Laparoscopic treatment for a symptomatic esophageal stenosis following Nissen repair

Laparoscopic fundoplication has revolutionized the surgical treatment of gastroesophageal reflux disease. Careful patient selection, identification of the short esophagus, and accurate construction of the fundoplication can lead to a decrease in the incidence of postoperative dysphagia. This is an interesting video in which a critical analysis in performing a redo operation is clearly given to each surgical step.

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Laparoscopic treatment for a symptomatic esophageal stenosis following Nissen repair

Authors

B Dallemagne, J Marescaux

Abstract

Laparoscopic fundoplication has revolutionized the surgical treatment of gastroesophageal reflux disease. Careful patient selection, identification of the short esophagus, and accurate construction of the fundoplication can lead to a decrease in the incidence of postoperative dysphagia. This is an interesting video in which a critical analysis in performing a redo operation is clearly given to each surgical step.

Classification

complex cases

Keywords

Laparoscopic treatment, symptomatic esophageal stenosis following Nissen repair

Media type

Surgical video

Duration

13'14''

Publication

2009-06

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E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2606.htm

Laparoscopic treatment for a symptomatic esophageal stenosis following Nissen repair

1. Case presentation 00'18''

This is the case of a 45 year old female patient with a past medical history significant for open fundoplication in 1996 characterised by early recurrence of GERD symptoms. A new laparoscopic Nissen fundoplication was performed in 2005, but 4 years later, the patient developed regurgitation not responding to PPI. A barium swallow was performed, which showed an intra-thoracic migration or slippage of the valve.

2. Entering the peritoneal cavity 00'54''

We enter the abdomen through the left hypochondrium to be sure that we are away from these adhesions at the midline. We can see that the left part of the abdomen is quite free so hopefully we will not have too many problems in getting access to the hiatus. This area should be free, we can open the suspensor and we are going to have a look through this window and get access to the right hypochondrium. We are using an angulated scope, getting a good exposure is a critical point for this sort of redo operation. Very fatty liver. The challenge now is to not break the liver in 2 pieces.

3. Freeing the adhesions 01'51''

To begin the division of the adhesions, we usually prefer to work with scissors, they allow a more precise dissection than the ultrasonic system. We have to be as precise as possible to avoid all the bleeding and respect the cleavage plane, because that is important to get your landmarks. This is already the stomach. We will increase the space a little bit. The first step is to try and get access to the crura, either the right or the left. We don’t know yet because these are the crucial landmarks before we do any dissection into the mediastinum and look for the esophagus. Usually a good landmark is to get access to the segment 1 of the liver because it gives you the way to the crura and an idea about the position of the vena cava. And if you follow the cleavage plane along the segment 1, you usually get access to the crura. First impression after having freed the adhesions is that we have a valve inside the abdomen.

4. Slippage identification 05'05''

Maybe this is the esophagus and both parts of the valve, so maybe that instead of an intrathoracic migration, we have a slippage, that is a herniation of the stomach through the fundoplication. This observation is quite typical of a shortened esophagus and a traction back into the mediastinum of the abdominal esophagus. These adhesions here are quite typical of a laparoscopic operation; very thin adhesions and we are finding the spleen over there, it’s a very nice view. We will try to get the lower part of the esophagus with the loop, but we still have some adhesions.

5. Mediastinum and anterior vagus identification 07'52''

We are entering the mediastinum. We have identified the anterior vagus trunk, which was located a little bit on the side. We will need an endoscopy to know exactly what structure we have because there is a very large esophagus there. When we look at this picture, we have the feeling that we have a dilation of the lower segment of the esophagus and/or the stomach, because I think that this may be some stomach. Dilation that provokes esophageal stasis and postural regurgitation. That explains why the patient is not controlled by the PPI, because we know that the PPI does not reduce the regurgitation rate. So there is probably a progressive dilation related to some outflow obstruction at the level of the valve.

6. Peroperative endoscopy 09'34''

This maybe stomach but we will do a per-operative endoscopy to control the exact positioning of the Z line. I need to see the junction. We are trying to recognize the position of the Z line while using the endoscope, and the Z line is there. We were totally wrong, it’s a very huge dilation of the lower esophagus; it is in fact an outlet obstruction and she probably had the symptoms of regurgitation because of the stasis, so we were totally wrong preoperatively. We are marking the GE junction with a stitch so that we can use it afterwards to locate the repair. You can go inside now and do a retroflex just to see the valve. Not bad, a little bit too long. We are just wondering now what to do with this sort of problem, an outlet obstruction, redoing a Nissen is not a good thing, leaving without an anti-reflux is not a good thing, so I will probably leave the posterior repair and not touch anything else to allow the emptying of the esophagus and reduce the regurgitation. Doing a Collis is not a good thing, we know that the esophagus is not very long but that is not a big issue. I will fix the valve there.