Laparoscopic reversal Nissen fundoplication for dysphagia

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Laparoscopic reversal Nissen fundoplication for dysphagia

Authors

D Mutter, J Marescaux

Media type

Surgical video

Duration

07'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1621.htm

Laparoscopic reversal Nissen fundoplication for dysphagia

1. Case presentation 00'14''

This is the case presentation of a 31-year-old male. Two and one half months ago he was previously operated for reflux disease with a Nissen Rossetti procedure. At that time, the patient presented immediately with minor dysphagia that was treated with esophageal dilatation 3 times without relapse of the dysphagia. During this time period, he had a 10 kilogram weight loss. After discussion with the patient, we will plan for revision of the reflux procedure.

2. Trocar position 00'53''

We will use the previous port sites again for visualization of the abdomen. The optical trocar will be placed mid-distance between the umbilicus and the xiphoid. The 4 remaining ports will be placed below the costal margin in the right and left hand side.

3. Wrap dissection 01'11''

We note an adhesion between the liver and the right side of the wrap. We do not identify any other postoperative adhesions impeding our procedure at this time. Here is the wrap. It is easy to identify as you can see. There appears to be good mobilization behind the wrap with no evidence of adhesions. The anterior portion of the wrap is also mainly devoid of adhesions. In this situation where no other abnormality exists, the appropriate measure to take is to undo the wrap to alleviate the dysphagia symptomatology. This will not be technically demanding as the lack of adhesions as we see it will speed our procedure. The first suture is grasped and cut. We utilize blunt dissection in the adhesed area and note a small amount of bleeding. Often times a natural plane of dissection can be noted using this technique. After continuing we identify the second stitch. Note how the adhesions are stabilized adjacent to the liver avoiding any tension towards the liver and thus promoting significant hemorrhage. This 2nd stitch is grasped and cut in similar fashion as the first. We take care to note that one of these stitches likely has the anterior esophagus included in it and too much tension on this stitch could injure the esophagus. The remainder of the dissection of the wrap is uneventful. However it is interesting that we have not been able to identify the third stitch on the wrap. We will continue our dissection.

4. Crural approach 02'58''

We now inspect the crural stitch. We are continuing to investigate this patient’s post-surgical anatomy to explain the reason for the dysphagia. We see the wrap did not have significant tension and was easily taken down. We will now see if the crural suture was placed such that it caused in acute angle of the esophagus creating the dysphagia. After removing the suture, we encircle the esophagus with a tape to retract it and improve our visualization. With this, we note a twist of the esophagus. This likely created a malrotation of the esophagus which is consistent with the patient’s symptoms. We will take this posterior adhesion down from the wrap to allow for a more natural and anatomic position of the esophagus. We review the gastroesophageal anatomy to note of injury that we may have caused. We do not note any injury that we have caused. However, an additional band will be taken down posteriorly. We see the esophagus is freely mobile at this time within the abdomen. Here is the posterior part of the wrap. Here is the anterior part and here is the greater curvature of the stomach. We do not feel another antireflux procedure is indicated at this time. We will plan for the patient to improve his protein calorie deficiencies in the coming months and re-evaluate his symptomatology at that time.

5. Removal of trocars 07'00''

This marks the end of the procedure. We will remove the trocars under direct vision to note the incidence of hemorrhage from the port sites as is customary for our laparoscopic procedures. Finally, we will close the 12mm port with a 2/0 absorbable suture on the fascia and the remainder of the port sites will have skin closure.