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Laparoscopic 360 degree fundoplication for GERD with posterior fixation of the valve

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Laparoscopic 360 degree fundoplication for GERD with posterior fixation of the valve

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hiatal hernia, treatment by laparoscopy, coelioscopie, cure RGO, GERD

媒體類型

手術影片

期間

18'15''

刊物

2006-05

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最愛

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WeBSurg.com, May 2006;6(05).
URL: http://www.websurg.com/doi-vd01en1958.htm

Laparoscopic 360 degree fundoplication for GERD with posterior fixation of the valve

1. Trocar placement 00'19''

Once again, we have the same view of anatomy; I find it very consistent. We have a replaced or an accessory left hepatic artery in this patient. It’s very consistent to have the pars flaccida in this morbidly obese patient.

2. Start of procedure 00'54''

I start a little bit lower and when you have a large vessel, I think that it’s worth taking some time to mobilize a little bit.Then our first landmark is the right crus as we saw before the vena cava is down behind the caudate lobe, and I start just as we saw before with blunt access to the mediastinum. And I tend to start with clearing off the left crus.

3. Mobilization of esophagus 02'32''

So once again, we identify the esophagus within the mediastinum. So I like to clear off the right crus early in the case it’s a good landmark. As you see it’s the posterior vagus. So I like to identify the left vagus early, the right vagus rather, the posterior vagus. Some people are dissecting the vagus trunk from the esophagus because they like to have the valve between the vagus trunk and the esophagus telling that it might stabilize the fundoplication on the GE junction. What is your opinion? It might help do that a little bit, but I think the trauma that you cause to the vagus is probably not worth it. Some say that fixing the fundoplication prevents slippage of the fundoplication down on the stomach.

4. Freeing of crura 04'23''

I’m using the angled scope which is now looking from right to left and you can see the difference. You see the left crus. It gives you a very good direct view of the back of the GE junction. Here’s the back wall of the stomach which is my landmark from the posterior left crus. I clear the back of the stomach off. Sometimes at this stage of the operation when you’re working on the left crus, it’s difficult to find the plane between the stomach and the peritoneum covering the left crus and sometimes you’ve a tendency to go between the peritoneum and the muscle itself, and you can’t find your way. You progress and you try to find the stomach and in fact you’re between the muscles and the peritoneum. So what you’ve to do at this stage is to go back and work on the left crus to find back the right plane. That’s true and you don’t want to damage the peritoneum on the crura. It’s very difficult to get a good closure. Here it’s the adrenal gland. You can see right underneath the stomach up in this area. So I’ve cleared my window from behind. I’ll get the rest from up above. Now this lady is lucky because she has a nice esophageal length already, what we could call a type 1 dissection, not really much mobilization. It’s the lymph node in the way. Are you using a lot of endoscopes when you have some problems to appreciate the length of the esophagus? Our operating rooms have endoscopes in them. So we use them very often. Any difficulty with the bougie, any history of Barrett’s, we’ll do an endoscopy or difficulty identifying the GE junction. I like to find the anterior vagus inside the mediastinum. It’s very difficult to find that in the fat pad. Here I think that you can injure it. Here it’s easy to see. Here’s our anterior vagus. Have you any sense of how many anti-reflux procedures are done surgically in the US annually? The last time somebody counted there was about 65,000. It may have gone down a little bit as you know it’s not quite as commonly done as surgeons would like to see it and there’s been a little bit of a decrease in referrals. Because of the endoscopic procedures? No, because those are very uncommon also I think just medication is very good and the cost of medication has decreased and a lot of disinformation about the long-term effectiveness of fundoplication. Of course, we’re biased. We went into surgery because we didn’t like pills. Here’s our anterior vagus. Let’s keep it in view. So just a lot of gentle blunt dissection, I don’t like to cauterize even with the ultrasonic too close to the vagus nerves. I think that Alfred Cushieri showed that there was more heat generated by this. It’s really clear on both patients that we previously operated. We take our time to mobilize the esophagus and we’re just taking time to get a good length without too much tension. It’s a really crucial part of the operation. Here’s our posterior vagus from this side. We’re in less than a hurry to rush through this part. We’ve seen a lot of blood vessels pulled off the aorta or accidentally hurting the vagus, so very easy dissection for the esophagus and even on easy ones I do about that much dissection not up to the pulmonary vein like you showed but now we’ll look for the lipoma of Dallemagne. You see the difference with an angled scope is that we’ll be doing this division looking down from above whereas Bernard Dallemagne would lift it up and do it from underneath and will have the same bleeding.

5. Freeing of fundus 11'32''

It’s like doing cholangiograms with lap choles if it’s OK to do it selectively but then you really need to do it. You’re not as good at it and it’s more of a stress. You do it every single time and it’s just automatic and very easy. So once again I stay pretty close to the stomach, it’s my orientation and just we do not have a lot of fat to drag around behind the esophagus. So you’ll notice I grab the stomach just once and the omentum just once and can do pretty much the whole mobilization. Now we’re back to the posterior attachments. We’ll divide these up to the posterior vagus right here. So I continue the dissection until I can see all of the posterior vagus. You can see now the left crus, the aorta and the right crus from the other direction, so know we have a complete window. We probably have 3 or 4cm of esophagus, very easy exposure in this patient.

6. Fundoplication 13'48''

As I pull it through I look for the short gastric vessels once again as my landmark. And I also use as my landmark on the other side, will use the short gastric vessels which is also a little bit different than Tom DeMeester does, well he doesn’t use the short gastrics. Make sure that there’s no twist and you have adequate length and then as we talked about it earlier, I like to bring it over to the 10 o’clock, 10:45 position. And so instead of using a tape I just use the fundus itself as a retractor to expose the crura.

7. Hiatoplasty and valve fixation 15'07''

It looks like laparoscopically I think people take very small bites, so through the telescope this looks big but if we’re looking at this open I think this would be relatively small. I try to make it so the crura is just kissing the edge. This is another odd suture. I put 2 fixation sutures in between the wall of the wrap and the esophagus. So I do the same little fixation suture on this side. At this stage, I’d typically put a bougie down but I don’t think we have a bougie.

8. End of procedure 18'00''

We’re just finished and you can see it, the only difference I think in mine and Bernard is that mine is fixed posteriorly.