Videos and Text Contributors
Sofiane El Djouzi
1. Patient Positioning And Trocar Placement
Surgeons choose one of two patient positions for laparoscopic foregut surgery.
Supine position is utilized with the Surgeon to the patient’s right, and the first assistant on the patient’s left. The patient’s arms are both out and all pressure pints are adequately padded. Trocars are then placed with the camera (using a 30 degree or greater angled scope) on the left and the assistant’s trocar in the mid clavicular line on the left approximately 3 finger breadths below the rib cage. The surgeon’s trocars are to the right in the paramedian line and in the mid clavicular line on the right approximately 3 finger breadths below the rib cage. The liver retractor is in the mid epigastrium
Split leg position requires a split leg table or use of stirrups. The Surgeon is in between the legs and the assistant is to the patient’s left. All pressure points have to be well padded. The patient’s arms are both out. The camera trocar is to the left and superior to the umbilicus, approximately 12 cm from the xiphoid process. The assistant’s trocar is to the left in the anterior axillary line at or above the level of the umbilicus. Both of the surgeon’s trocars are in the mid clavicular line approximately 2-3 fingerbreadths below the ribcage. The liver retractor can be in the right anterior axillary line or in the mid epigastrium.
FIGURE 1. SUPINE POSITION AND TROCAR PLACEMENT
FIGURE 2A. SPLIT LEG POSITIONING
FIGURE 2B: SPLIT LEG POSITION TROCAR PLACEMENT
2.Retraction of the Left Lobe of the Liver
Retraction of the left lobe is the requisite next step to expose the hiatus for any foregut operation including a Nissen fundoplication. Most commonly two approaches are used to accomplish this. The first includes making a small incision in the epigastric region under the xiphoid to place a Nathanson retractor. Care must be taken to ensure that the tip of the retractors does not injury the diaphragm or the pericardium. Visualize the Nathanson tip as the retractor is placed and removed. Placing the Nathanson in patients with a very thick abdominal wall can be difficult.
The second approach is using a flexible liver retractor (Atlas). For this retractor placement a 5mm trocar is placed under the right costal margin. The flexible retractor is introduced through this trocar and pointed towards the left upper quadrant. As the retractor is advanced a black dial on the back of the retractor is twisted in a clockwise direction to curl the flexible distal half of the retractor. Once the retractor is fully curled it is used to retract the left lobe. The external part of the retractor is then connected to a bed post.
Nathanson Liver Retractor Placement
Atlas Liver Retractor Placement
3.Division of Short Gastric Vessels
Some surgeons choose to mobilize the short gastric arteries as the first step of the Nissen fundoplication or a paraoesophageal hernia repair. This step allows for exposure of the left crus of the diaphragm. In patients with a larger hiatal hernia, the short gastric arteries may be well above the diaphragm at the beginning of the dissection and releasing the hernia sac from the hiatus anteriorly, or the right, or higher on the left crus is a better place to start.
Some controversy exists on the need to divide the short gastric arteries. This debate was more relevant before advanced energy devices made dividing these arteries so quick and effective. Most published literature supports routine division of the short gastric arteries. A randomized trial showed no statistically significant differences between division and non-division of the short gastric arteries, except epigastric bloating, which was more common with short gastric division. The short gastric vessels are divided using ultrasonic or advance bipolar energy. The lateral retraction by the assistant is a key step to expose the vessels and avoid splenic injuries. Towards the top part of the fundus, the body of the stomach is retracted medially to improve visualization.
4. Hiatal Dissection
Once the gastro-hepatic ligament is divided the right crus will become visible. Hepatic branches of the vagus are divided. The fat pad medial to the right crus is grasped and retracted medially to expose the right crus completely. The peritoneum over the right crus can be scored with monopolar electrocautery or divided with advanced energy. The retroesophageal window is created. This can be done bluntly with graspers, being careful to identify the posterior wall of the esophagus. A Penrose drain is often used to retract the esophagus. This is passed under the gastroesophageal (GE) junction via the retroesophageal window. The Penrose is secured with an endoloop or by passing a one tail through a slit in the drain itself. This is used for atraumatic manipulation of the esophagus.
