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Laparoscopic Nissen-Rossetti fundoplication for gastroesophageal reflux
Authors
Abstract
The description of the laparoscopic Nissen-Rossetti fundoplication for gastroesophageal reflux covers all aspects of the surgical procedure used for the management of gastroesophageal reflux disease.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, mobilization of esophagus, dissection of crura, creation of fundoplication, suturing the fundoplication.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, mobilization of esophagus, dissection of crura, creation of fundoplication, suturing the fundoplication.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-02
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WeBSurg.com, Feb 2001;1(02).
URL: http://www.websurg.com/doi-ot02en003.htm
URL: http://www.websurg.com/doi-ot02en003.htm
Laparoscopic Nissen-Rossetti fundoplication for gastroesophageal reflux
1. Introduction
Since fundoplication was first reported by Nissen in 1956, several modifications to his original procedure have been proposed:- shortening the 360° fundoplication to 2 cm,
- division of the short gastric vessels.
Short gastric vessels were not divided by Nissen.
Like Anvari and Allen (1998), we propose a minimal paraesophageal dissection:
- to reduce postoperative dysphagia and paraesophageal hernia,
- to avoid inadvertent damage to vagal fibers.
2. Anatomy
• Anti-reflux zone
1. Lesser omentum2. Left lobe of the liver
3. Esophageal hiatus
4. Diaphragm
5. Pleura
6. Spleen
The normal ''anti-reflux zone'' anatomy (ARZ) is composed of a 2 to 5 cm segment of esophagus fixed below the hiatus to the diaphragm, crura and stomach by ligamentous attachments. Maintenance of normal relationships between these structures is essential to the integrity and function of anti-reflux mechanisms.
• Attachments
1. Liver attachment zone2. Phrenoesophageal ligament
3. Gastrophrenic ligament
4. Gastrosplenic ligament
5. Short gastric vessels
6. Left kidney
7. Toldt’s fascia
8. Crura
• Mechanisms
• Principles
1. Anterior vagus nerve2. Lesser omentum (cut off)
3. Crura
4. Aorta
5. Esophagogastric angle
6. Cardia of the stomach
Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:
- the esophagogastric valve (EGV),
- the lower esophageal ''sphincter effect'' (LESE).
• Esophagogastric valve
Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:- the esophagogastric valve (EGV),
- the lower esophageal ''sphincter effect'' (LESE).
• LES effect
Two primary concordant anti-reflux mechanisms are demonstrable in patients with intact ARZ anatomy:- the esophagogastric valve (EGV),
- the lower esophageal ''sphincter effect'' (LESE).
3. Classification
• Hiatal hernias
1. Thoracic esophagus2. Thoracic cavity
3. Right crus
4. Left crus
5. Abdominal esophagus
6. Fundus of the stomach
Hiatal hernias cause most gastroesophageal reflux diseases (GERD).
• Type I hiatal hernias
• Classification
Type I, or sliding hiatal hernias, have an intact attenuated phrenoesophageal ligament.They can be subclassified according to 3 anatomically distinct stages of evolution.
• Stage 1
Sliding hiatal hernias occur when the abdominal esophagus migrates through the hiatus while the gastroesophageal junction (GEJ) and stomach remain below.As the abdominal esophagus migrates, the EGV disappears due to the widening of the esophagogastric angle, and the LESE diminishes due to the loss of anatomical relationships and extrinsic pressures.
This may not be appreciated on endoscopy or barium study.
This would explain the reports of GERD without a hiatal hernia.
• Stage 2
Stage 2 sliding hiatal hernias occur when the gastroesophageal junction and stomach migrate above the diaphragm. The EGV can reform above the diaphragm, preventing reflux.
This may explain reports of sliding hiatal hernias without GERD.
• Stage 3
Stage 3 sliding hiatal hernias have a shortened esophagus with fixation of the gastroesophageal junction above the diaphragm due to scarring.True stage 3 hiatal hernias are rare.
• Type II hiatal hernias
Type II, or paraesophageal hiatal hernias, occur through a defect in the phrenoesophageal ligament.The gastroesophageal junction nonetheless remains in the abdominal cavity.
