Laparoscopic Nissen Rossetti fundoplication using AESOP

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Laparoscopic   Nissen   Rossetti   fundoplication   using   AESOP

Authors
J Leroy
Mots-clés
stomach,operation,gerd,gastroesophageal reflux disease,hiatal hernia,robot
Type de vidéo
Durée
29'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en0039e.htm

Laparoscopic   Nissen   Rossetti   fundoplication   using   AESOP

1. Case demonstration 00'13''
It’s not the port position for hiatal hernia repair. I never introduce my port through the umbilicus. You can see a lot of adhesions between the small bowel and the omentum and the abdominal wall. On the patient’s right side, we have a window. Here’s the right colon, right liver and we will try to see even more. One possibility is to introduce the scope through this area and see where we can work. We don’t use immediately a reverse Trendelenburg. The 1st step is to expose our operative field. The classical port position is usually here. With this inside view, it’s amazing to see that the left hypochondrium is free. When we are creating the pneumoperitoneum, usually we are using the left hypochondrium and I’d say in all patients, we don’t have adhesions in this area so it’s quite safe to place your Veress needle in this area. I will try to avoid mobilizing and as you see, I will introduce a 10mm port first at the junction between the rib and the left subcostal margin and the mid-clavicular line. Always introduce it towards your operative field. Now I’ll introduce my scope above the adhesions. And now I’m in the same disposition where I put my scope. Usually I introduce my scope for hiatal hernia repairs at mid-distance between the tip of the flexure and umbilical line. I will try to avoid carrying out the adhesiolysis. Now it’s necessary to introduce a retractor and usually I introduce it laterally. So I’ll try to divide this area and create a window just under the round ligament to introduce the retractor. The patient is in a supine position and not in a Trendelenburg position. We will change that soon. As basic equipment, do you still have the bipolar coagulation and monopolar cautery. All the different devices are ready. At the moment, I’m working with one hand. Another way to get access for the liver retractor is to go through the liver suspensor. You just open the liver suspensor and then you can pass the liver retractor easily. This is only to introduce instruments. I can also introduce my retractor here. Now progressively I’m reaching the correct operative field. The port is well introduced. When you have a long port, you need to use protection when you introduce your instruments. I think it’s no good to use short ports. To avoid losing your instrument, you can grasp tissue as you can see here. Now we put the patient in reverse Trendelenburg. Now we have to retract the stomach. Why aren’t you using the lateral trocar on the patient’s right side in order to retract the liver so that you have 2 hands with your 2 superior ports? I agree though it’s not what we are doing now. This is possible only if you have large angles. Now we empty the stomach. In our strategy, we open widely the lesser omentum. We begin to incise at the inferior margin of the pars flaccida. And we divide progressively from up to down using either a hook or like this. It’s an obese patient too and we divide also the hepatic ligament. Now we follow the dissection of the pars condensa of the lesser omentum and we progressively dissect the phrenoesophageal ligament. Now Aesop! Right in! Move down! Stop! Up!! So I’m dividing progressively the peritoneum and the phrenoesophageal ligament. We have a problem since the stomach does not fall completely due to the adhesions. The stomach is too much in the upper part of the abdominal cavity. Now I’m trying to find the line between the esophagus and the right crus. And as Bernard Dallemagne points out, we try to create a small window and find the correct plane, not only cutting but using counter-traction. We have to stay against the anterior edge of the right crus. We have the right crus and the left crus here. Now we have to dissect from right to left to find the good plane. Now to the access to the left crus and the left part of the esophagus, and Joel is working from the right side of the esophagus. It’s nice and he knows where the planes are but I’d recommend to clear a little bit the left crus before trying to go behind the esophagus. The problem is that the stomach doesn’t fall completely and we don’t have such a beautiful view as usual. We are dividing the phrenoesophageal ligament. The role of the assistant is essential as he’s placing traction on the peri-esophageal fat pad and that creates the dissection plane. And if he’s releasing traction a bit, we’re losing the plane and we can’t dissect anything any longer. The width of the retroesophageal window is essential in order to have a valve, which stays in place without any traction or congestion. What is your strategy when faced with a short esophagus? Do you perform a Collis gastroplasty? Only if you really have to, usually you can go high into the mediastinum and 90% of the time it’s enough. See now the GE junction, 1cm under it and at mid-distance between the greater curvature, it will be where I’ll put my grasper. To be sure it’s the correct position, I put a stitch to locate it perfectly. Only in difficult cases, we do that. Usually we introduce a grasper. Perhaps a ribbon loop would help there to see better and you’ll see why the esophagus doesn’t want to move up. What we have to do is choose the GE junction, and do like this, and then the esophagus will move down because there is a lower traction. It’s not too tightened. You see it’s a floppy Nissen-Rossetti. I’m sure tomorrow this patient won’t have any dysphagia. I was concerned about 2 things: one, about the length of the esophagus (my tendency would be to have dissected it more, and whether or not body was used or not for the wrap), I think it’s ok. See with this suture it’s going up inside the mediastinum. And the wrap is pulling behind the esophagus. Is there tension, is there length are the questions any surgeon must ask himself. You’ll see that at the end, the stomach pulls the esophagus down and not the opposite. Can you show us how you do the knots? Classical ones externally. We can evaluate the opening of the crus and I think I’ll close in this case and put a stitch here. It is a floppy valve. Very laterally, when you put tension on your sutures, just show us how you use your left hand to direct the suture and avoid stretching the tissues. The pulley is not here. You have to be in the direction where you exit. If it’s like this, you cut your tissue. And like this, you don’t cut. I will now perform a Toupet knot and you see that I can tighten the loop like this. And if I want to lock, I lock immediately and there is no tension. And if I want to unlock, I can modify and push. I don’t completely tighten the loop. I try to close the crura and it’s sufficient. Do you use that kind of trick? I use a posterior gastropexy suture in my wrap. I use only fixation of the wrap to the crura in a redo Nissen only when I have a patient with a recurrent intrathoracic paraesophageal hernia, I fix the wrap to the crura and to the diaphragm. I don’t think it’s important because if you have the mechanism that will lead to migration, it will migrate. The problem is the esophagus and not the fixation of the valve. I have the experience with partial, and when I’m doing a partial, I fix it to the crura and I’ve migration of partial into the chest. The problem is the length of the esophagus for this migration. We have to shorten the length of this distal thread. It has 2 fingers and I don’t move too much.