WebSurg中文版尚未完成，翻譯工作進行中！

Laparoscopic Nissen fundoplication: a perfect case to start

This video of laparoscopic Nissen fundoplication is suitable for surgeons learning to perform this procedure. The patient is young with very few adhesions and the operative steps are very clearly presented by Dr. Dallemagne. Critical points and technical tips are emphasized throughout the procedure. The author describes this as an ideal case for surgeons learning the procedure because this young patient with severe reflux has few adhesions. Working with a zero-degree scope, the author examines the peritoneal cavity. The dissection begins at the caudate lobe of the liver and moves toward the right crus of the diaphragm. After identifying the right and left crura, the author opens the lesser omentum to gain access to the right crus. It is important to identify the inferior vena cava as a landmark.

瀏覽全世界
虛擬大學
繁體中文 ▼

Laparoscopic   Nissen   fundoplication:   a   perfect   case   to   start

作者群
B Dallemagne, J Marescaux
摘要
This video of laparoscopic Nissen fundoplication is suitable for surgeons learning to perform this procedure. The patient is young with very few adhesions and the operative steps are very clearly presented by Dr. Dallemagne. Critical points and technical tips are emphasized throughout the procedure.

The author describes this as an ideal case for surgeons learning the procedure because this young patient with severe reflux has few adhesions. Working with a zero-degree scope, the author examines the peritoneal cavity. The dissection begins at the caudate lobe of the liver and moves toward the right crus of the diaphragm. After identifying the right and left crura, the author opens the lesser omentum to gain access to the right crus. It is important to identify the inferior vena cava as a landmark.
關鍵字
Nissen fundoplication, laparoscopy, GERD
媒體類型
期間
17'17''
刊物
2007-05
普通的
最愛
Favorites Media
音訊
en es
副標題
en
數位出版
WeBSurg.com, May 2007;7(05).
URL: http://www.websurg.com/doi-vd01en2107.htm

Laparoscopic   Nissen   fundoplication:   a   perfect   case   to   start

1. Trocar placement and exploration 00'13''
This is the case of a young patient with a very severe reflux with both digestive and pulmonary complications. You can see that this is the umbilicus and this is the optical port. I’m working a little bit higher on the midline between the umbilicus and the xiphoid process that is over there. Why? Because I’m working with a zero degree scope. If I worked with a 30 degree scope, I could work probably in this patient from the umbilicus. On the left side of the patient, this will be used for my right hand, and laterally this is the port for retraction. It’s on the mid-axillary line. What we’ve done is initially we’ve checked the peritoneal cavity. No problem with the liver, no problem with the gallbladder. The stomach is macroscopically safe. The left colon is not that high. You can see the spleen over there. You see the anatomy is very clear in this patient. This is the lesser omentum with the pars condensa, the pars flaccida. There is probably a small artery in this lesser omentum. So we’ll preserve the artery and the branches of the anterior vagus trunk. This is the right crus, this is the left crus there. And you see this anatomy is abnormal; that explains why this young patient has a severe reflux because with this anatomy and with the orientation of the crus, you can imagine that the high pressure zone, which should be in the abdomen is most of the time located within the mediastinum. So this is a negative pressure environment and that explains probably why she has such a severe reflux.
5. Mediastinal dissection 05'40''
And in all patients I’m doing such a mobilization to get a very good length of the esophagus back into the abdomen. The objective is I should have it without tension. That’s why I’m doing this mobilization. You see the pleura is there so you use blunt dissection (the same way as you do with a finger in open surgery) You see the pulmonary veins are over there. In this patient it is easy because there is no peri-esophagitis. You can go to the left side. I’m using this instrument like a finger. You see the pleura and the lung. This woman has a lot of pulmonary infection due to the reflux and you’ll see that in this area we find some more severe attachments of the esophagus. So I’m just preserving the vagus trunk. No coagulation at all here. As soon as I’ve dissected, I can divide with the ultrasonic device. Everyone agree that we need this mobilization to get the length of the esophagus. And that’s probably the main problem in antireflux surgery. I’ll clear a little bit more this posterior area. I’m safe. I won’t do anything else because I don’t think it has a very high incidence or consequence. And you have some people with 2 or 3 previous operations, it’s difficult again to find the vagus trunk, and we’ve seen that without such identification at the time we’re dividing the trunks, we don’t have that many problems afterwards but it’s important to try and preserve it. I think that it represents the quality of your dissection. I’ll go back on the left upper side of the esophagus. This is the pulmonary vein there, that’s usually my upper limit. There are some typical adhesions there. The problem is that they are very close to the anterior vagus trunk. You see this: it fixes the esophagus. But we have to divide that to get more length. You see the fixation on the esophagus, so I’ll divide that. The problem is that you have to be sure not to divide the posterior trunk.