New curved and reusable instruments for single access transumbilical laparoscopic Nissen fundoplication

Since the first operation performed in 2005, single incision laparoscopic surgery has been used around the world to perform many procedures. Problems still remain for exposure. This video shows a single incision laparoscopic Nissen fundoplication with new curved and reusable instruments.

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New curved and reusable instruments for single access transumbilical laparoscopic Nissen fundoplication

Authors

G Dapri, J Bruyns, L Casali, J Himpens, GB Cadière

Abstract

Since the first operation performed in 2005, single incision laparoscopic surgery has been used around the world to perform many procedures. Problems still remain for exposure. This video shows a single incision laparoscopic Nissen fundoplication with new curved and reusable instruments.

Classification

single port, contribution

Keywords

New curved and reusable instruments, single access transumbilical laparoscopic Nissen fundoplication

Media type

Surgical video

Duration

10'15''

Publication

2010-07

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E-publication

WeBSurg.com, Jul 2010;10(07).
URL: http://www.websurg.com/doi-vd01en3016.htm

New curved and reusable instruments for single access transumbilical laparoscopic Nissen fundoplication

1. Trocar insertion 00'19''

After incising the skin on the umbilicus and placing a purse-string on the fascia, a reusable 10mm trocar is placed, which harbours a 10mm angled-scope.

2. Curved grasper introduction 00'35''

Subsequently, special graspers have been designed and are used placed alongside the optical trocar. The curved shape of the grasper and of the coagulating hook allows to recover the principles of triangulation, which are typical for good laparoscopy.

3. Gastro-hepatic ligament incision and crura dissection 01'38''

Here we perform a Nissen fundoplication as usual by incising the gastro-hepatic ligament, localizing the right crus, incising the superficial peritoneal sheet anterior to the esophagus, incising the anterior leaflet alongside the right crus not too deep so as to keep the esophagus out of harm’s way.

4. Bi-curved grasper insertion 02'18''

Finally, the surgeon inserts his left hand grasper with a special bi-curved shape under the esophagus lifted anteriorly and subsequently the fundus is grasped and pulled towards the right of the patient, which puts the gastroesophageal and the phrenogastric ligaments under traction. One can appreciate the perfect ergonomic position of the surgeon and the fact that inside the abdomen, the movements are kept smooth and very much like with regular laparoscopy.

5. Phrenogastric ligament incision and esophagus traction 03'14''

The phrenogastric ligament has now been incised from the left; again, the esophagus is lifted and an umbilical tape is introduced and looped around the distal esophagus and the cardia of the stomach. Once can appreciate that there is absolutely no difference between what’s being done here and what’s usually done with regular laparoscopy. The umbilical tape is tied loosely around the distal esophagus and will be helpful in providing traction for subsequent dissection and suturing. The esophagus is thanks to that loop lifted anteriorly and the phrenogastric ligament is incised through all its layers until the free peritoneal cavity is visible from right to left. The fundus is then snapped and looped behind the esophagus, and by pulling the fundus anterior to the esophagus, the short gastric vessels are put under traction and they are freed and severed “à la demande”, which means that only those vessels are severed, that need to be so in order to provide sufficient slack for the fundus. A 2/0 silk stitch is introduced through the 10mm trocar with a straight grasper but then a bi-curved specially designed needle holder is introduced in its typical way right alongside the trocar without any effort, very gently.

6. Bi-curved needle holder 06'00''

And it can be appreciated here that this bi-curved needle holder is very easy to handle, performs good suturing by following the curve of the needle and again is very much like in regular laparoscopic Nissen fundoplication.

7. Crura closure 06'30''

A figure of eight stitch is placed joining both crura posterior to the esophagus whilst no nasogastric or orogastric tube is inside. The stitches are tied by intracorporeal knotting technique, again using those back-curved instruments in both hands. 2/0 silk has been used in our department for several years and proved to be reliable.

8. Wrap creation 07'18''

After the crural closure, the fundus, which previously has now been freed by dealing with the short gastrics “à la demande”, is wrapped in its typical Nissen fashion and the wrap is kept in place by a couple of stitches of silk 2/0 again tied intracorporeally. In the meantime, it’s important to keep an eye on the umbilical tape so as not to incorporate it in the stitching. The ergonomic conditions are, as said before, excellent, and inside the peritoneum, nothing is performed with a minimum of problems. The stitches are cut again thanks to specially designed scissors, again curved in a special way and the stitch is removed alongside the 10mm trocar. An anchoring stitch will keep the wrap in place so that the second wrap stitch does not need to take a bite on the esophagus. Hence the wrap is constituted of 2 stitches of silk 2/0 wrapping the distal esophagus very proximal to the Z-line. The umbilical tape is removed. The floppiness of the wrap is checked by introducing a tool in between the wrap and the esophagus and the stomach, and the wrap is stabilized placing a simple stitch from the left side of the collar to the left side of the upper cardia, again with the surgeon in a very ergonomic position. Finally, a second anchoring stitch is placed from the right side of the paraesophageal cardia to the right side of the wrap. These stitches are important so as not to allow a paraesophageal hernia later on, or indeed to avoid a slipped Nissen. The orogastric tube of 34 French is now removed by the anesthesiologist and the procedure is finalized.