Laparoscopic redo for severe dysphagia following open Nissen procedure 15 years ago

Nissen fundoplication is a commonly used antireflux operation. After this operation, symptoms such as dysphagia, inability to belch and vomit, and gas bloating are frequently reported in the literature. The objective of this film is to demonstrate a surgical intervention carried out in a 78-year-old patient who had benefited from a Nissen-Rossetti fundoplication for the management of a gastroesophageal reflux disease associated to a voluminous type I hiatal hernia 15 years ago.

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Laparoscopic redo for severe dysphagia following open Nissen procedure 15 years ago

Authors

B Dallemagne, J Marescaux

Abstract

Nissen fundoplication is a commonly used antireflux operation. After this operation, symptoms such as dysphagia, inability to belch and vomit, and gas bloating are frequently reported in the literature. The objective of this film is to demonstrate a surgical intervention carried out in a 78-year-old patient who had benefited from a Nissen-Rossetti fundoplication for the management of a gastroesophageal reflux disease associated to a voluminous type I hiatal hernia 15 years ago.

Keywords

Laparoscopic redo, Nissen fundoplication, acute, dysphagia, open, Nissen, Nissen Rossetti fundoplication

Media type

Surgical video

Duration

15'26''

Publication

2010-11

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E-publication

WeBSurg.com, Nov 2010;10(11).
URL: http://www.websurg.com/doi-vd01en2927.htm

Laparoscopic redo for severe dysphagia following open Nissen procedure 15 years ago

1. Clinical case 00'18''

The objective of this film is to demonstrate a surgical intervention carried out in a 78-year-old patient who had benefited from a Nissen-Rossetti fundoplication for the management of a gastroesophageal reflux disease associated to a voluminous type I hiatal hernia 15 years ago. Currently, the patient presents with an extremely severe dysphagia with acute episodes of aphagia. Several endoscopic dilatation attempts, however unsuccessful, have been made. The patient has considerably lost weight. Preoperative work-up includes endoscopy, which demonstrates the presence of a grade A esophagitis. On radiology, a migration of the fundoplication wrap in the thorax can be observed in association with a slippage of the fundoplication on the superior portion of the stomach. A proximal dilatation of the esophagus can also be noted. These clinical signs are evocative of pseudo-achalasia.

2. Access to abdominal cavity 01'21''

This clinical situation drives us to carry out a laparoscopic re-intervention. Five trocars are used. They are placed conventionally in order to access the supramesocolic space and the hiatal region. The pneumoperitoneum is established through insufflation in the left hypochondrium. Formerly, the patient had had a first intervention performed laparoscopically, however converted into open surgery. Adhesions are found as soon as peritoneal entrance is made. They are sequelae of the former laparotomy.

3. Dissection of adhesions 01'59''

As it is usually the case in this type of intervention, the first part of the procedure consists in reducing all adhesions in order to access the hiatal orifice.

4. Identification of stomach and wrap fundoplication herniation 02'14''

A substantial herniation of the superior portion of the stomach and of the fundoplication wrap towards the mediastinal region can be observed immediately. The intervention will include the progressive mobilization of this hernia and its reduction. At the beginning of the procedure, dangers related to this type of intervention are linked to the fact that the position of the esophagus is still unknown. The position of the different intramediastinal viscera is totally disturbed. The pleura are displaced. Consequently, the difficulty of the technical maneuver lies in the identification of the different cleavage planes. Scissors are commonly used in order to perform a very meticulous and precise dissection. They allow to identify the cleavage planes more easily and to ensure an almost bloodless surgery.

5. Crura identification 03'27''

Progressive mobilization allows to guide the dissection in a stepwise fashion. The two diaphragmatic crura are systematic landmarks. They should be identified systematically in order to be re-orientated during the intervention. In this patient, the objective is to reduce or even eliminate dysphagia. The gastroesophageal reflux remains secondary. The objective is to perform an intervention that would also allow to control gastroesophageal reflux at least partially, but primarily to eliminate dysphagia symptoms.

6. Intramediastinal dissection 04'22''

The intramediastinal dissection is uneasy. The cleavage planes are hard to find. The presence of clips or suture material placed during the first intervention may aid in finding one’s way. In this type of operation, it is very common to cause right or left pleural injuries that have no consequence yet since ventilation parameters may be adjusted. It is therefore important to inform the anesthesiologist when such perforations of the pleura occur.

7. Esophagus identification 05'09''

An area is identified here, in this dissection plane. It had been formerly preserved. This portion should be dissected in order to identify the orientation of the main anatomical structures, and especially of the esophagus. There is a major risk of causing a visceral injury, and notably an esophageal injury unidentified during the dissection. As soon as the esophageal axis is established, dissection becomes much easier and less dangerous. The fundoplication wrap can be noted on this image. It is still present in the inferior portion of the mediastinum. The esophagus is visible here. This wrap is still present. It is long. It is situated on the superior portion of the stomach and not on the cardia. This accounts for the patient’s clinical signs.

