Laparoscopic Nissen FundoplicationVideo Type: CVideo
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Author: Ciro Andolfi
Specialties: General Surgery
Schools: University of Chicago
A 51-year-old man seeks medical attention for intermittent chest pain. He describes the pain as “burning” and it has become increasingly frequent after meals over the last 4 to 6 months. In addition, he experiences regurgitation, and often wakes up at night with a feeling of choking. He has also noted hoarseness and cough. Proton pump inhibitors are very helpful for the heartburn and chest pain but do not improve the regurgitation. Long-term results have shown that a fundoplication provides control of reflux in about 90% of patients. To achieve these results the surgeon should focus on the technical elements of the operation, rather than on the eponyms. The technical elements of the operation are the following: (1) division of the short gastric vessels to achieve complete fundic mobilization; (2) extensive dissection of the distal esophagus in the posterior mediastinum to bring the gastroesophageal junction at least 3 cm below the diaphragm; (3) meticulous closure of the right and left pillar of the crus with non-absorbable sutures; (4) use of a bougie to decrease postoperative dysphagia; (5) a short fundoplication with three interrupted stitches placed at 1 cm of distance from each other (2-2.5 cm long). All these technical elements have been shown to positively impact long-term outcomes. Patients who are still symptomatic postoperatively must be thoroughly evaluated to identify the cause of failure, and treatment must be individualized.
Editor Recruited By: Jeffrey Matthews, MD
The patient lies supine on the operating table in low lithotomy position with the lower extremities extended on stirrups with knees flexed 20-30 °; a bean bag is inflated to avoid sliding of the patient; an orogastric tube is placed to decompress the stomach; the surgeon stands between the patient's legs, while first and second assistant stand on the right and left side respectively. A five trocar technique is used for this procedure; a first trocar is placed 14 cm inferior to the xiphoid process, in the midline, for a 30° scope; a second trocar is placed in the left midclavicular line, at the same level with the first trocar, to introduce a Babcock clamp; a third trocar is placed in the right midclavicular line, at the same level of the other two trocars, and it is used for the insertion of a retractor to lift the liver; a fourth and a fifth trocar are placed under the right and left costal margins and they are used for the dissecting and suturing instruments.
Symptoms not controlled by medications, presence of a pathologic amount of reflux documented by 24-h pH monitoring.
There are no contraindications to a laparoscopic fundoplication as the patient is otherwise healthy.
Excluding placement and removal of trocars, we can consider seven major steps for this surgery.
1. Division of gastro-hepatic ligament; identification of the right crus of the diaphragm and posterior vagus nerve.
2. Division of peritoneum and phreno-esophageal membrane above the esophagus; identification of the left crus of the diaphragm and anterior vagus nerve.
3. Division of short gastric vessels.
4. Creation of a window between gastric fundus, esophagus and diaphragmatic crura; placement of Penrose drain around the esophagus, incorporating anterior and posterior vagus nerves.
5. Closure of the crura with interrupted 2-0 silk suture.
6. Insertion of the bougie (56 Fr) into the esophagus and across the esophageal junction.
7. Wrapping of gastric fundus around the lower esophagus; the two edges of the wrap are secured by three 2-0 silk interrupted sutures placed at 1 cm of distance from each other. The wrap should be no longer than 2-2.5 cm.
His work consisted of the following tests: 1) barium swallow which showed normal flow of contrast into the stomach and no hiatal hernia; 2) upper endoscopy which showed LA grade B esophagitis; 3) esophageal manometry which shows a hypotensive lower esophageal sphincter and normal peristalsis; and 4) ambulatory pH monitoring that shows a pathologic amount of reflux (score 76, normal being < 14.7), and strong correlation between episodes of reflux and symptoms. The essential investigations are barium esophagram, manometry, endoscopy and 24h pH monitoring.
Anatomy and Landmarks
In case of a severe impairment of esophageal peristalsis, a partial fundoplication should be considered. There are two options:
1.Partial posterior fundoplication: 240 - 270 degrees
2.Partial anterior fundoplication: 180 degrees
Intra-operative complications are pneumothorax, esophageal or gastric perforation, splenic injury, and vagal nerve injury. Post-operative complications are dysphagia and persistent or recurrent reflux, and symptoms. The patient started a soft diet the morning of the first post-operative day; it's important to avoid meat, bread and carbonate beverages for 2 weeks; 85% of patients are discharged within 23h and 95% within 48 hours.
Disclosure of Conflicts
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