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Laparoscopic floppy Nissen fundoplication for GERD with calibration of the valve

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Laparoscopic floppy Nissen fundoplication for GERD with calibration of the valve

作者群

關鍵字

hiatal hernia, treatment by laparoscopy, coelioscopie, cure RGO, GERD, hernie para-oesophagienne

媒體類型

手術影片

期間

08'00''

刊物

2006-06

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Jun 2006;6(06).
URL: http://www.websurg.com/doi-vd01en1971.htm

Laparoscopic floppy Nissen fundoplication for GERD with calibration of the valve

1. Start of procedure 00'18''

After exposure of the hiatal region by lifting the liver with the retractor, and vision of the lesser omentum with the pars flaccida, the pars condensa, and the nerve of Latarget, we begin the procedure preparing the left crus of the left diaphragm, freeing the gastrophrenic ligament. The preparation of the fundus is very important, especially for the Nissen technique. We’ve chosen for this patient a floppy Nissen because he has very good esophageal motility and he suffered from a severe esophagitis.

2. Opening of inferior part of the lesser omentum 01'15''

After dividing the Bertili membrane, we pass over the right crus. For us, the best way to do this is to pass through the pars flaccida

3. Dissection of right crura 01'27''

sparing the nerve of Latarget, and if it is present, the accessory hepatic vessel as well. With the division of the caudal part of the pars flaccida, we approach the right crus very easily. We try to remain in direct contact with the diaphragm as this is very important for the preparation of the gastroesophageal junction. Under direct vision, we continue to prepare the retro-esophageal and the retrogastric window. We can clearly see the retrogastric passage and the complete previous preparation of the left crus. Now we must complete the preparation of the right crus. To complete this, once the right crus has been approached caudally, it is best to leave it and to continue on opening the pars condensa higher up than the nerve of Latarget.

4. Mobilization of esophagus 02'58''

We’re now going to mobilize the esophagus. This is very important in order to achieve a good repair and a good fundoplication of the stomach. At the end of this, you will see the complete preparation of the crura. We pass an atraumatic grasper behind the esophagus and a loop, which lifts the esophagus. We continue the preparation of the esophagus behind, respecting the posterior vagus. In the Nissen Rossetti technique, division of the short gastric vessels is usually not performed but we believe that in some cases it is necessary to divide the first short gastric vessels in order to obtain a tension-free fundoplication for a true floppy Nissen, and we believe that this is the best solution to avoid postoperative dysphagia. To verify this is really necessary, you must pass the valve behind the esophagus and leave it in place. If it remains to the right of the esophagus without tension, we can avoid dividing the short gastric vessels. If it immediately retracts as in this case, we are obliged to divide the short gastrics. We pull the gastric fundus to the right to expose the gastrosplenic ligament and we carefully cut the first three short gastric vessels starting from below. As you can see, the fundus is now well mobilized. We should be able to perform the fundoplication without tension.

5. Cruroplasty 05'16''

We perform a hiatoplasty using a braided non-absorbable suture passed twice through the 2 crura.

6. Valve calibration 05'56''

We pass a 60 French lighted dilator into the esophagus to calibrate the fundoplication. We pass the gastric fundus behind the esophagus. We place 2 non-absorbable sutures following the Rossetti principles taking the gastric fundus

7. Fundoplication 08'03''

without touching the esophagus, creating a para-esophageal tie. We can see here that there is no tension in the valve. We remove the loop and the dilator, and as suggested by Rossetti, we put a suture between the fundoplication and the lesser curvature in order to avoid slipping of the wrap.

8. End of procedure 07'29''

We complete the procedure by putting a last suture between the esophagus and the valve to reduce the possibility of high migration of the valve.