Laparo-endoscopic Single Site (less) Toupet Fundoplication with Reduction of a Giant Hiatal Hernia

Introduction: The journey from conventional laparoscopic operations to truly “minimally invasive” operations naturally includes progression from operations involving multiple trocars and multiple incisions to operations involving access through the umbilicus alone. Laparo-Endoscopic Single Site (LESS) surgery promises improved cosmesis by reducing the number of access incisions to a single incision hidden in the umbilicus, which is unapparent with healing. Now, LESS surgery is being progressively applied to advanced laparoscopic procedures.

Technique: This operation was undertaken in a 62 year old female with a history of a failed “open” gastric volvulus repair. One 10mm trocar and two 5mm trocars were placed through a multi-port trocar located at a single 12 mm incision at the umbilicus. Adhesions were divided using an ultrasonic dissector. A gastrotomy site was taken down and repaired. The dissection was taken up and down the right crus and ventral to the esophagus. The short gastric vessels were divided and the esophagus circumferentially freed at the esophageal hiatus, delivering about 8 cm of esophagus into the peritoneal cavity. The esophageal hiatus was closed with multiple sutures to close the hiatus snug, but not tight around the esophagus. Both anterior and posterior vagus nerves were identified and preserved. The posterior fundus was then brought behind the esophagus and the fundoplication was constructed utilizing eight interrupted sutures. The first sutures fixed the posterior fundus to the lateral surfaces of the esophagus. The anterior fundus was then sutured to the left side of the esophagus. The wrap was placed well above the gastroesophageal junction. The posterior fundus was anchored to the right crus to avoid tension promoting the wrap to come undone and to prevent twisting of the esophagus. Finally, the incision at the umbilicus was closed with a figure of eight of absorbable suture and the skin was approximated using absorbable sutures. A sterile dressing was placed.

Conclusions: Laparo-Endoscopic Single Site (LESS) Toupet fundoplication can be safely undertaken with improvement in cosmesis. LESS surgery will be embraced by patients; laparoscopic surgeons will need to meet patient demands.

Session: Video Channel

Program Number: V066

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