Laparo-Endoscopic Single Site (less) Giant Hiatal Hernia with Nissen Fundoplication

Sharona B Ross, MD, Harold Paul, BS, Natalie Donn, BS, Alxander S Rosemurgy, MD. University of South Florida & Tampa General Hospital

LESS surgery represents a paradigm shift in minimally invasive surgery; it improves cosmesis, reduces pain and shortens recovery time. LESS surgery is applied to various laparoscopic operations including Nissen fundoplication for the treatment of gastroesophageal reflux disease.

This video of LESS reduction of a giant hiatal hernia and Nissen fundoplication is undertaken through a 1.2 cm incision at the umbilicus. A multi-trocar port is utilized and visualization of the operative field was obtained with a 5mm deflectable tip laparoscope. The hiatal hernia was reduced and the sac is excised. The distal esophagus was circumferentially dissected from its surrounding tissue, while both the anterior and posterior vagus nerves were identified and preserved. Next, the gastric fundus was mobilized by dividing the short gastric vessels and the hiatus was reconstructed with interrupted polyester sutures. A bougie was placed per os into the stomach. The posterior fundus was then brought behind the esophagus and the fundoplication was constructed utilizing four interrupted sutures; the first two bringing the anterior fundus to the esophagus and then to the posterior fundus. The next two interrupted sutures bring only the anterior fundus and posterior fundus together at the gastroesophageal junction. Once the fundoplication is completed, it is anchored to the right crus to avoid tension that would cause twisting of the esophagus, as well as to prevent the fundoplication to become undone. Once the posterior crusoplasty and the Nissen fundoplication are completed, the umbilical defect is closed with an absorbable monofilament suture in a figure-of-eight fashion. The skin is approximated with an interrupted absorbable suture.

Cosmesis following LESS surgery is outstanding. Patient demand for better cosmesis will increase the application of LESS surgery for the treatment of GERD.