Laparoscopic Nissen-Rossetti fundoplication

This video demonstrates a routine Laparoscopic Nissen fundoplication in a thin patient. The surgeon demonstrates mobilization of the distal esophagus, identification of the anterior and posterior vagal trunks and division of the short gastric vessels. The esophageal hiatus is repaired posteriorly and a loose wrap is constructed and sutured to the crura posteriorly.

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Laparoscopic Nissen-Rossetti fundoplication

Authors

Abstract

This video demonstrates a routine Laparoscopic Nissen fundoplication in a thin patient. The surgeon demonstrates mobilization of the distal esophagus, identification of the anterior and posterior vagal trunks and division of the short gastric vessels. The esophageal hiatus is repaired posteriorly and a loose wrap is constructed and sutured to the crura posteriorly.

Catégorie

routine cases

Mots-clés

Laparoscopic, Nissen fundoplication, short gastric vessels

Type de vidéo

Vidéo chirurgicale

Durée

18'00''

Publication

2005-11

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2005;5(11).
URL: http://www.websurg.com/doi-vd01en1877.htm

Laparoscopic Nissen-Rossetti fundoplication

1. Trocar positioning 00'11''

This patient is quite small, she has very narrow ribs, this is her costal margin so it’s almost like doing pediatric surgery, trocars are by necessity very close together. The good point is that she has no fat inside. I do my trocars slightly different than Bernard Dallemagne does, this is my midline and I stay off it, I put my camera a little bit off to the left and my assistant’s retractor a little bit off to the right, liver retractor in the right upper quadrant and my two hands are up separated from the camera.

2. Hiatus approach and esophageal mobilization 00'50''

Very nice non-obese patient, I don’t typically worry too much about the hepatic vagus but I am going to save it. As a landmark I use the caudate lobe, which is very consistent to find the right crus, which in this case is very easy to do. I am very careful to avoid grasping the crus because it is a very fragile structure. We can already see the aorta, here is the left crus, right crus. I like to take this dissection down quite low. Here is the peritoneum on the left crus, be careful to keep that. Here is the back wall of the stomach. I like to do as much of this dissection from the right side as possible, as it allows good visualisation. Retraction is everything in this type of surgery. Here is the posterior vagus and we’ll be careful now to keep that retracted up with the esophagus. Here it is once again, I will just keep pushing it up against the esophagus. Now I identify the anterior vagus which I can already see right there. This is what we would call a type 1 mediastinal dissection, it’s going to be very easy unlike Bernard’s case, no inflammatory changes, everything just falls off the esophagus, quite a simple exposure. I think it’s very important to keep the peritoneal covering onto the crus it’s for the strength of the repair. This is where we stopped our dissection from behind, I can see the window. We can see the crus very nicely there. Once again here is our window from behind. Just as we saw the left crus from the right side, now we can see the right crus from the left side. We are going to have some pretty good length, 4 or 5cm on the esophagus posterior vagus, anterior vagus also easy to see.

3. Gastric fundus mobilization 05'33''

So now we will take down the short gastrics and look for the lipoma of Dallemagne. Would you say that in the USA that the vast majority of people do 360° Nissens? Yes, by far. She has quite large short gastrics for such a small person. We will go through them slowly since we don’t have Joël Leroy’s Ligasure. You will notice I try to grab the stomach as little as possible, so I have grasped it once and I will do as much of the mobilisation as I can before I re-grab it. I am just going to come down and mobilise the back wall of the stomach, it’s important to stay right on the stomach back here because, especially in a thin person, because the splenic vessels are adjacent. Coming up to the left crus here, rotating the stomach as it goes. We are starting to see the upper part of the left crus. This large vein is frequently a branch-off of the celiac access. The non-active part of the scissors is in contact with the stomach, this gives me almost like an extra retractor, I’ll push down with them to make it safer. I continue the posterior dissection until I can see the posterior vagus once again. Here is the posterior vagus.

4. Repair of hiatus 09'18''

There is our window from behind. Once again, we don’t need any tension on it, mobilisation does a nice job with that. I use the short gastric vessels as my landmarks and do a nice shoeshine. I also do not use a Penrose drain except in some rare circumstances. I like to tack the back of the wrap to the crural closure. If you did need to go back on this sort of thing, it would make it more difficult in terms of taking it down? It does, but we looked at our experience before we did gastropexy and after and did find a lower rate of migration of the wrap, so I think it adds a little bit even though it was not substantially lower. There are different ways of doing it but I think that having a curved tip on your needle holders is very helpful. I also like to grab the peritoneum and pull it around so I get a double layer. I don’t tie these knots too tight because I think they can cut through the flesh. The critical thing is to keep the peritoneal covering on the crus so you are not just sowing muscle and you take good bites. Typically our patients stay for 24 hours after a routine fundoplication and I send them home on a lot of anti-medics, because a cause of early failure is vomiting, and a pureed diet for two weeks. In the postoperative period, do your patients complain mostly of left shoulder pain related to the crura repair? When we looked at it, 50% of our patients complained of shoulder pain, we don’t know why some people have it and some don’t. For myotomy, we do not perform crura repair and those patients never have left shoulder pain, so I think that the left shoulder pain is related to crural repair.

5. Fundoplication 13'05''

I use infiltration of the crura at the end of the operation and that reduces the amount of pain quite dramatically. I think that it is interesting for people who do that surgery in one day clinics; we inject marcaine in the crura. We are working on it and will see if it is statistically worth it, it certainly seems to be causing a lot of pain in the patients. I have tried putting marcaine on the diaphragm and that did not seem to help a lot, but injecting it in the muscles helps. I add two sutures on the inside of my wrap, here and then over here in order to avoid slippage because as you know when you do a redo, this back part just comes apart very easily when you do the dissection, there are very little adhesions so I try to create some adhesions so it will stay together a bit better. We do have a bougie inside, I have stopped using one on a routine basis, then we did a study to look on dysphagia rates and found that there is a higher postoperative dysphagia rate. Bougies are not without their problems from time to time. We can get a good view of where the vessels were divided originally. That is my landmark. Here is our anterior vagus right there. I hate doing a redo fundoplication, so I do anything I can do to minimize that. The only difference is that the wrap is fixed to the closed hiatus and that may or may not help, but other than that it’s a 2cm wrap.