|
English - 20'00''
|
|
|
| 00'11'' | Case presentation
I’m Dr. Steven Rothenberg, I’m a paediatric surgeon at the Mother and Child Hospital at Presbyterian St Luke’s in Denver and it’s my pleasure today to bring you the first of 3 live web broadcasts, which are sponsored by Karl Storz and Network1. This is being brought to you by a very generous educational grant, which is allowing us to bring live surgeries to surgeons and physicians all over the world in an attempt to advance and teach minimally invasive techniques. Today is the first broadcast, which is going to be a laparoscopic Nissen fundoplication in a 13-year-old male with severe reflux esophagitis. Today, we are very fortunate to have with us a doctor who is the chief of surgery at the Children’s Hospital in Kansas City, he will be moderating the broadcast for us. As many of you have already realised, you will be able to send us questions and comments through email, which we will be able to respond to during the procedure. Today’s patient is a 13-year-old male who has had a year long history of severe dysphagia, has gross reflux by upper GI and on recent upper endoscopy underwent biopsies which show grade 4 esophagitis and has not been responsive to medical therapy and for these reasons, he is going to undergo a Nissen fundoplication. This time, I would like to introduce Dr. Hocam, I’m going to turn this over to him as we get this procedure going. As Steve said, this is an educational session so we want to encourage everyone to email their questions. Click on the direct access link and you should be able to get a link to email a question and we will try to answer as many of them as possible. |
| 02'09'' | Trocar placement
We use a closed technique, so we will insert a Veress needle directly left up on the abdominal cavity and then place in the Veress needle. Most children you can actually feel the pop and then you can see the Veress needle passing into the abdominal cavity. This is a very safe technique, I think you should do what you feel safe with but we do all our insertions closed. We are going to go ahead now and insufflate to a pressure of 15, I find that most children, even neonates, tolerate pressures of 15 without any problem. We insufflate slowly at first with low flow of about 1 litre, many children complain of shoulder pain or abdominal pain and I think it’s worst if you inflate the abdomen too quickly. Since I do it every time the same way, I inject all my incision sites, I make all the incisions and then I put the trocars all in in a sequential fashion and I find that can save 10 to 15 minutes per case rather than making an injection, one incision, putting in one trocar and then switching. With procedures like this where you do the same way every time, it’s good to get a routine, in that way you are not wasting time on a part of the procedure that doesn’t really take much. My first assistant has the camera, he’s on my left side and we have our scrub technician on my right. |
| 03'45'' | Description of instruments
This is my liver retractor and you can see it has got a special handle on it, on a Babcock clamp. It’s a self-retaining retractor and we’ll show you how it works in a minute. The other upper hand port is a Babcock clamp that I use to retract the stomach. The other instruments we use for this procedure if you look down on the tray are a Maryland dissector in my left hand, a regular Meds scissors and depending on the size of the patient, we may use the regular cautery or in a larger patient, we’ll use something like the Harmonic scalpel. |
| 04'27'' | Start of procedure
Now if we can go inside now. You can see we have a pretty good look, we may need to do a bit of dissection before this will fully hold but I like to grab the hiatus with this clamp. You can see what beautiful retraction we have without ever retracting the liver. We are going to start the procedure by taking down the gastrohepatic ligament and I don’t worry about taking the vagal fibres as they come through this if there isn’t a bad left gastric or left hepatic that will preserve that. As for the workup, I think it depends on the age of the patient. In babies who have gross reflux, you can see it clinically and then we always get an upper GI to document it and make sure there is no anatomic abnormality, I think that’s important in kids even though it’s not as important in adults. Most of those children then get a pH probe, I think that’s very helpful to quantify the degree of reflux. In older children, many of them get endoscopy and biopsies and I think that’s happening more and more often, we are seeing more of that. I don’t routinely get manometry, I think it’s really not that helpful in the majority of children unless you are suspecting achalasia. So we have taken down the ligament, now we are going to go across the top of the esophagus and identify the crus. I just want to take down the peritoneal reflection. Again, you can do this with a Harmonic or hook cautery, scissors. Do you have an age range that you usually transition from the cautery to the Harmonic scalpel? It’s more of a weight, probably around 20 kilos. Because we are here, I am going to go ahead and expose the right crus. Now we have retracted, I am using the left upper quadrant trocar with the Babcock to retract the stomach medially and now I am working with my right hand on the left side of that trocar, we are going to do this to take down the short gastrics. You can see we have really nice exposure and again you can do this with Harmonic, with the Ligasure, with hook cautery in small enough patients. Now you can see what would happen if we had tried to come behind the esophagus, the stomach is adherent down there and so the risk of getting into that stomach inadvertently is pretty high. I’d agree with that it’s important to mobilise this before trying to get behind the esophagus. Now we are starting to see the patient’s left crus, there is usually a posterior gastric vessel there which we just took. Now we can see the left crus, and that’ll be very safe to come across. I like to leave this membrane intact if I can to decrease the incidence of hiatal hernia postoperatively. So we’ve got that pretty well mobilised. As a general statement, you would say that you don’t mobilise that much more of the intra-abdominal esophagus than is already there. I usually do, it depends on whether we have a hiatal hernia, but I do most of it from this side. Now you can see that very easily right behind the esophagus we fall right back in there, the posterior vagus nerve is right there so we see that and protect it and we use a kind of chopstick manoeuvre to bluntly open up the space. Then what I will have my assistant do, is he is now creating intra-abdominal esophageal length by pulling down on the Babcock. We don’t put in a Penrose or anything like that. That is another reason why I like the positioning of the left upper quadrant retractor, it allows me good access. Now we can identify a good length of intra-abdominal esophagus, we have got a nice mobilisation; so that’s a reason why I think it’s very important to take down the upper short gastrics as well as for safety and as we deform the wrap I think we’ll get better anatomy. |
