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Laparoscopic redo Nissen fundoplication using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) Imaging System

This video demonstrates a redo laparoscopic Nissen fundoplication in a 46-year-old woman with recurrent gastroesophageal reflux symptoms 10 years after the previous antireflux repair, in which a functional lumen imaging probe "the endoFLIP" was used.

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Laparoscopic redo Nissen fundoplication using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) Imaging System

著者

B Dallemagne, S Perretta, J Marescaux

要約

This video demonstrates a redo laparoscopic Nissen fundoplication in a 46-year-old woman with recurrent gastroesophageal reflux symptoms 10 years after the previous antireflux repair, in which a functional lumen imaging probe "the endoFLIP" was used.

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Laparoscopic redo Nissen fundoplication, EndoFLIP®, Endolumenal Functional Lumen Imaging Probe Imaging System

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手術のビデオ

期間

10'51''

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2010-04

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WeBSurg.com, Apr 2010;10(04).
URL: http://www.websurg.com/doi-vd01en2934.htm

Laparoscopic redo Nissen fundoplication using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) Imaging System

1. Clinical case presentation 00'18''

This video demonstrates a redo laparoscopic Nissen fundoplication in a 46-year-old woman with recurrent gastroesophageal reflux symptoms 10 years after the previous antireflux repair, in which a functional lumen imaging probe “the endoFLIP” was used. Preoperative work-up included high resolution manometry and 48 hour pH monitoring, which demonstrated a hypotonic lower esophageal sphincter together with the suspicion of wrap migration and confirmed GERD recurrence. The patient is placed supine in a modified lithotomy position; 5 trocars are used.

2. Taking down the fundoplication 00'59''

The first step consists in taking down the previous fundoplication in order to identify the mechanism underlying the failure of the initial repair and to identify the different anatomic structures: the right and left pillars, the esophagus, the fundoplication and the stomach. There are only a few adhesions at the inferior surface of the left liver. The access to the esophageal hiatus is therefore straightforward.

3. EndoFLIP insertion 01'23''

The EndoFLIP® catheter with a 10cm long deflated balloon is inserted orally and positioned to straddle the esophagogastric junction (EGJ). The right side of the fundoplication is identified as it is adherent to the right crus; the right crus is followed so as to locate the esophagus and access the mediastinum. Once the dissection is complete, it is easy to understand the mechanism underlying the recurrence of GERD symptoms in this patient. The valve was malpositioned and the upper portion of the stomach has herniated through the fundoplication. The next operative step consists in undoing the previous wrap. The different cleavage planes are found and dissection is guided by the identification of the old sutures.

4. Opening the wrap 02'13''

The wrap is opened and the two sides, the right and the left of the fundoplication, are freed from the esophagus. The right side of the fundoplication is dissected and once again the sutures placed during the first operation help to follow the correct planes. The right part of the fundoplication is then dissected along the right margin and posterior surface of the esophagus. At this level, dissection must be done carefully to avoid any injury to the vagus. Dissection should be performed in close contact with the old fundoplication. Adhesions due to the retro-esophageal position of the stomach should also be freed. The aim of this wide dissection is to reconstruct the original anatomy of the stomach by undoing the first fundoplication wrap totally.

5. Identification of cardioesophageal junction 03'13''

Once this has been performed, the cardio-esophageal junction is identified. Next, mediastinal dissection up to the level of the inferior pulmonary vein is routinely carried out. In order to do this, an umbilical tape is placed around the gastroesophageal junction (GEJ), which should rest without traction at least 2 to 3cm below the diaphragmatic hiatus. In this patient, no mediastinal dissection was obviously performed at the first operation since we soon encounter a virgin plane of dissection.

6. Dissection of short gastric vessels 05'08''

The short gastric vessels are routinely mobilized up to the posterior fundic artery and all the gastro-phrenic attachments are taken. The success rate of laparoscopic Nissen fundoplication depends on proper creation of a floppy and symmetric wrap together with a suitable crural repair. The rate of failure following fundoplication varies from 2 to 30%, and revision is required in many of the patients who have recurrent or new foregut symptoms. Common causes of failure include hiatal hernia, wrap disruption, slipped wrap, and misplaced wrap. Most failures and complications due to technical mistakes during antireflux surgeries are related to an incomplete or inadequate intraoperative evaluation of the wrap and crural repair. Therefore, a complete intraoperative evaluation of the wrap configuration and tightness and of the crural repair is crucial for the Laparoscopic Nissen Fundoplication (LNF) procedure. The EndoFLIP® can show a live modification on esophagogastric junction (EGJ) capacity and diameter, which is of particular interest when performing antireflux procedures.

7. Crura re-approximation 06'41''

The crura are re-approximated with 2 non-absorbable sutures, taking care not to overtighten the hiatus. The fundus of the stomach is passed behind the esophagus in the newly created retroesophageal window. Several techniques have been described to assist in the creation of a floppy, symmetric Nissen. Intraoperative manometry, the use of a large esophageal bougie, and use of on-table endoscopy (EGD) all have been reported to be useful. The use of a bougie does not entirely eradicate the risk of an over-tightened wrap or of a wrap misconstruction.

8. EndoFLIP measurement 07'41''

The functional lumen imaging probe (EndoFLIP®, Crospon Ltd.), combines measurements of the esophagogastric junction (EGJ) resistance to distention and provides a geometrical reconstruction of the esophagogastric junction itself. We hypothesize that this “smart bougie” could be integrated into the surgical routine of esophageal functional surgery for GERD, providing a reliable immediate visual feedback of the impact of surgical maneuvers on the esophagogastric junction (EGJ) physiology and could therefore improve and facilitate surgical training and learning curve in this arena. The EndoFLIP® Imaging System (Crospon, Galway, Ireland) comprises a measurement display unit, and a sensing 25mm balloon probe. The balloon bag houses an array of sixteen electrodes spaced 5mm apart to measure multiple cross-sectional areas (CSAs) at fixed intervals along the catheter. The system determines the diameter between each pair of electrodes using an impedance measurement technique. Pressure within the balloon probe is also measured using a solid state sensor. The cross-sectional areas (CSAs) are used to build a dynamic representation of the luminal geometric changes in the esophagogastric junction (EGJ) as the bag is distended on the catheter. Real-time diameter data and balloon pressure are at all times displayed on the system monitor and available to surgeons.

9. Short floppy fundoplication 09'55''

A short floppy fundoplication is fashioned using 2 anterior sutures to secure the wrap. One extra suture is placed distally to secure the inferior left border of the fundoplication to the esophagus at the level of the phreno-esophageal membrane. A contrast swallow study was performed on the first day after surgery and a normal diet was resumed on postoperative day one.