Laparoscopic Nissen Fundoplication
- three or four 5mm, one 12mm disposable trocars
- 30 degree endoscope
- Two 5mm fenestrated Johan grasping forceps
- 5mm Harmonic scalpel
- Nathansen retractor
- Two 5mm needle holders
- 5mm harmonic scalpel
Position the patient supine with 30% reverse Trendelenburg. Either stand between the patients legs or on the patients left. The monitor is placed on the patients right hand side.
Place the 12mm port in the midline, mid way between the xiphisternum and umbilicus. Place 5mm left and right operating ports 5-6cm lateral to the 12mm port. Introduce the Nathansen liver retractor through a 5mm stab incision below the xiphisternum and elevate the left lobe of the liver.
The first step is to reduce the stomach and define the hiatus hernia. This is done by retracting the stomach towards the left lower quadrant. Take care not to grasp the stomach too vigerously as gastric perforations do occur! This maneuvre places the phreno-oesophageal membrane on traction.
Crural dissection begins with identification of the right crus of the diaphragm.
Begin the dissection by incising the portion of the gastrohepatic (lesser) omentum by above and below the hepatic branch of the anterior vagus. Avoid/preserve the left hepatic artery (present in 1/4 patients). Free the right crus from bottom to top and from anterior to posterior retracting the stomach to the patients left. The medial portion of the right crus leads into the mediastinum and is entered by blunt dissection (see below).
Expose the oesophagus anteriorly followed by the left crus whilst pulling the stomach to the right hand side. Lift the oesophagus and dissect the inferior part of the left crus. Meticulous haemostasis is critical. Irrigation should be kept to a minimum. Finally move to the anterior crural confluence sweeping the oesophagus downward and to the right. Divide the anterior crural tissue and identify the left crus laterally.
Dissect the left crus as completely as possible along with the attachments of the fundus to the left diaphragm ans so create a retro-oesophageal window. The dissection of the hiatus is now complete. Whilst our preference is to use the harmonic scalpel it is not essential.
Circumfrential dissection continues inside the mediastinum using blunt dissection. Leave the vagi in contact with the oesophagus. Mobilize about 5-10cm of oesophagus.Remember that there is a tendency to dissect towards the left pleura - don't! If you havent done so already, free the fundus from its diaphragmatic attachments and divide the gastrophrenic ligament. If the fundus can not be mobilized, divide the short gastric vessels as necessary with the harmonic scalpel. Ensure that the fundus is sufficiently mobile to be brought through the retro-oesophageal window using a fenestrated forceps.
After completing the posterior dissection pass a grasper via the left hand port behind the oesophagus and over the left crus. Pass a soft tape around the oesophagus and use this as a retractor.
Holding the oesophagus anterirly and to the left close the hiatus by suturing both crura (big bites) with three interrupted non-absorbable sutures eg Ethibond O. Start just above the aortic decussation. Intracorporal knotting is fast. If the hiatus opening is very large, avoid stricturing of the oesophagus by placing one or two sutures anteriorly. Extracorporeal knot tying is perfectly appropriate.
Grasp the fundal wrap (mid portion posteriorly) and pass it left to right through the retro-oesophageal window with a upward clockwise twisting movement. Manipulate both the posterior and anterior fundic lips to allow the fundus to envelope the oesophagus without twisting. We prefer to fix the wrap posteriorly by suturing it to the closed crura.
The Nissen 360 degree valve is wrapped completely around the oesophagus. Both valves of the wrapped fundus and the anterior part of the oesophagus, avoiding the anterior vagus, are then sutured together with four non absorbable multifilament sutures.
The most common error is to attempt to grasp the anterior portion of the stomach to construct the fundoplication rather than the posterior fundus.
and the surgery is completed.
A nasogastric tube is unnecessary. Allow a soft diet the following morning.
NB Unrecognised perforation of the oesophagus or stomach are the most serious of complications; recognition and repair is the key.
Meta-analyses, Systemic reviews and randomised controlled trials
Laparoscopic fundoplication is superior to open fundoplication
Laparoscopic fundoplication is superior to medical treatment
Total vs. 180 degree anterior fundoplication
Divison of short gastric arteries