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Laparoscopic fundoplication for GERD

This video demonstrates a laparoscopic Nissen fundoplication with division of short gastric vessels, crural repair and a 360° wrap. The surgeon carries out moderately extensive esophageal mobilization in the mediastinum through the hiatus to achieve adequate transabdominal length of the esophagus.

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Laparoscopic fundoplication for GERD

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摘要

This video demonstrates a laparoscopic Nissen fundoplication with division of short gastric vessels, crural repair and a 360° wrap. The surgeon carries out moderately extensive esophageal mobilization in the mediastinum through the hiatus to achieve adequate transabdominal length of the esophagus.

分類

routine cases

關鍵字

GERD,Nissen,esophageal mobilization, short gastric division

媒體類型

手術影片

期間

19'00''

刊物

2005-11

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Nov 2005;5(11).
URL: http://www.websurg.com/doi-vd01en1868.htm

Laparoscopic fundoplication for GERD

1. Trocar placement 00'11''

This is the optical trocar. In the subxiphoid area, I have another 5mm trocar and I’ll use it for my left hand. On the right side of the patient, this is a clear division of the abdomen. On the right side, there is a trocar in which we introduce the liver retractor. Usually the liver retractor is fixed on a mechanical arm on the table so it doesn’t move any longer. And on the left side of the patient, we have the active ports with my right hand coming through this subcostal port and very laterally the port for the assistant and this port is used for traction, grabbing.

2. Exposure and hiatus approach 01'05''

You can see on the screen that we have a small sliding hiatal hernia. It’s not that big but the reflux disease is not proportional to the size of the hernia. This patient can have very severe regurgitation even through a small hiatal hernia. I’m using this ultrasonic system most of the time because it’s quite comfortable, it coagulates, it can help you to dissect. You see that in most of the patients, I’m trying to preserve the hepatic branches of the vagus trunk and I’m starting on the pars condensa of the lesser omentum, and dividing that, you have this 1st landmark, which is the right crus and you can see that the assistant is retracting the GE junction and the phreno-esophageal membrane comes really in front of you so it’s easy to dissect and to divide. You know that laparoscopic surgery is always a problem of traction, counter-traction so we’re very dependent on the assistant. The spleen is not that far. I’m coming back on the right crus, which is there. It’s an essential landmark. I’m trying to clean a bit this landmark, trying to find the plane between the muscle and the potential location of the esophagus. I don’t try to coagulate, I’m just trying to do a blunt dissection in order to avoid injuries to the esophagus as much as possible. By gentle dissection, you can see that I’m entering the mediastinum. No coagulation because you don’t know exactly where the esophagus is so it can be dangerous if you’re going straight ahead with electrocautery. I’m turning around the diaphragm with both crura that are apparent. I’m using this instrument like a finger. My assistant is putting down the GE junction and I’ve a very nice view and dissection plane on the right crus. I’m working very deep on the left crus because I’m preparing the next step of the operation, which will be the posterior dissection of the esophagus so if you clear it well here down there, you won’t have any problem to pass and find your way behind the esophagus. So I’m moving back to the right side of the esophagus. There you have the pleura. We remove the pleura. You see the posterior vagus trunk is just at the back here, with my grasper I retract this nerve. I have the left crus coming behind the esophagus so I’m continuing this dissection because I know that the vagus trunk is not there so I can go straight ahead. You see the aorta is there and then I’m really identifying the left crus there. As soon as I know where the vagus trunk is, I’m retracting it and I can open this space. I’ve prepared the way from the left side. We are used to retracting the GE junction. It’s atraumatic so you don’t have any grasper on the esophagus or the GE junction. It’s also important to avoid these unknown little visceral injuries. Does the patient have a nasogastric tube? Starting the procedure with anesthesia, I’m just checking that the stomach has been well emptied. If it is so, we remove the nasogastric tube because otherwise the GE junction is a little bit rigid and there’s a risk for perforation of the esophagus.

