Laparoscopic approach for a late-onset complication after Nissen-Rossetti procedure for GERD: slippage of the valve

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摘要

This video demonstrates a case of revision of previous Nissen-Rossetti fundoplication in a patient with a slipped wrap. The previous wrap is completely taken down and converted to a Toupet fundoplication.

分類

complex cases

關鍵字

redo fundoplication, slipped wrap, toupet fundoplication, reoperation,

媒體類型

期間

20'30''

刊物

2006-04

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Apr 2006;6(04).
URL: http://www.websurg.com/doi-vd01en1931.htm

Laparoscopic approach for a late-onset complication after Nissen-Rossetti procedure for GERD: slippage of the valve

1. Trocar placement 00'14''

Now to trocar placement. I try to re-use some of the previous port holes.

2. Liver exposure 00'38''

When we are entering the cavity, we don’t have that many adhesions. That means that the first operator was a good one. I will start with the division of these small adhesions. Here is the liver, and along this segment, we’ll find the crura. I don’t work in this area right now. At the moment, we can’t say if it’s a stenosis of the valve, if it’s a gastric valve. Be careful there because I don’t know where is the vena cava. Here I’m working with scissors instead of ultrashears because I prefer a very precise dissection in such a redo procedure. Again as I don’t know exactly the anatomy of the patient, so I have to be careful. You can imagine in some patients that due to the distortion of the 1st operation, you could find some vessels in this area. Some patients may also have a very large hepatic artery so that’s why I’m checking very carefully. I use very few cauterizations because when you are in the correct plane, it does not bleed. Redo is interesting because part of the operation is that you try to understand what the former surgeon has done. I’m following the liver. We can see some stitches there. The only thing I did is leave the adhesions on the segment of the liver here, and you see that the vena cava is there.

3. Dissection of the crura 04'31''

The risk when you work on this liver segment is that you don’t know exactly where is the vena cava, so it’s an essential step. I’m now beginning to feel more comfortable because I’ve seen my landmarks. Again you see this is the crus. To feel even more comfortable, I’d love to see the esophagus. That’s why I’m starting again on this crus and we see if we can find the esophagus. I think the esophagus is here. It’s quite clear here but sometimes it’s not. We find clips here. Why don’t you use Ultracision in this case? You see the scissors are very precise. I can’t get the same result with the Ultracision system. It’s too large and I’m not that precise. You see how I can find again the different planes. Probably the left crus is there. And I can even use cautery. This is the muscle. I’m moving to the upper part, and again we can see the muscle. We can see quite well the crura. Here I’m cautious because I don’t know exactly where the lateral side of the esophagus is. I think it’s over there. I think that we’re entering the mediastinum. I’m trying to reproduce exactly what I did in my previous case. I try to work with the same landmarks systematically. Again I work on the right crus, and I’m moving on the anterior border of the hiatus, then I’m moving to the left crus. It’s exactly the same way, the difference is that you have slightly more adhesions. Now I’m safer since I know where the esophagus is. I’m dissecting again. My left crus should be somewhere there. My objective is now to descend alongside the left crus, in close contact with the muscles and not with the esophagus. There is some tension in this crural repair, it might one of the causes of dysphagia. It’s very strong. This is probably part of the valve. We have the cleavage plane between the fundoplication and then the esophagus. These are only attachments. We see very well the left part of the valve. When we look at this, we can’t see very well what the cause of dysphagia is. This is probably the stomach, but we should do an endoscopy to be sure of that. I thought it was very strong there. We’re going to open the previous valve now, and work again on the esophagus and try to mobilize. We’ll just take a look at the mediastinum. Here once again we have to mobilize you see it is coming, this is the stomach, so the junction should be somewhere here, so the valve is on the stomach. I open the valve and then work again on the GE junction, mobilize the esophagus quite high in the chest, and then see if we can identify exactly the GE junction. If we can’t identify it, we’ll do an intraoperative endoscopy just to be sure that we’re in the correct place. This is essential as we have to place it perfectly well this time. I think that what we’ve seen here corresponds to what you’ve seen on the X-rays, when you describe this gastric fold above the fundoplication. I don’t know if it’s the vagus trunk there but I’m trying to preserve this part. So left part of the valve, right part. No it’s not the vagus trunk.

4. Dissection of the valve 11'00''

My strategy is to dismantle the old fundoplication, trying to get the GE junction, putting a drain around the GE junction, mobilizing the esophagus as high as possible into the chest, controlling the position of the GE junction, and then try to create probably not a Nissen fundoplication because of this history of dysphagia, but I’d probably favor a partial posterior fundoplication.

5. Hiatoplasty 17'50''

6. Repositioning of the valve 18'23''

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