Our Simple and Practical Procedure in Anti-reflux Surgery for Gerd Patients

Tatsushi Suwa, MD, Satoshi Inose, MD, Kazuhiro Karikomi, MD, Eishi Totsuka, MD, Naokazu Nakamura, MD, Keigo Okada, MD, Tomonori Matsumura, MD, Kenta Kitamura, MD. Dept. Surgery, Kashiwa Kousei General Hospital.

INTRODUCTION
Laparoscopic techniques in anti-reflux surgery for GERD patients are still considered complicated by many surgeons. We have simplified it and established a simple and practical procedure.

SURGICAL PROCEDURE
Setting
Our 5-trocar setting with patients in the reverse Trendelenburg’s position for laparoscopic Nissen fundoplication is as follows. A 5 mm trocar was inserted just below the navel for a laparoscope (A). A 5 mm trocar was inserted in the upper right abdomen for a snake-retractor to pull up lateral segment of the liver, and a holder was used for a snake-retractor. A 5 mm trocar was inserted in the upper right abdomen for operator’s right hand. A 5 mm trocar was inserted in the upper left abdomen (B). A 5 mm trocar was inserted in the middle left abdomen (C). The operator is positioned between the patient’s legs.
Step 1
Under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. The right crus has been dissected free, and the esophagus is being recognized. The soft tissue at the posterior side of the abdominal esophagus was carefully dissected. Then the left crus of the diaphragma was recognized from the right side. In this part of the procedure, laparoscope uses 12 mm trocar (A), the assistant uses 12 mm trocar (B) to pull the stomach to left lower side and the operator’s right hand uses 12 mm trocar (C).
Step 2
The branches of left gastroepiploic vessels and the short gastric vessels were divided with LCS. The left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. In this part of the procedure, laparoscope uses 5 mm trocar (A) at the beginning of dividing left gastroepiploic vessels, 5 mm trocar (C) when dividing short gastric vessels and 5 mm trocar (B) at the last part of opening the window at the posterior side of the abdominal esophagus. The assistant uses 5 mm trocar (B-C-A) to pull the stomach.
Step 3
The right and left crura are sutured with interrupted stitches to reduce the hiatus. From the right side, the stomach is grasped from behind the esophagus. Then the fornix of the stomach is pulled to obtain a 360 degree "stomach-wrap" around the esophagus (fundoplication). Such as taping technique is not needed. Using nonabsorbable braided suture, stitches are placed between both gastric flaps.

THE CHARACTERISTIC FEATURES OF OUR PROCEDURE
1. Floppy Nissen fundoplication
2. No use of bougie device or taping technique for esophagus
3. Rotation of scope site

RESULTS
We have performed this procedure in over 60 cases. This procedure needs 2 surgeons (the operator and the assistant (scopist)). The mean operation time was about 60 min. A favorable outcome was assessed by radiograms performed during hospital stay. Resolution of the symptoms was noted at follow-up 1 month postoperatively in mostly all cases.

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