| 09'24'' | Hiatoplasty
This is a 2/0 Ethibond suture, it’s a braided non-absorbable, obviously you need to use non-absorbable sutures because these sutures need to stay to maintain the repair. I like how the 2/0 Ethibond ties, it’s a sturdy suture so you are less likely to thread. When you’re suturing, it’s important to set yourself up at good angles and I use a sort of a C reverse C mode of suturing. You want to be careful, I like to use just a needle driver and my Maryland. This is a needle driver, which is made by Storz which I really like, it’s a very nice fine movement, it’s got a release with the finger. You just set it up to make it easier for yourself, small movements, so that was a reverse C, now we’ll just switch hands, come across. You can see if you set it up right, you have a very nice movement. So I think that’s a sufficient crura repair, I sort of gauge that just by eye, if you want you can put the bougie down and measure it but I tend not to do that because I have a pretty good feel for what it is. |
| 11'03'' | Fundoplication
Now we’ve got our intra-abdominal esophagus, we’ve got our crura repair, I lift up the liver a little bit more so you can see. We are going to go ahead and get our mobilised portion of the stomach and pull it through. Do you use a bougie? Yes I think it’s wise to do it, it’s one of those things that as you get more experienced, you probably don’t need to, I’ll show you that this wrap is plenty loose. What I like to do is bring around a portion of the stomach where I have taken the short gastrics and basically you want to sort of whistle the esophagus as opposed to wrapping the stomach around like that and torking it, you just want it to sit very naturally. This is a shoeshine manoeuvre to make sure that there is no tension and I can see that just sitting right there, so that’s a nice tension-free wrap. We will go ahead and put a bougie in. We have an oral gastric tube in that we put in at the beginning of the procedure to decompress the stomach. We will take that out now and I will have the anaesthesiologist pass the bougie. I will go all the way back to where the short gastrics are, get a good bite of stomach. See how my assistant is pulling down on the stomach, he’s using that like a Penrose drain to help me elongate the esophagus, so we are creating a good length of esophagus. Here is the GE junction right about there, I’m going to grab this fat pad and make it even longer, then I’m going to get a little bite of the esophagus at about 10 or 11 o’clock. This first stitch I like to grab a little bit of the crus, to try and help prevent wrap migration into the chest.
Is that a new technique based on previous experience or you have always done that? I pretty much have always done that, for a while I was putting collar stitches in, so stitches between the wrap itself and the crus and I found that didn’t really change whether kids got a hiatal hernia or not and so I quit doing it because I think it they get more dysphagia. Once we have that, to help set it up I ask my assistant to grab this fat pad to keep those tissues out of the way. I think this is a great place especially if you’re early on in your experience and use a knot pusher for this particular stitch. You can see that I use the knot pusher just to set that right up against the esophagus, go ahead and put the bougie down. We have the bougie down there and I’ll show you the wrap. We’ve got a nice positioned wrap, it is setting up right where I like at about 11 o’clock. I think that prevents any tension or torsion on the stomach and decreases the incidence of dysphagia greatly. It looks like you’re making a concerted effort to get the suture at around 10 or 11 o’clock as opposed to straight up at 12 o’clock, is that done in order to prevent dysphagia? I think so, there is a study by Jeff Peters; if you look at the anatomy and this is actually based on how the stomach comes around the esophagus and freeing of the short gastrics, that this is the way to create the most tension-free wrap. Now we are going to put in two other sutures, and make the wrap about 2 to 2.5cm in length. For this I get the stomach, esophagus but not this and then stomach again. Again you should be in a comfortable position suturing. It’s very easy then to grab the tail and pull it through.
I think the kids that run into the most problems are those with congenitally short esophagi, kids like TEF tend to have a higher risk of recurrence and so I think it’s important to try and make sure that you get a good length of intra-abdominal esophagus if you can, but even doing that, sometimes it’s not quite enough. I truly believe that mobilising the short gastrics and the upper short gastrics is key to having a good wrap and to decreasing the incidence of dysphagia. In babies, it can be done easily with a hook cautery, in older children by using some other energy source, you can see it basically took us about a minute to mobilise the upper short gastrics so it doesn’t really add much time at all to the procedure. The technique of using our retractors in the upper ports, a lot of people try to retract the liver and the stomach from the lower ports and I think you end up having a lot of instrument duelling, by moving those retractors to the upper ports, you can diminish that significantly. At no time during this procedure have I ever run into or conflicted with one of my other instruments. Pull out the bougie now. You can see that this is not tight at all, it is a nice loose wrap, we still have about 4 to 5cm of esophagus below the wrap. You can see again during the whole time maybe we can take one shot of this retractor before we take it down. This instrument is a standard Babcock.
I have had an incisional hernia even in a kid who has a 3mm port in the lower side where sometimes a piece of omentum gets stuck up in it. |
| 18'27'' | End of procedure
My instruments are both 5mm and 3mm instruments, they’re duplicate heads only smaller, so again in a 10 or 15 kilos child or under, we will use the 3mm instruments and ports. So these are the Storz ClickLine instruments? That’s right, we have worked with a lot of instruments but these are very well made, they’ve held up very well, if they break it’s the shaft and not the handle.
95% of these patients go home the next day. |
|
Homepage
Log in
Feedback
Contact us
Site map
Print
Bookmark
Laparoscopic Nissen fundoplication in children
Add to my favorite list
Top
Looking for anything specific?