Upon retracting the Penrose laterally and to the left loose areolar mediastinal tissue will become visible. The mediastinum is now entered and the phrenoesophageal ligament is lifted up. The esophagus is now separated from the phrenoesophageal ligament starting at the right crus and heading towards the left in a clockwise direction. The edge of the phrenoesophageal ligament near the right crus is grasped and lifted up with the left hand while the esophagus is gently dissected free from the ligament with the right hand. As we proceed towards the left crus the anterior vagus nerve will have to be separated from the phrenoesophageal ligament and preserved. It is important to preserve the peritoneum over the left crus during this maneuver.
Once freed the phrenoesophageal ligament is sequentially divided with an energy device – monopolar cautery, advanced bipolar, or ultrasonic shears based on surgeon preference. There are usually some more adhesions external and posterior to the hiatus which needed to be divided with an energy device to ensure the fundus can eventually be brought through the retroesophageal window with ease.
5. Mediastinal Dissection/esophageal Mobilization
ESOPHAGEAL MOBILIZATION FOR A LAPAROSCOPIC NISSEN FUNDOPLICATION
Esophageal mobilization for a laparoscopic Nissen fundoplication or any foregut operation involves three key steps:
1.Retraction of the GE junction
2. Separation of the esophagus from the phrenoesophageal ligament
3. Circumferential mobilization of the distal esophagus
Once the phrenoesophageal ligament has been divided the mediastinum will be become more readily visible. All loose areolar tissue around the esophagus is now divided with gentle blunt dissection. Small blood vessels are divided using ultrasonic shears or other energy devices. The pleura will be in close proximity (more so on the right side) to the esophagus and will be have to be separated gently to avoid a pleurotomy. Posterior to the esophagus loose areolar tissue will have to be dissected and the aorta will become visible. At this point, the posterior the vagus nerve will be visible and should be preserved. It is not uncommon to find a lipoma in close proximity to the posterior vagus nerve. Circumferential mobilization of the esophagus high in the mediastinum is performed; the anterior dissection is usually more challenging due to the beating heart and should not be rushed. Once mobilization is complete the arch of the hiatus anteriorly as well as the decussation of the crural fibers posteriorly should be clearly visible ensuring all the peri-hiatal tissue has been adequately divided and at least 3-cm of esophagus distal to the hiatus without tension has been obtained. It is important to know exactly where the GE junction is to ascertain esophageal length. It there is any doubt, upper endoscopy can be a valuable adjunct at this point to confirm the GEJ and assess esophageal length.
6. Hiatal Closure
Principles of Repair:
1) The diaphragm is approximated with a posterior cruroplasty using nonabsorbable sutures. Some surgeons use a combination of anterior and posterior sutures to prevent angulation of the esophagus.
2) The type of closure, type of nonabsorbable suture, type of needle driver or mechanical suture devices, use of pledgets and knot tying vary among surgeons.
Steps of Hiatal Closure:
1) Once it has been determined that adequate length of the intraabdominal esophagus has been attained, attention is directed toward diaphragmatic closure
2) The Penrose is used to retract the esophagus and is pulled anteriorly
3) The diaphragm is approximated with a posterior cruroplasty using nonabsorbable sutures. In this video we use 0 silk (Braided) suture with pledgets on an SH needle. As mentioned earlier there are wide variations noted and some surgeons also use barbed nonabsorbable sutures.
4) These sutures are placed 5 mm apart, require deep bites of the left and right crura of the diaphragm, and are tied intracorporeally in interrupted fashion. Extracorporeal suturing and adjunctive suturing methods are utilized based on the surgeon preference. The use of pledgets to reduce tension on the closure is also practiced.
5) When using pledgets it is important to not use pledgets on the last suture to avoid any erosion of pledgets into esophagus
6) Care must be taken to avoid any injury to adjacent structure such as the aorta, IVC, caudate lobe, esophagus, or stomach.
7) The hiatus should be closed until the tip of a grasper easily fits between the esophagus and the hiatus with no tension on the esophagus and without a bougie in place. Avoid compression of the esophagus by the crural closure at rest. There is some controversy over whether an esophageal bougie should be used during fundoplication surgery. Most surgeons historically have chosen to use a 56-60 French bougie for a Nissen fundoplication. The use of a bougie in partial fundoplications such as a Toupet is less common. If a bougie is to be used, some surgeons chose to place this prior to hiatal closure. The bougie is heavy and a posterior hiatal closure may make it difficult to pass the bougie. If a bougie is in place at the time of hiatal closure, we recommend that the hiatus be closed until it is snug on the bougie, and that the closure be reassessed at the end of the case once the bougie is removed according to the above criteria. Interrupted hiatal closures (as opposed to a running closure with a unidirectional barbed suture) have the advantage of being able to remove a single stitch if the hiatal closure appears too tight on final assessment.
