare that we have something there; usually, it’s a little posterior on the left. This is the diaphragmatic muscle. Now I try to get access to the mediastinum and see what happens with these crura. I don’t know why it’s so fibrotic on this side. Maybe that’s not the right plane. You can see a line, it may be pleura. We’ll test again. There’s a little bleeding there. Small dilation of this side of the esophagus. That’s the diverticulum on the X-ray. You see the bougie is there. It blocks here as a matter of fact. It does correspond quite well to the picture that we have. There’s some sort of fibrosis on the repair. I’ll open that. It’s a pseudo diverticulum. The valve is there. The esophagus has a normal size here and is dilated there. The problem lies there.

8. Demonstration of abnormal anatomy 20'23''

The stitch on the esophagus is here so you see the distance. It is a little bit low. We can see that it really blocks on the diaphragm there. Maybe one stitch too many here. Personally I’d leave it like this regarding the valve. This is very fibrotic at this level. There’s no longer any big obstacle there and I’ll try to open a bit this space.

9. Division of fibrotic band around distal esophagus 22'37''

There’s a band right there. We can see the print of this band on the lower esophagus, like a bowel occlusion.

10. Intraoperative upper GI endoscopy 23'00''

Show me the Z-line. We’re using the endoscope and check the Z-line, which is here and the valve is on the Z-line. So there’s no question about the position of the valve. Can you check coming down from the esophagus into the stomach if you have some blockage slowly since we have a small diverticulum dilation of the esophagus on the back? There’s still the posterior part of the anti-reflux mechanism. You can deflate and go back. Should we take down the posterior repair or not? I wouldn’t. We’ve checked again and we can see very well the level of the occlusion. The question is if this would create a hyper-pressure mechanism and lead to some decompensation of the lower esophagus. When discussing with the patient, he wanted the mechanism out because it was too uncomfortable for him. If surgeons can find the cause of discomfort, maybe we could keep some part of the mechanism. If we leave that, there is some little risk of impairing the lower esophageal motility that would allow for the development of this pseudo diverticulum.

11. Take down of previous fundoplication 26'23''

We can find quite easily the different planes so the problem is not related to the valve.

12. Conclusion of operation 28'33''

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