Live laparoscopic reoperation for slipped fundoplication with intraoperative endoscopic monitoring

Authors

Abstract

This video shows a laparoscopic reoperation for slipped fundoplication with intraoperative endoscopic monitoring during a live demonstration.

Keywords

laparoscopic reoperation, slipped fundoplication, intraoperative endoscopic monitoring

Media type

Duration

22'00''

Publication

2011-05

Popular

Favorites

Audio

Subtitles

E-publication

WeBSurg.com, May 2011;11(05).
URL: http://www.websurg.com/doi-vd01en3334.htm

Live laparoscopic reoperation for slipped fundoplication with intraoperative endoscopic monitoring

1. Introduction 00'48''

We have probably already the diagnosis because we have seen that there was a small recurrent hiatal hernia, and in fact it is probably a slippage of the fundoplication. It means that the valve is on the stomach side instead of the esophagus or the GE junction. On the middle picture, you can see a little part of stomach above the fundoplication. It’s very typical. In our experience, it’s generally associated with the Nissen-Rossetti technique, so Nissen is done without gastric mobilization because you have some traction mechanisms that attract the valve down on the stomach.

2. Intraoperative view 01'39''

This is the view we can get inside the peritoneal cavity. You can see very few adhesions. The first surgeon made a very clear dissection so it’s probably not too difficult to redo. Technically speaking, we’re using the same placement of the ports as for a primary repair. You see that I’m starting with the scissors instead of using the bipolar because with the scissors I have a more precise dissection and I can recreate all the anatomical planes. Probably we will need redos between 6 and 10 or 15% of the population.

3. Identification of right crus 02'29''

I choose to work on the liver side. I’ve now my landmark, which is the right crus. You don’t have to fix yourself on one point. It’s just to work from one side to the other side, trying to find the window where you become more comfortable with the landmarks. There I know that the axis of viscera is there, so I’m just close to the liver. The vena cava is down there, probably somewhere here, so I’m safe here. If I have some visceral injury, that will be probably on the stomach, which is not very important. Again I’m choosing the liver side. Sometimes, it’s difficult to find exactly where you have to go. Then we’ll prepare with an endoscope inside. We leave the endoscope inside the upper esophagus, just to get ready to control at each step of the operation. I’m back to an anatomy that I know, with the right crus there. Probably the valve is somewhere here because we can see the stitch. See the valve is here. One point immediately is that you see this fat pad is probably a little bit above the valve and that’s probably a little bit of stomach. That explains why you have this recurrence. It’s not tight, it’s down.