8) We recommend use of absorbable mesh when there seems to be tension on the crural closure or if the crural muscle is starting to tear. Mesh type, configurations, and methods of fixation vary depending on surgeon preference. A common approach is a biosynthetic mesh cut into a U-shaped configuration, with the mesh covering the posterior hiatal repair, anchored with suture.
9) One author’s technique involves a # 1 nonabsorbable suture prepared with two simple knots at the end and an absorbable clip proximal to the knot. The suture is run in a continuous fashion from the apex of the “V” of the crura. A 32 Fr Orogastric tube is used for calibration. After the last stitch, another absorbable clip is placed to help secure the knot.
7. Creation of Wrap
The GE junction fat pad maybe excised selectively if needed to visualize the GE junction. Care must be taken not to injure the anterior vagus nerve while performing this excision. Retrogastric attachments should be meticulously divided. Once the fundus is fully mobilized, an atraumatic grasper is passed behind the esophagus, and the posterior part of the upper fundus is grasped and brought thru the retro-esophagogastric tunnel. A shoe-shine maneuver is performed to ensure that the stomach is floppy and not twisted. It is important that the retro-esophagogastric tunnel is wide enough to allow the fundus to be brought thru without tension. A 56 – 60 F tapered bougie is now introduced into the esophagus and into the stomach. The two sides of the stomach should be brought together to be sure there is no tension. The apex of the fundus which will lie to the right of the esophagus is anchored to the greater curvature on the left at the take-off of the short gastric vessels. The wrap should be 1.5 – 2cm in length and be adequately floppy to minimize post operative dysphagia. Usually, three permanent sutures are used and the most superior one incorporates a bite of the longitudinal muscles of the anterior esophagus taking care to avoid the anterior vagus. Some surgeons will place more than one suture incorporating the esophagus. The wrap should wholly be on the esophagus, above the GE junction and not the stomach. Some surgeons anchor the wrap to the crus, but this is not universally practiced. The wrap when completed, with either intracorporeal or extracorporeal knot tying, should allow a 5 mm instrument to pass between the wrap and the esophagus.
Some surgeons prefer to map out the piece of anterior and posterior fundus to be used for the fundoplication in advance. To do this, a point 5-cm down from the GE junction on the greater curve is grasped. The stomach is flipped upside down such that the posterior wall is visualized, and the greater curve is retracted to the patient’s right. Another point 5-cm down from the GE junction on the posterior stomach and about 4-5-cm from the previously measured point on the greater curve is grasped and marked with a seromuscular suture. The tails of the suture are left long. The stomach is then placed back in the normal orientation with the anterior side up and the greater curve to the patient’s left. The mirror image location on the anterior stomach is marked with a seromuscular stitch in the same manner as described for the posterior stitch. Each marking stitch should now be 5-cm below the GE junction and about 8-10-cm away from each other when grasped together across the greater curve. These are the 2 pieces of stomach that will be wrapped around the esophagus. The posterior stitch is placed at the base of the left crus and grabbed from behind. A shoe-shine maneuver grasping each stitch as described is now performed. The fundoplication is performed as described using the two stitches to mark the bottom of the fundoplication on each side. While slightly more work, the advantage to the latter technique is that the surgeon can be certain that the wrap is fundus to fundus and symmetric. A wrap constructed with fundus to body of the stomach or anterior fundus to anterior fundus is a set-up for failure. In patients with a very large hiatal hernia or when there is excessive intra-abdominal or peri-esophageal fat, it can be difficult to be certain the correct piece of fundus is being used.
Intraoperative endoscopy is performed frequently to ensure the fundoplication is not too tight and is configured appropriately. A well-constructed Nissen fundoplication creates a nipple valve with stacked coil appearance that rests parallel and snug to the endoscope. The squamocolumnar junction should be visualized at the end of the wrap, ideally on retroflexion with the endoscope.
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