Laparoscopic treatment of severe dysphagia after Nissen fundoplication

This video demonstrates the laparoscopic revision of slipped Nissen-Rossetti fundoplication performed previously by open technique. The patient's primary symptom was dysphagia and the surgeon decided to take down the previous wrap and perform a gastropexy. No redo fundoplication was done in this case.

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Laparoscopic treatment of severe dysphagia after Nissen fundoplication

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Abstract

This video demonstrates the laparoscopic revision of slipped Nissen-Rossetti fundoplication performed previously by open technique. The patient's primary symptom was dysphagia and the surgeon decided to take down the previous wrap and perform a gastropexy. No redo fundoplication was done in this case.

Classification

controversial cases

Keywords

revision of fundoplication, slipped wrap,gastropexy,

Media type

Surgical video

Duration

21'15''

Publication

2006-02

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E-publication

WeBSurg.com, Feb 2006;6(02).
URL: http://www.websurg.com/doi-vd01en1915.htm

Laparoscopic treatment of severe dysphagia after Nissen fundoplication

1. Barium swallow 00'21''

2. Case description 00'21''

We use quite a typical placement of trocars. As this woman has had a previous open operation, we insert the first trocar in the left hypochondrium in order to assess the eventual adhesions on the midline. In this patient, there were not too many adhesions, just a few very floppy adhesions from the lesser omentum. Going inside the abdominal cavity, you see that we have already divided some adhesions from the left liver lobe, not too many adhesions you see that the field is quite clear demonstrating that these adhesions were not very important. We will go progressively from the lower part of the abdomen to the upper part. We have already identified a hole, which is probably the diaphragm. We saw on the operative report that there were no crural repair. We have seen some sutures here, probably the fundoplication is somewhere here. This area is very strong, I don’t know why, I wonder if besides the problem of the gastric valve there isn’t some inflammatory response to the sutures. This is probably part of the valve. We will go progressively to the diaphragm and see what happens.

3. Start of procedure 02'11''

First, we try to restore as much as possible the original anatomy. We see perfectly well this liver lobe, very strong adhesions here between the liver, probably some sutures or clips. I am mostly using scissors because so far with all the ultrasonic devices we have, they are not as precise for this sort of dissection, you need a very precise plane. I know from the report that there is no left hepatic artery, so I am quite free in this area because sometimes in redos when you go up, you get the left hepatic artery. If we take down these adhesions, we get access to everything. Now we have restored the normal anatomy and we start to try to understand what happens. The liver segment one, the vena cava should be somewhere there, this is probably the right crus, very strange anatomy.

4. Exposure of crura 04'06''

Somewhere there the mediastinum, stitch here, I should clear a little bit there. Very strong adhesions there, I think I need to clear that to understand, the vena cava is not that far. The esophagus should be somewhere here. Vagus trunk there you see, so this is probably the diaphragm here. The left crus is there. Stitches everywhere, there is probably some stomach there. I think this is stomach, so we’ll go on the other side. The left crus is there, adhesions there, and you see there is stomach there just passing behind the esophagus. This is the esophagus, the valve starts here, you see the line here. This is part of the stomach but there is some valve here, valve that is fixed on the right crus. The problem when I look at that you see that there is some angulation of the esophagus there then you have the valve that creates this angulation. That can also be part of the mechanism. Now we clear the valve from the fundus, you can grab the valve here. I will try to clear this, so we have to go on the crura. This is the retro-esophageal channel.

5. Valve exposure 07'56''

You see there is some stenosis, this is the valve that is placed on the stomach, a little bit too far from the GE junction and it’s also quite stenotic because this valve is 4 years old and you see that’s its still quite tight on the esophagus.

6. Dissection of the valve 08'53''

I haven’t seen the vagus trunk yet, so this is why we are looking a little bit more before cutting. This is the vagus trunk which is outside the fundoplication. We can keep it there, we know where it is and we know that it’s still there. I want to clear this, I will try to preserve this nerve. We can see more and more as we are dissecting. The angulation of the esophagus and the valve go like this, a little bit too low, so the esophagus probably can’t empty very well. This is a little bit of stomach I think, and if we look at the position of the esophagus, it usually goes straight there on the left. This woman didn’t have reflux symptoms beforehand, I think she had more emptying problems of the stomach. We will dismantle this valve, maybe we can find something else and we will do some sort of gastropexy there on the angle of His. On the manometry study there was no complete relaxation of the ileus, so there is still something that can control reflux. This stitch is stenotic, it’s quite large there and here it’s stenotic. We are dismantling the fundoplication, we test the lower esophagus by putting down the esophageal tube which is 34 French, so it’s not very large or big but I just want to be sure that there is nothing left besides the fundoplication and be sure that there is no intrinsic stenosis. So this is the tube, we know that after dismantling the fundoplication, there is no outlet obstruction anymore. The first aim of the operation is probably reached, the 2nd problem now is should we redo a fundoplication? In this patient, I don’t think so because there is no history of reflux disease but more probably a history of gastric emptying problem, we will just dismantle the fundoplication. We could leave it like this but I am afraid that the fundoplication twists a little bit on the left side. Horizontal crura instead of vertical crura, it’s very typical in young and thin women that complain of these types of problem. I have seen it a lot of times and you probably also have, it is very difficult to do a good fundoplication in these patients because it is difficult to place properly the fundoplication there instead of there. If you do it, you should place the fundoplication here and not here. This is the right part of the fundoplication, when I am redoing, I always use scissors and coagulation instead of the ultrasonics or those sorts of devices because of precision. I am not used to having bipolar on my operating table, it’s probably a difference in philosophy between France and Belgium; in Belgium, the surgeon rarely uses bipolar cautery, it’s more used by the gynecologist. But looking at the different indications for bipolar, I think it’s very helpful but I can’t work with it. Maybe we can create a gastro-esophageal reflux disease by the first operation and then dismantling it, so we don’t know but the choice between the two options, either dysphagia versus recurrent symptoms of heartburn, dysphagia can be treated with medication, heartburn can’t be treated so we will choose this first option. Then if once we have some difficulties to deal with reflux disease, we will probably have new options of intraluminal treatment such as the Stretta procedure. I prefer to create a reflux disease than persistent dysphagia, that is the option we will go for in this precise patient. When patients have dysphagia and recurrent symptoms, I get the option of redoing the fundoplication but here it’s not the point. There are still some adhesions there. You feel it when you hold the structure; the previous surgeon used part of the body of the stomach to create the fundoplication and that explains the radiological image with medial gastric stenosis.

7. Reconstruction of angle of His 18'39''

The idea of restoring a GE junction has no place here, it’s another problem. The image they got through the endoscope was related to vomiting but anyone who vomits will have some erythema of the esophagus, it’s a wrong diagnosis initially I think. Besides that, the anatomy of this patient is very typical of dyspeptic patient and this anatomy is very difficult to deal with when you want to do a Nissen fundoplication because most of the time you place the fundoplication too low. The fact that there is this angulation plus a valve that is gastric, determines a twist of the esophagus. So you have both the indication and the surgery that creates the problem. A little hemostasis and then we have finished. We are going to see what happens with that patient, we hope to relieve the dysphagia, we will see if we are creating some reflux disease. If so, we have different options to treat this reflux disease, if there is a problem with emptying of the stomach, we also have different options. This stomach is not typical of a stomach that is volvuling. We are trying to treat a problem, which is dysphagia, I think we have probably reached this goal and we will see what happens in terms of reflux. No tube, usually we allow this patient to drink water in the evening. I am used to checking them with barium swallow or graphin swallow on the first day and then they start with soft food.