4. Operating room set-up
• Patient
• Principles
- general anesthesia- 30° reverse Trendelenburg
- supine position
- dual lumen gastric tube
- urinary catheter (not mandatory)
• Steep table position
To enable a steep reverse Trendelenburg position (30°), especially used in obese patients, the patient is strapped to the table with thick adhesive strips.• Team
1. The surgeon stands between the legs of the patient2. The first assistant stands on the patient's left
3. The second assistant stands on the patient's right
4. The scrub nurse stands on the surgeon's right
• Equipment
1. The first monitor is used by the surgeon and the first assistant.2. The second monitor is used by the second assistant.
The laparoscopic and video units are placed on the patient's right.
5. Trocar placement
• Anatomical landmarks
1. Xiphisternum2. Costal margin
3. Midline
4. Midclavicular line
5. Anterior axillary line
Most procedures are performed with 5 trocars.
Ports should always be placed so as to prevent instruments from interfering with each other.
• Pneumoperitoneum
A Veress needle is inserted on the midclavicular line immediately below the left costal margin and the abdomen is insufflated with CO2 gas to a medium pressure of 12 mm Hg.• Trocars
Port A: 10mm in size, accommodates the laparoscope, located on the midline midway from the xiphisternum to the umbilicusPort B: 5mm in size, accommodates the liver retractor, located on the epigastrium just below the xiphisternum
Port C: 5mm in size, accommodates the grasping forceps, located on the midclavicular line just below the right costal margin
Port D: 5mm in size, accommodates the atraumatic grasper, located on the left anterior axillary line just below the costal margin
Port E: 5mm in size, accommodates dissecting and suturing devices, located on the left midclavicular line just below the costal margin
6. Instrumentation
• Instruments
A: 0° laparoscopeB: Liver retractor
C: Grasping forceps
D: Atraumatic grasper
E: Hook dissector and scissors for diathermy, suction-irrigation device, needle holder
• Optical device
A: Most procedures are completed using the 0° laparoscope, although the 30° laparoscopecan exceptionally be useful if vision is inadequate.
• Operating devices
C: Grasping forcepsE: Hook dissector and scissors for diathermy, suction-irrigation device, needle holder
• Retracting devices
B: We prefer the reusable liver retractor, but a disposable liver retractor can be used.D: Atraumatic grasper
7. Major principles
The five principles for the creation of an antireflux mechanism are:(DeMeester & Stein, 1992)
1. The operation consists of restoring lower esophageal sphincter pressure so that it is twice as high
as intragastric pressure during minimal activity.
2. During the operation, at least 1.5 to 2 cm of the lower esophageal sphincter must be exposed to positive abdominal pressure.
3. Treatment must enable neocardia relaxation when the patient swallows. The sphincter is only surrounded by the fundus since both organs relax simultaneously during deglutition.
4. Fundoplication must not induce sphincter resistance superior to the esophagus peristaltic force (360°, fundoplication length inferior to 2 cm).
5. The fundoplication must be set in a tension-free fashion.
8. Exposure
• Reverse Trendelenburg
The reverse Trendelenburg position causes spontaneous lowering of the abdominal organs, thus allowing exposure of the operating field.• Gastric clearance
A dual lumen gastric tube is placed to decompress the stomach.It is removed at the beginning of the posterior esophageal dissection.
• Retracting the organs
• Operative step
While the first assistant controls the laparoscope (via A) and grasps the cardia of the stomach (via D), the second assistant elevates the left lobe of the liver (via B) to help display the esophageal hiatus.1. Inferior part of the lesser omentum
2. Hepatic branch of the anterior vagus nerve
• Trocars/ Instruments
Port A, used by 1st assistant, accommodates the laparoscope, used to control the scopePort B, used by 2nd assistant, accommodates the liver retractor, used to elevate the left lobe of the liver
Port C, accommodates the grasper, used by the left active hand of the surgeon
Port D, used by 1st assistant, accommodates the grasper, used to retract the cardia of the stomach
Port E, accommodates dissecting devices, used by the right active hand of the surgeon
9. Mobilization/esophagus
• Principles
The following structures are respectively dissected:1. Inferior part of the lesser omentum
2. Phrenoesophageal ligament
3. Phrenogastric ligament
The dissection enables the surgeon to reveal the caudate lobe of the liver, the right crus, and the esophageal hiatus.
