Robot-assisted Nissen-Rossetti fundoplication for the treatment of hiatal hernia

This is a totally robotic Nissen fundoplication performed by an experienced laparosopic surgeon. It is detailed, commencing with robot set-up, which is done with the help of the scrubbed assistants. All the same steps of laparoscopic Nissen fundoplication are reproduced easily with robotic instruments.

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Robot-assisted Nissen-Rossetti fundoplication for the treatment of hiatal hernia

Authors

Abstract

This is a totally robotic Nissen fundoplication performed by an experienced laparosopic surgeon. It is detailed, commencing with robot set-up, which is done with the help of the scrubbed assistants. All the same steps of laparoscopic Nissen fundoplication are reproduced easily with robotic instruments.

Catégorie

complex cases

Type de vidéo

Vidéo chirurgicale

Durée

20'00''

Publication

2006-11

Popularité

Favoris

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Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2006;6(11).
URL: http://www.websurg.com/doi-vd01en2020.htm

Robot-assisted Nissen-Rossetti fundoplication for the treatment of hiatal hernia

1. Robotic set-up 00'17''

The set-up of the robot usually is performed by the assistant at the bed-side. The assistant is in charge of cutting, suction, and retraction; also if needed the assistant changes the robotic instruments for the operating surgeon. The patient is positioned supine with legs apart. The reverse Trendelenburg position results in spontaneous lowering of the abdominal organs facilitating exposure.

2. Start of procedure 00'45''

The pneumoperitoneum is established in a normal fashion with a maximal intra-peritoneal pressure of 15 mm Hg. A dual lumen gastric tube is placed to decompress the stomach. It is moved up to the middle third of the esophagus once the stomach has been decompressed before starting the esophageal dissection. The liver retractor held by a robotic arm is used to lift the liver.

3. Dissection of crura 01'12''

The operation begins with the mobilisation of the gastro-esophageal junction. The successive dissection steps allow to identify the essential anatomic structures: the diaphragmatic crura, the esophagus, the vagus nerves, the mediastinal pleura, and the aorta. The pars condensa of the lesser omentum is opened making sure that the hepatic branch of the vagus nerve and the left hepatic artery are preserved. This helps to identify the right diaphragmatic crus, the essential anatomic landmark that needs to be identified before beginning the dissection of the esophagus. Incision of the phreno-esophageal membrane is continued on the medial part of the right crus. Known traumatic dissection of the cleavage plane found internally to the right crus allows to identify the position of the esophagus. Finding that area is facilitated by lifting the distal portion of the esophagus and the cardia anteriorly and to the left. That step allows access to the crura, the posterior edge of the esophagus and the posterior vagus nerve. Once the position of the esophagus is identified, the phreno-esophageal membrane is opened transversally along the anterior border of the hiatal orifice and towards the left crus. At this level, a non-traumatic dissection of the internal aspect of the crus is recommended to avoid damage to the anterior vagus nerve. The dissection is then continued towards the most posterior part of the crus to prepare the retro-esophageal dissection. Dissection of the posterior aspect of the esophagus allows to create a retro-esophageal window. The dissection is carried out from right to left posterior to the esophagus and in contact with the external border of the left crus.

4. Retraction of esophagus 03'11''

The posterior vagus nerve is identified and retracted against the wall of the esophagus. A Penrose drain or a loop is passed through the retro-esophageal window and then placed around the esophagus. It allows to avoid any traumatic grasping of the esophagus and helps to mobilise the GE junction in different directions during the next steps. Division of the posterior attachments of the cardia on the diaphragm allows to enlarge the retro-esophageal window. The possibility of a left diaphragmatic artery crossing through that space must be kept in mind. Dissection of the esophagus into the mediastinum lengthens the abdominal portion of the esophagus. This portion should be at least two centimetres long without tension. If the cardia cannot be lowered by this dissection, further dissection of the esophagus into the mediastinum should be performed. The vagus nerve must be systematically identified and preserved.

5. Hiatoplasty 04'30''

The closure of the diaphragmatic opening should be performed routinely as it not only contributes to restoring one of the elements of the anti-reflux barrier, but also stabilises the anti-reflux wrap into the abdominal cavity. While the esophagus is retracted distally, uninterrupted non-absorbable sutures are placed on the crura to repair the hiatal defect posterior to the esophagus. Unquestionably, the freedom of movement of the articulated instruments and the three-dimensional vision facilitate the placement of sutures, which can be particularly challenging in such a relatively small confined space. The technical principles of the robotic Nissen fundoplication are the same as in the laparoscopic approach. Mobilisation of the cardio-esophageal junction, mobilisation of the gastric fundus by successive division of gastrophrenic ligament and short gastric vessels and a short 2 cm 360degree fundoplication. The short gastric vessels are originally divided. The gastrosplenic ligament is exposed using traction on the fundus of the stomach towards the patient’s right and lateral traction on the gastrosplenic ligament towards the patient’s left. Incision of the gastrosplenic ligament gives access to the omental sac. Two to three short gastric vessels are divided. Division of the posterior layer of the gastrosplenic ligament is continued until the left crus is entirely visible, also by division of a gastrophrenic ligament. To build our Nissen fundoplication, the anterior and posterior walls of the gastric fundus are mobilised.

6. Fundoplication 06'43''

In fact, the valve should be tailored using the gastric fundus; caution must be taken not to fashion the valve with the body of the stomach as there is a risk of partitioning the stomach into two parts. The posterior wall of the gastric fundus is retracted to the right of the esophagus through the posterior esophageal window. The anterior fundic wall is brought to the posterior aspect of the esophagus. Once tailored, the valve should be sufficiently stable to remain distal from the spleen. The mobilisation of the stomach should be sufficient to avoid any tension on the valve itself and prevent any twist of the lower esophagus. The two parts of the valve are joined together using three non-absorbable sutures. The first upper most suture does not attach the valve through the esophagus; the next two sutures complete the fundoplication and incorporate the anterior aspect of the esophagus. This stitch completes the 360 degree Nissen fundoplication which is 2 cm in length. Although the robot assistant provides a clear improvement in the visualisation of the operative field, superior instrumental capabilities and better ergonomics, the use of the Da Vinci system in the Nissen fundoplication provides no clear-cut advantage when compared to the laparoscopic approach. Surgeons who are about to start robotic surgery can perform Nissen fundoplication to learn the basic concept of the system, and practice the dissection and suturing capabilities before proceeding to more complex procedures. Robotic Nissen fundoplication can also be an attractive procedure for surgeons who are starting to do Nissen fundoplication since robotic systems are designed to enhance endoscopic manoeuvrability.