4. Valve dismantling 04'37''

Now I will try to dismantle that so that I have an easier access to the axis of the esophagus. There’s a problem sometimes when you have patients referred with the work-up: you can’t see what you would like to see. That’s the typical aspect. Maybe some little bleeding on the fat pad or the anterior esophageal wall. Now I have the right part of the valve here and I will try to find the cleavage between the valve and the right crus. Yesterday I was discussing with someone that people are sometimes fixing the valve on the diaphragm so we have to be aware of that. The adhesions are not too bad. Do you think that in some people who have bad adhesions in some sort they’re not so bad, do you think that maybe patients who don’t make adhesions are at higher risk of failure? I don’t think so. Adhesions that would prevent recurrence are adhesions between the valve and the esophagus in this circumstance when you have the slippage, but I think it’s more related to the traction that you put on your repair, and we know that when we’re doing a Nissen-Rossetti, we know that we’re doing sutures under tension and to my knowledge in surgery, if you are considering traction on your sutures, you increase the risk of rupture of this suture. So for me, it’s more this mechanism. It’s too much traction or malposition or something like that that leads to recurrence instead of adhesions. See it’s a minimal dissection at the time. Remember one paper published in Annals of Surgery saying that to avoid migration, etc., you should do a minimal dissection, almost no dissection inside the mediastinum and that was a time when the team was looking at this method, that’s why you can see that there is no access within the mediastinum, no previous dissection at all. You can see that I’ve been very careful on the left crus because at a time we’ve seen the vagus trunk, you see we discussed that yesterday and the vagus trunk was tucked here. So as you said the strategy is to find one landmark; in this patient, it was the right crus so I know that if I’m working very close to the right crus, I will find some structures, either the stomach like here or the esophagus and then once I have got my cleavage plane there, I can go up and identify exactly the position of the esophagus. So at this point, I’d say that I’m safer. So now I’ll try to get behind the esophagus. Usually, and you know when we’re starting this sort of redo, we’re trying different approaches, we’re trying on the right, on the left, just to get the easiest access, I don’t know probably here. See probably the cleavage is here. So the risk at this point is to do a perforation of the stomach, which is not a big deal if you recognize that you’ve done one. See I found the plane between the valve here. No blind maneuver, see at all times, I’m just controlling by the view, and here you see I’m a little bit clocked so as Nat was saying, I’ll go on the other side now because I’ll find the cleavage plane between the valve and the esophagus. As we know that there is no gastric mobilization at the first, we’ll do it now and as Nat Soper was saying, we’ll find the virgin plane at the back of the fundus probably down there. So the basic rule in all these redos is first to try to get back to the normal anatomy, then analyze the situation and look for the best option that you have with of course this anatomical consideration. And so I’ll try to get access from the other side just to look at the back of the fundus and then maybe I’ll have more ideas but I’ve probably some stitches on the back. We can see that the valve has passed behind the esophagus there and there are still some adhesions there. When I look at that, probably there was some cut of the gastrophrenic ligament at the first surgery probably. The problem of the mesh comes when we have to treat intrathoracic migration or re-herniation or recurrent hiatal hernia, etc., because sometimes in this redo, we have very large orifices and yesterday we had a nice discussion with Lee Swanström and Nat Soper and we all three agreed that we have to go for a mesh in very exceptional situations when we have no other options because first even if there is some ideas that of course the mesh will diminish the recurrence rate, it doesn’t suppress. That’s not the only mechanism that explains the recurrence. And the second point is that you have to consider the type of recurrence that you may have and third, you have to consider the problem that may create with the mesh. And altogether makes it a very complex situation and really yesterday we were just saying that we have no perfect answer to this problem and to this challenge and I don’t know if Lee or Nat want to comment on that. I think that the lack of adhesions is a problem of recurrence because when we want to find the cleavage plane, sometimes it’s tough. So probably there, enough adhesions. See the vagus trunk, so the valve is outside of the vagus trunk. And it’s very important to take it down because when you want to consider another repair, you see there are some clips there, so it’s always interesting. So you see the leak that I have. But I think that we’ve got the valve back at this point so now I’ll focus a little bit more on the repair of this leak. Right to do some partial fundectomy. You’d love to do that. So you see that I’m looking at the back just to be sure that I’ve got everything. I can see that it follows I’d say the normal anatomy so this is the stomach. See it’s normal anatomy. It’s a triangular shape. You don’t have this angle, but it’s going this way that usually is more fundus and difficult to do a Nissen in this fundus. I will repair this at this point because I don’t want too much gastric liquid inside of my field. It does need to be a perfect repair. We’re just in the upper fundus, so it has to be sealed. I always check the reducibility of the GE junction when the patient is moving during the upper GI series. So if you have a spontaneous descent of the GE junction below the diaphragm when the patient is standing up, I think it gives you already some little indications about reducibility of the junction. For me, it is quite interesting an indicator.

5. Intraoperative endoscopy 17'28''

Endoscopy is going to be ready in 5 minutes. I will come next to Lee so that he can comment. Lee is saying that he’s just checked that we’ve taken down all the fundoplication and you can see there the U-turn, the retroflexive view of the stomach. This is the repair we’ve done in this injury of the gastric fundus. We’ve tested that with water and there is no leakage so we don’t have to do anything more regarding this junction. We’ll go back to the GE junction inside the esophagus and then you’ll have a good view on the GE junction. You see there’s some little metaplasia just at the junction of the gastric fold and the esophageal fold. This is the true esophageal sphincter. Just look at my mark. That’s really the point where I was. I find the other difficult thing in this case is to tell what part of the fundus to use because it’s distorted. We’ve tested before. I would do this. I check now. Looks OK. It does not look perfect, not like the first time but it never does. It could be a little bit tighter do you think? OK. What do you think about the valve? I agree it looks a little bit loose but I think otherwise it looks good. And certainly on the outside, it looks appropriate. What I think it’s a little concerning on this view is that you see gastric folds going inside the wrap. Now it’s better. Now I will finish with this valve. Maybe Lee can stay inside the esophagus and then at the end of the repair, we will check again with endoscopy. Thank you very much, that’s a wonderful demonstration.

Username
Password
	Remember me (needs cookies)