Pediatric laparoscopic Nissen fundoplication

This video demonstrates a laparoscopic Nissen fundoplication in an 18-month-old baby with severe GERD. The patient had a TEF repair as a newborn. Five 3-5 mm ports are inserted. The surgeon first mobilizes the esophagus and preserves an accessory left hepatic artery coming off the left gastric artery. The short gastric vessels are mobilized and a retroesophageal window is created. The hiatus is closed with a single 2-0 non-absorbable suture. Then the Nissen fundoplication is constructed without a bougie. The wrap is anchored to the right crura by the first suture.

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Pediatric   laparoscopic   Nissen   fundoplication

Authors
S Rothenberg
Abstract
This video demonstrates a laparoscopic Nissen fundoplication in an 18-month-old baby with severe GERD. The patient had a TEF repair as a newborn. Five 3-5 mm ports are inserted. The surgeon first mobilizes the esophagus and preserves an accessory left hepatic artery coming off the left gastric artery. The short gastric vessels are mobilized and a retroesophageal window is created. The hiatus is closed with a single 2-0 non-absorbable suture. Then the Nissen fundoplication is constructed without a bougie. The wrap is anchored to the right crura by the first suture.
Classification
routine cases
Keywords
pediatric surgery, Nissen fundoplication, laparoscopic, accessory left hepatic artery
Media type
Duration
19'25''
Publication
2006-07
Popular
Favorites
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jul 2006;6(07).
URL: http://www.websurg.com/doi-vd01en1995.htm