• Opening/lesser omentum
Dissection of the esophagus begins with the vertical division of the transparent window of the peritoneum forming the cephalad part of the lesser omentum above the hepatic branch of the anterior vagus nerve. This nerve can almost always be seen crossing to the right.• Dissection/ligaments
1. Cardia of the stomach2. Fundus of the stomach
The phrenoesophageal ligament is incised using electrocautery up to the anterior wall of the esophagus and then further anteriorly over the left crus.
At this point, gentle caudal traction of the fundus allows the surgeon to divide the posterior gastrophrenic attachments anchoring the posterior fundus to the diaphragm.
• Variation
Division of the hepatic branch of the anterior vagus nerve:The hepatic fibers of the anterior vagus nerve should be sacrificed if necessary for the mobilization of the esophagus.
1. Inferior part of the lesser omentum
2. Hepatic branch of the anterior vagus nerve
10. Dissection of crura
• Principles
1. Right crus2. Esophagus
3. Posterior vagus nerve
4. Pleura
5. Left crus
Care must be taken not to dissect too high or too far behind the right and left crura to prevent damaging the pleura or the posterior vagus nerve.
• Right crus dissection
• Objective
The aim is to clear the right crus until the inferior part of the left crus appears.• Cardia retraction 1
1. Caudate lobe of the liver2. Right crus
3. Esophagus
The cardia is pulled in the direction of the left iliac fossa by the first assistant (via D).
• Cardia retraction 2
Port A, accommodates the laparoscope, used to control the scopePort B, accommodates the liver retractor, used to elevate the left lobe of the liver
Port C, accommodates the grasper, used by the left active hand of the surgeon
Port D, used by 1st assistant, accommodates the grasper, used to retract the cardia of the stomach
Port E, accommodates dissecting devices, used by the right active hand of the surgeon
• Vertical dissection
1. Right crus 2. Left crus
The dissection is started at the hiatus. The space between the right crus of the esophageal hiatus and the esophagus is dissected vertically using a hook dissector or scissors for diathermy.
• Left crus dissection
• Objective
1. Esophagus2. Right crus
3. Left crus
The retroesophageal dissection is performed on the left side of the left crus and a ''window'' is dissected out behind the esophagus until the spleen appears.
• Esophageal retraction 1
1. Left crus2. Posterior vagus nerve
The esophagus is retracted anteriorly with a grasper by the first assistant (via D).
In case of bleeding, the same maneuver can be performed using the suction-irrigation device (via D).
• Esophageal retraction 2
Port A, accommodates the laparoscope, used to control the scopePort B, accommodates the liver retractor, used to elevate the left lobe of the liver
Port C, accommodates the grasper, used by the left active hand of the surgeon
Port D, used by 1st assistant, accommodates the grasper and the suction-irrigation device, used to retract anteriorly the esophagus and for hemostasis care
Port E, accommodates dissecting devices, used by the right active hand of the surgeon
• Window opening
The window is created between the left crus, behind, and on the left side of the esophagus.This window is small (about 3 cm) but large enough to allow easy passage of the stomach. It ensures a compression-free fundoplication.
The gastric tube is removed.
• Danger
Posterior dissection:During the posterior dissection of the esophageal hiatus, the esophagus is retracted anteriorly and on the left by the surgeon, using a grasper (via C). The surgeon should not pursue the dissection through the hiatus and upto the mediastinum. If this is done, the left pleura is visualized, and the risk of pneumothorax increases.
• Variation
Dissection of the posterior vagus nerve:The posterior vagus nerve is visualized.
It usually lies on the right posterior aspect of the esophagus. It can be dissected away from the esophagus if it is not to be included in the fundoplication.
