Laparoscopic Nissen Fundoplication
TECHNIQUE Positioning of the patient
TECHNIQUE Positioning of the patient
A nasogastric sump tube (Salem n° 18) is inserted. The patient lies supine,
thighs fully abducted and slightly bent. The operation table has a 20° reversed
Trendelenburg tilt. The surgeon stands between the patient's legs. The first
assistant is standing on the patient's left side, the second assistant on the
right side.
Five trocars are needed for the operation: a 10 mm trocar well above the
umbilicus, a 5 mm trocar in the right subcostal area, a 5 mm trocar in the left
subcostal area, a 10 mm trocar between the first and the third one, and a 10 mm
trocar under the xyphoid process. They allow the introduction of: a 30° angled
laparoscope, a liver retractor, a coagulation hook, and two grasping forceps.
Exposure of the esophageal hiatus
The second assistant retracts the left liver lobe thus exposing the esophageal
hiatus. The right pillar is readily seen through the peritoneal covering of the
gastrohepatic ligament.
Dissection of the esophageal hiatus
1. The lesser omentum is widely opened. Extragastric vagal branches are
as sacrified, if necessary for exposure. The right pillar of the hiatus can now
be seen.
2. The peritoneal sheet covering the phreno-esophageal ligament is
incised.
3. The incision is taken to the left where the phrenogastric ligament is
reached and severed.
4. The right pillar of the crus is dissected from top to bottom, until
the lowermost part of the left pillar is reached. A forceps coming from the top
trocar is now inserted in the angle between the right crus and the oesophagus.
The stomach is pulled caudally and laterally. Localizing the left pillar is
essential before any further dissection of the retro-esophagus is undertaken.
The posterior vagus nerve is identified at this time. The retro- esophageal
area is dissected well inside the abdomen, and, by doing this, the lowermost
portion of the phrenogastric ligament is severed.
5. The left pillar is dissected going upwards, care being taken not to
injure the vagus nerve. While the esophagus is retracted away from the left
pillar, dissection is carried out under direct vision.
Suture of the pillars
A needle-holder and 2.0 silk thread are introduced through a 10 mm trocar under
the left subcostal area (3). The grasping forceps(E) is introduced in (2).
Mobilization of the greater curvature
A grasping forceps pulls the stomach in its middle to the right. By
countertraction a second forceps exposes the gastrosplenic ligament. The short
vessels are isolated with a coagulation hook.
Hemostasis of the short vessels
Hemostatic control is performed by placing clips. Mobilization of the greater
curvature is carried out by severance of the upper-most (about five) short
vessels.
Luxating the wrap behind the esophagus
A forceps grasps the fundus at the greater curvature and passes it to a second
forceps inserted behind the esophagus. This latter forceps pulls the fundus
until it reaches the right side of the esophagus. The wrap stays in place by
itself, without need to maintain it.
Performing the 360° fundoplication
A 33 F Maloney dilator is introduced in the esophagus. By moving the wrap back
and forth behind the esophagus one can make sure that no torsion of the luxated
fundic wrap has occurred. Suturing is initiated only then. The interrupted
sutures of 2/0 silk take a bite through the stomach, the anterior wall of the
esophagus and the gastric wrap. The lowermost stitch does not include the
esophageal wall. Five stitches are put in total. Before conclusion, the Maloney
dilator is removed and a regular nasogastric tube is inserted. No external
drains are left.
Final aspect of the fundoplication
The nasogastric tube is removed on the first postoperative day; the integrity
of the gastric wrap is checked by barium swallow and a liquid diet is
prescribed for three weeks.
Per-operative complications
gastric perforation treated
by intracorporeal suture
pleural perforations
liver laceration
conversions to laparotomy
because of left liver lobe hypertrophy