Pediatric   laparoscopic   Nissen   fundoplication

4. Laparoscopic view 03'51''
You can see now we are not holding that at all, that’s a self-retaining retractor and now we’ll grasp the Babcock with our other retractor and pull it out of the way. Dr. Blumen had asked me about indications, and basically this child had been on anti-reflux medication since the first day of life and was managing ok but the parents actually came in and said that they were noticing a lot more reflux but also that they were starting to have respiratory symptoms. That’s when we re-studied him and on upper GI he had gross reflux up to the thoracic inlet, and at that point my concern became that he would be having possible life-threatening reflux or aspiration and would start to have pulmonary consequences. This is another instrument I really like to have for smaller babies or children. This is a little 3mm hook and it’s just perfect for getting at small vessels like this and getting in so that you don’t injure other tissues; it’s a great dissecting tool. Now that is an important point, it seems like that is a common place for inadequate dissection. It really is and I will tell you that in the majority of the re-do’s that I get asked to do, what I find is that this veil has not been completely taken down. The dissection stops somewhere here as opposed to way up at the diaphragm and so in fact the Nissen is formed down low at the level of the GE junction, we want the wrap to be well above the GE junction, that gets to one of the basic principles, is that you have to establish a good length of intra-abdominal esophagus. You can see it would have been easy to stop below this but really now that we are up there how much easier we can see it, especially in a child with TEF who we know is going to be prone to having a short esophagus. So we want to get up as high as we possibly can. Now we have done that part of the dissection. Can you pull your NG2 back a little bit? You can see our NG2 in the stomach it’s a little bit far and actually distorting the stomach for us so we are going to pull it back. The safest way to get behind the esophagus is after you have exposed the patient’s left crus and I think if you do that before then, if you go behind there, it is easy to blunder into the back of the esophagus or get into the back of the stomach.
6. Mobilization of esophagus 08'05''
Look for muscle fibres. Then always when you are dissecting at the esophagus, always dissect away from the esophagus, in that way you can decrease the risk of injury. We just fell into that space. You can do this with electrocautery or you can do it with the scissor. Now we have got a better view of the esophagus. We are going to do a little more work there and we will come back here, try and fall into that plane. Now again I dissect away, here is the vagus nerve do you see it right there, I’ll try to show it to you better. What I would much rather do is use a relatively blunt tip, tips of two instruments until I feel myself pop through. We may need to go back to the other side and do a little more work because normally at this point you would be through and have a clear opening. Just come back here, re-grasp the stomach, we did have more attachments here than normal. Roll it out and come back and look; make sure that you are happy, we are still a little tethered here so we may do a little bit more. It is right in here. Here is the vagus and now you can see a nice big opening. So we got behind it safely but you can see that I was still taking down the stomach because I couldn’t get through. I kept having to mobilise more and more stomach and that’s ok, you just need to go slowly. Now I know that the nerve is safe, it’s away from the esophagus so I’m going to take some of this connective tissue just so I can see the hiatus a little bit. You don’t want to do unnecessary dissection, because you don’t want to create a hiatal hernia where there isn’t one, but you want to make sure you do enough dissection that you can see things clearly.
7. Cruroplasty 10'57''
We are going to put a curl stitch in now, this is a 2/0 Ethibond on a RB1 needle and that is usually a pretty good size for most kids, it will go through the 5mm port and if you drag it through with a 3mm needle dragger. Then we are going to go ahead, and this is a little tight because of that vessel but we are going to go ahead and get behind, get a good bite of crus. Usually unless it is a big hiatal hernia, a single stitch is enough. One of the other keys here is that you will notice that I did not take the peritoneum off of the muscle fibres, I think if you don’t do that you have a much better chance to have your stitch holding, if you de-peritonealise the muscle fibre then I think you have a higher risk of the stitch not holding and tearing through. That tight space illustrates why the more exotic needles like self-riding needles or some of the ski needles are not too useful in babies. I think there are a lot of different suture devices, more and more 5mm ones are coming out but unfortunately in small kids it’s a bit tough. So I think it’s really important to learn to tie intracorporeally. Now you can use a knot-pusher for this and I don’t think that is wrong and in fact I am going to show you at least one stitch with the knot-pusher, during learning and especially back here where things are under tension, it’s a difficult space to get to, it’s not wrong to use a knot-pusher but I think that you cant rely on that as your only means to be able to suture intracorporeally because if you do, you are not going to be able to do more advanced procedures. Now we use a 3mm hook, scissors, I like to open a little bit, mostly because I want my stitches way up here. It is a rather unusual hiatus. The success of this repair depends on an adequate esophageal length, how do you gauge that and what would you tell people to do if you felt like they don’t have enough there? I think that in a baby, you need to have a few cm at least of intra-abdominal esophageal length, if you don’t have enough, then you do dissection up into the mediastinum, make sure that you have done adequate dissection here like we talked about: taking the gastro-hepatic ligament down. I am going to try and put a wrap right along here 10-11 o’clock, we have got a nice length and here is the anterior vagus nerve right there. Now we will form the wrap, so hopefully by doing our mobilisation we will have a bit of stomach sitting somewhere back here just waiting for us.
8. Fundoplication 14'34''
The stomach was sitting right there, we just go through and grab it and the important thing here, I’m trying not to twist it. What tells me that I have got a good position for the wrap is I like to see where I took down the short gastrics and you can see this is where I have got the line of where I took down the short gastrics right here. Then what we will do is, you can see we already have a nice curl forming, this is a shoe-shine manoeuvre and what that tells you is that the wrap isn’t twisted, we haven’t twisted the stomach inadvertently. I definitely like to put the wrap above. So now you can see our wrap is just sitting there waiting to be done. We probably have 3 or 3 and a half cm of intra-abdominal esophagus and I am going to take what the stomach wants to give me so that I know it will be under no tension. It seems like the very first stitch is the most important one? Yes and what I try to do is I try to get up back far on the curve back towards where I’ve taken down the short gastric where it is going to sit naturally. I get a piece of the stomach and my assistant is going to help me by pulling the stomach down so I’m now less restricted by that vessel. Now we are going to get a bit of the crus right up at the apex, you can see again all the way up to where we have dissected. Then I like to put the stitch right under where I took the short gastrics. If I get those three elements, then I’m quite happy with the wrap. Then hopefully as we put this in it’s already starting to lay right at 11 o’clock. Now we are pulling down on the stomach to keep it out of the way to set up the wrap. I use pledgets more commonly, again you don’t want to curl in more stomach so try to get right in the edge of the roll and then roll your wrist. How do you avoid making the wrap progressively tighter as you go caudally? I think that is the part about not rolling in more stomach; you want to go in right at the edge of the wrap on both sides so that you are not curling more in, that’s really important. A lot of people start out with a wrap that is not too tight but by the time they get done they have rolled in enough more stomach that they have caused that. There is our vessel intact, there is our wrap, so you’re coming behind, want to make sure that it is free and loose, it fits nicely. So we are here, just to show you that the wrap is not too tight. So you can look in and see that we can spread our Babcock clamp in there, see all the way above so you know that the wrap’s not too tight. We have not distorted the spleen at all, it is sitting there nicely, we’ve got orientation at 11 o’clock. You notice that by retracting on the diaphragm as opposed to retracting on the liver other then a little needle mark I’ve made here we have avoided any liver injury and that is pretty much it, let me just trim up this suture.