8. Mobilization of esophagus 06'22''

The esophagus is mobilized. The cardioesophageal junction is progressively reduced towards the subdiaphragmatic region. The anterior vagus nerve will not be formally visualized during this dissection. However, the posterior vagus nerve will be seen later on. It will be perfectly identified and preserved. On these images, an important dilatation of the esophagus can be noted. This size is fairly frequently encountered in achalasia. This is why one may speak of pseudo-achalasia combining esophageal dilatation with episodes of severe dysphagia, even of aphagia.

9. Cardioesophageal junction identification 07'15''

The hiatal orifice is quite enlarged. The cardioesophageal junction is identified on a loop. This loop will allow to place different kinds of traction on the cardioesophageal junction and the esophagus without using any potentially traumatic forceps placed on the esophagus.

10. Wrap deconstruction 07'47''

The long wrap should be deconstructed. The dissection plane is guided by the presence of suture threads. In this patient, the decision was made at the beginning of the intervention to open this fundoplication wrap and to consider the anatomy prior to envisaging the creation of a new fundoplication. Because of the esophageal dilatation and the subsequent peristaltic disorders, and because of the patient’s age —78 years old—, and of the importance of dysphagia, the decision is made to open the fundoplication wrap and to leave only the posterior retroesophageal component of this wrap. Hence, it will ensure some reflux control, in the same way as a posterior partial fundoplication. In this dissection, the posterior vagus nerve can be noted. It will be preserved. The left portion of the fundoplication wrap is also freed from the esophagus. This is achieved in order to allow for a satisfactory re-expansion of the cardial and subcardial region.

11. Diaphragmatic orifice closure 09'47''

Once the fundoplication wrap has been deconstructed, the diaphragmatic orifice has to be closed. The muscular structures are relatively strong. Consequently, a cruroplasty will be performed by means of sutures, without any prosthetic material at this stage of the procedure. In order to ensure a correct positioning of the cardia subdiaphragmatically, the esophageal mobilization is extended. This mobilization is generally performed until the pulmonary veins. The dissection is made difficult by the sequelae of adhesions, which are relatively important. The vagus nerve is obviously protected at this stage of the dissection.

12. Cruroplasty 11'00''

The cruroplasty is carried out using interrupted Mersuture 2/0 stitches. Posterior, retroesophageal stitches are first placed. Figure-of-eight stitches are placed in order to limit mechanical constraints at the musculature of the crura. An alternative to this simple suture is to lean the sutures on pledgets or PTFE material. In this patient, it did not seem necessary to use this type of material. Cruroplasty is initially performed posteriorly. Attention must be paid not to extend this posterior cruroplasty too importantly; otherwise, an angulation of the esophagus would be caused at the level of its origin at the inferior mediastinum. From then on, a posterior repair of these large orifices will be combined with a lateral and anterior repair if need be. Here a lateral stitch is placed in order to further reduce the size of the diaphragmatic orifice. In this type of patient with extremely large hiatal orifices or in the case of paraesophageal hernias, a wide absorbable Vicryl prosthesis is usually placed at the end of the intervention. It is positioned on the diaphragm. Because of its short-term absorbable nature, it can be placed almost in a circular fashion around the esophagus. We have used this technique in a great number of patients without any problem at the level of the esophageal junction. This type of prosthesis seems to protect against early postoperative herniation that can sometimes be extremely important and necessitate an early surgical re-intervention. This Vicryl prosthesis should theoretically be absorbed in the 3 months following its placement. It can be noted that the esophagus can be largely covered without any risk of contact with the esophageal wall, and notably without any risk of stenosis, erosion or migration since this prosthesis is absorbable. In this patient, due the size of the hiatal orifice, a stitch is placed at the level of the right diaphragmatic crus and on the wrap. This is of double interest. Firstly, it helps to stabilize the anti-reflux wrap and allows to preserve some anti-reflux efficacy. Secondly, it helps to stabilize the mechanism below the diaphragm and to try to prevent any intrathoracic migration recurrence.

13. Vicryl prosthesis placement 15'25''

The Vicryl prosthesis is positioned in very close contact to the esophagus. One can note that during desufflation, such prostheses will most probably protect against too massive pressures at the level of the abdomen. Postoperative day 1 control proves satisfying. There is still a relative stenosis at the level of the wrap; however, the wrap is well positioned. A new radiological control is carried out 6 months postoperatively. Six months after the intervention, the patient is seen again as a hospital consult. He notices a marked improvement in his former dysphagia and has gained weight. The radiological control confirms the correct positioning of the fundoplication wrap underneath the diaphragm. The esophagus is still a bit dilated, which accounts for a slight residual dysphagia in this patient who is nonetheless very pleased with this surgical re-intervention.