11. Creation of fundoplication
• Principles
1. Wrapped fundus2. Esophagus
3. Anterior wall of the stomach
A tension-free fundoplication is created without dividing the short gastric vessels.
• Choices
• Anterior part/fundoplication
The anterior wall of the fundus, used to create the anterior part of the fundoplication, is grasped approximately 5 cm from the cardia and midway between the cardia and the greater curvature.• Common mistake
The anterior wall of the fundus, used to create the anterior part of the fundoplication, is grasped approximately 5 cm from the cardia and midway between the cardia and the greater curvature.• Good procedure
The anterior wall of the fundus, used to create the anterior part of the fundoplication, is grasped approximately 5 cm from the cardia and midway between the cardia and the greater curvature.• Retroesophageal passage
• Operative step
1. Fundus of the stomach2. Esophagus
3. Window
The previously defined anterior part of the fundus is picked up with a grasper held by the surgeon (via E) and passed to the jaws of another grasper (via C) behind the esophagus.
Once the surgeon is satisfied with the fundoplication obtained, the fundus is securely attached to the stomach, which is pulled around the esophagus.
• Trocars/ Instruments
Port A, accommodates the laparoscope, used to control the scopePort B, accommodates the liver retractor, used to elevate the left lobe of the liver
Port C, used by the surgeon, accommodates the grasper, used to receive the fundus from grasper E
Port D, accommodates the grasper, used to retract the cardia of the stomach
Port E, used by the surgeon, accommodates the grasper, used first to pick up the fundus
• Tension-free positioning
• Principles
The wrapped stomach is then approximated at the anterior wall of the stomach in front of the esophagus, aiming to form as loose a fundoplication as possible.• Common mistake
The wrapped stomach is then approximated at the anterior wall of the stomach in front of the esophagus, aiming to form as loose a fundoplication as possible.A common mistake consists of picking up the point X. This leads to a twist in the fundoplication.
• Good procedure
The wrapped stomach is then approximated at the anterior wall of the stomach in front of the esophagus, aiming to form as loose a fundoplication as possible.The animated picture shows the approximate region that will be picked up for the left side of the fundoplication.
• Danger
1. Grasper2. Spleen
Retroesophageal passage:
The grasper of the operating trocar (via C) is passed behind the esophagus at an oblique angle.
Since the grasper tip tends to pass above the diaphragm into the left chest, care must be taken to maintain the tip in the correct direction, through the window.
Care must be taken to avoid any injury of the spleen.
12. Suturing the fundoplication
• Objective
A 360° fundoplication of 2 cm in length (or less) is performed.• Fundoplication suturing
• Operative step
The first assistant grasps the right side of the fundoplication (via D).Three or four interrupted sutures are placed using 2/0 silk for intracorporeally or extracorporeally tied sutures.
The anterior esophagus is included in at least one suture.
• Trocars/ Instruments
Port A, accommodates the laparoscope, used to control the scopePort B, accommodates the liver retractor, used to elevate the left lobe of the liver
Port C, used by the surgeon, accommodates the grasper, used to perform the suture
Port D, used by 1st assistant, accommodates the grasper, used to grasp the right side of the fundoplication
Port E, used by the surgeon, accommodates the needle holder, used to perform the suture
• Fundoplication testing
A grasper is easily introduced behind the fundoplication and the anterior part of the esophagus to check for strangulation.• Suturing the crura
1. Right crus2. Left crus
3. Fundoplication
In patients with large hiatal hernias and significant risk of transhiatal herniation, the crural defect is closed without strangulation of the esophagus using 2 or 3 interrupted non-absorbable sutures.
Once the fundoplication has been completed, a dual lumen gastric tube is re-introduced into the stomach.
• Variation
Introduction of a bougie: Once a tension-free fundoplication has been fashioned, a 52 French-gauge bougie can be placed in the esophagus before suturing.
The introduction of a bougie is not mandatory.
We do not use it.
13. Postop management
The nasogastric tube is removed a few hours after the end of the procedure.Fluid intake begins on the same day.
Solid intake begins on the first postoperative day.
The patient usually leaves hospital on the second postoperative day.
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