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English - 20'00''
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| 00'10'' | Trocar placement
The head of the patient is over there, this is the xiphoid process, the trocar for the camera is placed above the umbilicus; the umbilicus is here so it is on the median line. The distance varies between men and women; if you work on a male patient, you have to work very high in the median line because the hiatus is higher in male patients as compared to female patients. The distance is shorter between the umbilicus and the optical trocar in a woman. On the right side of the patient, you see the costal margin here on the right side, you have one trocar used for the liver retractor. This trocar is for my left hand; this is a trocar for my right hand, and on the left side of the patient you have another trocar, which is used by one of the assistants to place traction on the GE junction to help the surgeon. |
| 01'25'' | Inferior part of lesser omentum
Usually when I am working, this trocar on the right side is fixed to the table so we don’t need anyone to hold the liver. This is the basic set-up, I am very comfortable because this is for liver retraction, these are the active ports for the surgeon and this is the retraction port for the assistant so I try to make some compartments. That avoids instruments crossing. We begin with retraction on the GE junction, this grasper will be held by one of my assistants and we are working with the ultrasonic system. I am used to trying to preserve the branches from the hepatic nerves as much as possible, so I am opening the lesser omentum above those branches. Sometimes when you have a big left hepatic artery, I also try to preserve it as much as possible.
I am looking for this landmark, which can be seen easily here, this is the diaphragm with the right crus. I am working on this phreno-esophageal membrane, keeping an eye on the right crus and I am starting to open this junction.
See the importance of the traction on the GE junction; if you have no traction, it is very difficult to see the different planes. Placing traction is just a grasper that is moving; for laparoscopy of this area, it is very important to work with traction, counter-traction because we have to find different ways of presenting structures. Here I am working on part of the phrenogastric ligament in order to prepare the next step of the operation. I move back on my first landmarks that I’ll clean a little because there are fatty tissues here.
If you are afraid of the anatomy, just release the traction and you can see that the crus is still there so you try to find a plane between the crus and the esophagus. You can’t go straight there so keep very close to the crura, and then you will probably avoid the main problems. |
| 04'43'' | Mobilization of esophagus
I have just asked the anesthesiologist to remove the nasogastric tube because it makes it just a little bit too rigid and it’s a bit dangerous. You see we have the right crus here; you see the probe is just going out; with blunt dissection I will try to open the mediastinum. You see no cutting, no coagulation, but just blunt dissection to find the plane. Now I know where the esophagus is, so I can cut now. In this manner, you avoid the main problem, which is the injury to the esophagus.
So you see the crural ring, the esophagus with a small hiatal hernia, and then I’m moving on the left crus trying to find a plane as well. I clean this part because sometimes you have the anterior vagus trunk, which comes alongside the left crus so you have to clean before cutting.
Step by step, we are identifying the main structures. I am cleaning the lower part of the left crus quite deeply because it will prepare one of the most difficult steps of the operation, which is the opening of the posterior aspect of the esophagus. |
| 06'35'' | Posterior vagal trunk
I am moving back on the right side, cleaning the mediastinum, and we try to identify the posterior vagus trunk, you see it, just between my two tips. I take it with me with my grasper, I know that I am safe here because I have moved the vagus trunk, I will clean a little bit on the posterior aspect of the left crus. Just being in contact with the left crus, with the vagus trunk on my grasper here, I can find my way easily behind the esophagus because I have already prepared it on the other side.
It is important to prepare the left crus and I’ll put it in the hole on the other side, I have my tape. I am sparing some clips by doing this knot on the tape. |
| 08'00'' | Posterior esophageal dissection
For the next step, we go into the mediastinum because I believe in the necessity of quite extensive esophageal mobilisation in order to get the esophagus back into the abdomen. So I’m used to mobilizing quite extensively into the mediastinum.
Now I am opening from the back just to control this fatness here and to clean the crura. I am really working hard on the GE junction, just trying to get it back.
We still keep traction on the umbilical tape and you see that it makes a difference. Always use traction, counter-traction to find a good dissection plane, that is very important. My left crus is there, these are some posterior attachments of the GE junction and I can divide these.
