Laparoscopic Antireflux Procedures

Technique: Laparoscopic Nissen Fundoplication - 360

An orogastric tube is in place, and the stomach is fully decompressed. A pneumoperitoneum is created and an intra-abdominal pressure of 15 mm Hg is maintained. The trocars are inserted as described. The telescope is inserted via the most medial trocar.

An ENDO RETRACT* Instrument or fan retractor is inserted via the right lateral VERSAPORT 11-5 mm trocar. The instrument is deployed and the inferior aspect of the left hepatic lobe is retracted upward exposing the gastro-esophageal junction. The left triangular ligament is usually not transected.

An ENDO BABCOCK* Instrument is inserted via the most lateral VERSAPORT* 11-5 Trocar . The anterior aspect of the stomach is grasped and retracted downward. In some cases, the anesthesiologist will be asked to rapidly move the orogastric tube to accurately locate the GE junction for the surgeon. The presence of a Hiatal Hernia is verified.

An ENDO SHEARS* Instrument and a non traumatic grasper are simultaneously used to dissect and expose the Gastro-esophageal junction. First, the Gastro-hepatic and Phreno-esophageal ligaments to the right or medial aspect of the GE junction are incised and the medial aspect of the Gastro-esophageal junction is exposed (upper lesser gastric curvature)

The exposure of the GE junction is continued on the lateral or left aspect. The short gastric vessels are meticulously dissected using the ULTRASHEARS* Instrument (cutting and coagulation) and the ENDOBABCOCK* Instrument (for retraction). Always initiate the dissection on the greater curvature advancing toward the gastro-esophageal junction.

Step 2: Creating the GE Window

Avoid manipulating the lower esophagus with graspers or the ENDO BABCOCK* Instrument. The ENDO RETRACT MAXI* instrument is inserted  and only part of the blunt memory blunt blade is opened. Using this instrument as a dissector, the right or medial aspect of the GE junction and the upper part of the stomach (lesser curvature) is bluntly dissected. This dissection is extended posteriorly behind the stomach and GE junction.

The Vagus nerves are visualized. The stomach is now retracted medially and the dissection is initiated on the left or lateral aspect of the GE junction. The ENDO RETRACT MAXI* instrument is then opened entirely and inserted behind the stomach. The operator should carefully observe the tip of the blade as it passes to the lateral aspect of the GE junction.

A GE window (between the cruras and the posterior esophageal or GE junction aspect) is now created. It is enlarged bluntly by moving the ENDO RETRACT MAXI* instrument up and down to slowly enlarge this window to a 4 cm size. Once this maneuver is completed, the diaphragmatic cruras are visualized. The anesthesiologist is asked to remove the orogastric tube and to replace it with a #50 French Bougie followed by a # 60 French Bougie.

Step 3: Dissecting the Short Gastric Vessels

The upper short gastric vessels are transected using the UltraShears Instrument or Harmonic Scalpel. This will release the tension on the lateral aspect of the fundoplication. The key to a successful outcome is to construct a tension-free fundoplication.

Step 4: The Diaphragmatic Closure

The surgeon should now assess if a crural closure is needed. The operator should remember that post-fundoplication the GE Junction will be moved forward thus partially closing the crural defect. If the defect is still estimated to be too large, a crural closure is then initiated. The cruras are slowly approximated anterior or posterior [easiest approach] to the esophagus with interrupted silk sutures (7''-O Softsilk or Silk) placed with an ENDO STITCH* Instrument or a laparoscopic needle holder. This closure is completed after leaving a small window (.5 cm) between the last crural suture and the esophagus.

Step 5: Creating the Fundoplication

 

The lateral ENDO BABCOCK*  Instrument is now used to grasp the fundus lateral to the GE junction. This is pushed behind the GE junction into the GE window as it is retracted forward by the ENDO RETRACT MAXI* Instrument.

Step 6: The Posterior Fixation

It is essential to anchor the fundoplication medially on the medial diaphragmatic crura. This will prevent a potential rotation of the fundoplication and a failure of the fundoplication. Using the Endostich instrument, 2 0 silk sutures are placed between the medial crura and the medial aspect of the fundoplication. The placement of these sutures should be planned not to impair the completion of the fundoplication.

Step 7: Completing the Fundoplication

Using the ENDO STITCH* instrument and a Dolphin Nose Atraumatic Grasper, three or four 0 SOFT SILK* sutures are placed to complete the fundoplication. The fundoplication should be two centimeters long and performed over a # 60 French bougie. The surgeon should verify the fundoplication is loose.

Step 6: Reinforcing the Fundoplication

This Technical Step is an additional modification to the standard Nissen Fundoplication  now performed routinely on our service.

A 1" x 2" SURGIPRO* Mesh is inserted in the intra-abdominal cavity. It is deployed over the Nissen Fundoplication and sutured or stapled.

The intra-abdominal cavity is irrigated and deflated. The trocars are removed. The trocar insertion sites are closed in the usual fashion. The patient is sent to the recovery room.