3. Mobilization of esophagus 06'56''

My recommendation is that you should do this dissection without any tube in place. Now I’m trying to mobilize the esophagus. The objective is to get a good length of the esophagus back into the abdomen so you need to do this little mobilization, sometimes it’s much more. For the length, I think 3cm is sufficient, but 3cm without any traction and that probably makes 5cm with traction. I’m just next to the nerve. In most of the patients, I’m doing this mobilization. Sometimes you need it much more. I’m convinced by the fact one very important step is to get it without traction into the abdomen. We’re now moving to the left side of the esophagus and then we have to be careful because the vagus trunk is somewhere. I can feel it, it’s there. It can be difficult to see the anterior vagus. But you can feel it when you have traction on the GE junction. I’m very careful in this area because we can meet the posterior vagus trunk. You can see all these attachments. Here you have to be careful because the left pleura is somewhere. You see the nerve is there. With this dissection, I’m trying also to appreciate the tension of these attachments. If I don’t feel too much tension, I try not to divide it. We open the pars flaccida now. I don’t know if it’s necessary to keep these small branches. For beginners, I’d recommend to divide them. I’d love to conduct a study to see if these branches do have some sort of influence on the general results of the operation in terms of bloating. I’m just making the window nice and large now. We know that one of the causes of dysphagia can be the posterior window because if you’re trying to put the stomach within a very small window, you can make some compression on the back of the esophagus so that can also explain some dysphagia.

4. Mobilization of gastric fundus 11'05''

The line where I’m starting with the gastric mobilization, I’ll show you where my landmarks are. This is the Dallemagne lipoma. I hope this female patient has one but usually we find it in all patients. I think it’s over there. That’s the one. You see it’s a small one. It’s a very good landmark and you see it in all the patients. Of course this part of the operation can be done without instrument like cautery, but you’ve seen that from the beginning of the operation I’ve used only one instrument, that is this one, to coagulate, to divide, to dissect. That’s why I like this instrument. I’m working from the back of the stomach. I like it this way because I can see all the attachments, all the things I have to divide to get a good gastric mobilization. It’s a very good trick going from the back rather than going from the side. To have a good gastric mobilization, you have to divide all that. You see we’re not mobilizing all the stomach, we’re really mobilizing the top of the gastric fundus here.

5. Repair of hiatus 13'40''

It’s not a gastrolysis you see. All the stomach is respected. I’m very carefully grabbing the left crus, the right crus, taking big bites. Here’s the inferior vena cava down there. You see the aorta is not that far. You see that I retract the segment 1 with my grasper because if you puncture this liver, you’ll get some bloody oozing. All the movements have to be very controlled because if it starts to bleed, you won’t get the good view and you’ll get into trouble. It’s a good exercise for self-control. You’ve always to control both instruments within the operative field in order to avoid puncture of the liver or any other organs. You’ve always done this figure-of-eight type of suture. Yes I have. I’ll check now.

6. Fundoplication 16'06''

Now we’ve finished with the crura repair. I’m looking at the gastric fundus, which has been prepared. This is the anterior wall. This is the back so I put it in a proper position and I’m coming from the right side and I should grab this. This is the anterior, this is the posterior so I’m looking if there’s no torsion, nothing wrong. The posterior fixations are here. You can do the valve of your choice. You can regulate, do it very tight, very large. By the time I’m doing my stitch, the gastric fundus is still in the same place so there’s absolutely no traction on the gastric fundus when I’m creating this sort of fundoplication. You see it’s very loose. And then I’ll fix the fundoplication onto the esophagus. Then we look very carefully at the GE junction because the anatomical junction is not the endoscopic junction. They are different ones. So we have to put the valve in a proper position, not this way but this way. With one stitch, I fix the fundoplication on the esophagus. This one takes the esophagus as well. This is another type of suture, it’s a 2/0 one.