Now I think we have finished with the mobilization, we move to the gastric mobilization. |
| 09'35'' | Mobilization of the fundus
There is a very typical anatomy in this area that you can find in all the patients, there is a small fat pad at the upper part of the gastric fundus. See the small fat pad, and you see this in all patients, whatever their size; this is my landmark. I grab the fat pad and I know that I can start my gastric mobilization here. It is really the upper part of the gastric fundus, I’m not working on the rest of the stomach. I have seen some people doing gastric mobilization but they do a full gastrolysis and I think it is a little bit too much. Working from the back of the gastric fundus, we can see the vessels that fix this gastric fundus. See all the posterior attachments, but if you work from the front, you can’t see that with a 0°; with a 30° scope, you can have it, so that why I’m working from the back. You see really well all these posterior attachments.
We end this dissection with the gastrophrenic ligament. You see Lee Swanström do a Nissen and you will see him probably defending the same principles. This is based on the experience of the surgeons. We had the opportunity to do a lot of operations. |
| 12'05'' | Hiatoplasty
We see a lot of complications so we can tell people that this is probably a good operation, this can probably be done easily or on the other hand that it will be difficult, which can give very good results but in very experienced hands. I won’t say that this operation is better than a good Nissen-Rossetti but it is probably easier to do again. I have to use some reinforcement like a mesh and in this field, we have more and more different technologies. Now we will check the size of the repair, my assistant will release the traction and you see that the esophagus is going easily in the hole without any structure from the crura. It is just placed on the crura repair, this is my calibration. I have grabbed the anterior wall there and I should come with the other part of the anterior wall. This is the Nissen Rossetti, anterior wall to anterior wall. It’s the anterior wall technique. |
| 14'05'' | Fundoplication
The other one, I am grabbing the fundus, this is the posterior wall of the fundus, I grab the posterior wall. We can do it two or three times if we want. I am sure that if I am suturing my valve like this, I won’t have any stenosis with the fundoplication, so I am safe, I am avoiding the main complication, which is the most difficult to deal with, that is dysphagia. That is the reason why I defend this procedure. Everything stays in its place without any traction. Study of the patients in the early postoperative period after fundoplication showed that 2 days after the operation, we still have some esophageal peristalsis, 2 weeks after the operation there is none left, it is a pseudo-achalasia. This peristalsis comes back after 3 to 4 weeks and usually when you look at your patient, you see that’s the time of the improvement in dysphagia. You can tell your patients that after the operation they will be OK, then eat quite easily but you have to know that after two weeks, there can be some increase in the severity of dysphagia. You see it comes very easily, I don’t put any traction on it.
I put one stitch and this stitch is not fixed to the esophagus because I want to check the shape of the fundoplication. You see that there is no twist or traction, see the anterior wall, posterior wall, I don’t use a bougie because I know that it is floppy. Then I will fix the rest of the valve on the anterior wall of the esophagus. Here you can see the shape or fold of the gastric wall that you can use to build the fundoplication, I find it quite helpful.
What is important when we compare this fundoplication to the Nissen Rossetti is that whenever we are holding or placing traction on the parts of the fundoplication, there is disruption of the fundoplication so I’m placing sutures without traction.
Two stitches, the valve has to be very short, usually 1.5 to 2cm and after each stitch, I check the fundoplication. I am still convinced that it is very floppy. I place the valve in a 10 o’clock position, I will put another stitch here. You can see immediately where the stitch has to be placed because the natural fold constricts the fundoplication. This is the phreno-esophageal membrane, so for me the Z line is about here, a little bit higher than the phreno-esophageal membrane.
More and more when we have questions about that, I do some more intraoperative endoscopy, that is very interesting because you can see that a lot of times your evaluation is not exact, that is the reason why I always tend to place my valve high on the esophagus. That is the reason why I want to have a very free esophagus so I mobilize quite largely the mediastinum.
I check again, the esophagus is there, the valve is there, there are no twists inside or outside the valve, and then I put another stitch, it may not be very useful but I am used to do it, it closes the space between the valve and the esophagus and it is fixed on the phreno-esophageal membrane, I have a feeling it keeps this fat pad out of my valve.
I am doing subserosal, because with endoscopy, it is very rare that it shows some sutures. So in laparoscopy we have to force ourselves to take quite large bites when suturing because you have to keep in mind that this is just 5mm. The valve stays without traction, without changing collars, no twists, we control the bleeding because I had some oozing from the left crus. Then it is finished, no drain, no nasogastric tube, the patient is allowed to drink on the first evening. I am used to performing a radiological swallow the next morning just to be sure that the valve is where I placed it. The patient is placed on an adapted diet and can be discharged on the same day or the next. |
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