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Laparoscopic redo fundoplication for a slipped Nissen

Authors

B Dallemagne, C Solano, S Perretta, J Marescaux

Abstract

This video demonstrates the laparoscopic revision of complicated prior Nissen's fundoplication. Description of the anatomy and all the technical steps of the procedure are discussed.

Keywords

laparoscopy, redo fundoplication, Nissen, slippage, revision

Media type

Duration

11'25''

Publication

2008-02

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Audio

Subtitles

E-publication

WeBSurg.com, Feb 2008;8(02).
URL: http://www.websurg.com/doi-vd01en2220.htm

Laparoscopic redo fundoplication for a slipped Nissen

1. Case details 00'16''

This video shows the case of a 31-year-old woman, with a past surgical history notable for appendicectomy and laparoscopic Nissen Rossetti fundoplication in 2002. She was referred for recurrent gastroesophageal reflux. The barium swallow shows the previous fundoplication was still in placed but had slipped over the superior part of the stomach leaving a small gastric pouch over the wrap.

2. Operative set-up 00'50''

The patient is positioned in a supine, reverse Trendelenburg position with her arms at a 90° angle and her legs apart. 5 trocars are used. A 10mm optical trocar is placed in the midline two thirds of the way between the xiphoid and the umbilicus and is used for a 0° laparoscope One 5mm working trocar is placed in the epigastrium just below the right costal margin and another in the mid-clavicular line in the left upper quadrant. A liver retractor is placed in the anterior axillary line just below the right costal margin. An additional 5mm trocar is placed on the mid-clavicular line on the left upper quadrant to aid with the dissection.

3. Operation commences with adhesiolysis and stomach mobilisation 01'45''

At the abdominal exploration, the radiographic findings are confirmed with the fundoplication being seen to have slipped over the superior part of the stomach. The operation begins by freeing all the adhesions from the previous procedure in order to completely take down the wrap. This is done to fully re-establish the anatomy of both the gastroesophageal junction and the gastric fundus. The dissection is carried out mostly using scissors with monopolar cautery. The first step of the operation is to identify the main anatomical landmarks, usually starting to the left side to visualize the left crus and subsequently move towards the esophagus. The hiatus is dissected anterior to the esophagus first, proceeding thereafter carefully towards the right crus. A mediastinal dissection is then carried out up to the level of the pulmonary veins. The anterior and posterior vagus nerves are identified and preserved. It is necessary to completely take down the previous wrap in order to ensure that normal anatomy is returned as far as possible.

4. Take down of prior Nissen wrap 05'29''

Examination of the stomach however reveals that the gastric fundus is really quite short and conical in shape.

5. Mobilisation of distal esophagus 05'40''

This will make a redo Nissen’s fundoplication impossible, and therefore it is advised to do a Guarner valve construction. Before this however, the esophagus needs further freeing from its mediastinal attachments until the gastroesophageal junction rests easily in a subdiaphragmatic position. A tension-free cruroplasty is now performed.

6. Crural repair 07'00''

This is accomplished using 3 interrupted posterior sutures. An additional stitch is placed on the anterior aspect of the crura.

7. Set-up and performance of Guarner wrap 08'08''

Given the particular anatomical situation with regards to the gastric fundus, a total fundoplication would increase the risk of further downwards sliding, and therefore lead to another recurrence. In this circumstance, the posterior 270° Guarner wrap is constructed. This wrap is fixed to the right crus by 2 separate stitches and to the left crus with 3 sutures. In general, we use Ethibond to perform this fixation. Here we see the specific wrap being constructed.

8. Conclusion 10'55''

After the anterior cruroplasty is being completed, the operation is over. The patient resumed a liquid diet on postoperative day 1, and was well enough to be discharged from the hospital on the 2nd postoperative day.

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