Laparoscopic Nissen

FundoplicationJessica J. Siu

M1, University of Kentucky College of MedicineMinimally Invasive Surgery Elective

20 April 2011

Objectives

• Indications for Nissen Fundoplication

• Laparoscopic vs. Open Procedure

• Operating Room Set-up• Equipment• Patient Position• Trocar Placement

• Procedural Steps

• Possible Complications

• Post-Operative Care

Case Study

• 25 year old Active Duty military male presents with consistent heart burn for 2+ years, with increasing frequency for the past 6 months.

• He complains of unintentional vomiting following meals and exercise.

• Diet and social history: 2 cups coffee per day, several beers during the weekend, prepared meals in the dining facility. Patient with a 10 pack year history.

• Current weight is within normal healthy limits.

• Patient scheduled to deploy in 6 months.

Case Study

• Patient diagnosed with Gastroesophageal Reflux Disease (GERD)

• GERD affects more than 10% of the adult population

• Symptoms of GERD• Heartburn from reflux of gastric acid• Regurgitation of gastric contents up into the

mouth• Severe epigastric pain with sudden onset

Case Study

• Conservation Treatment:• Lifestyle modification• Weight loss, effective only if patient is overweight• Reduced high fat food intake• Elevation of upper body for 30 minutes following meals • Cessation of smoking

• Medications• Antacids for improving heartburn symptoms• Proton pump inhibitors (PPI)

• Conservative treatment may improve symptoms but may not treat underlying cause of GERD.

Indications

• GERD has a complex pathophysiology:• Caused by an incompetent anti-reflux barrier, due to a

displacement of the lower esophageal sphincter into the chest, disruption of hiatal crura, or impairment of esophageal peristalsis

• PPI’s fail to control GERD long term, especially in the presence of large hiatal hernias, poor esophageal peristalsis, regurgitation of large volumes, or dysphagia

• Nissen Fundoplication Surgical therapy: • Addresses the functional nature of GERD• Restores anti-reflux barrier, strengthens esophageal peristalsis, speeds

gastric emptying, and improves gastric clearance

• Curative in 85-93% of patients • Research of post-operative Nissen Fundoplication patients have

supported good long term results, with low morbidity and mortality

Open Procedure versus Laparoscopic

• Open Procedure:• Incision of roughly 20-25 cm

in the abdomen• Hospital stay: Several days• Recovery time: 4-6 weeks• Indicated in patients who

have had multiple abdominal surgery

• Laparoscopic:• Minimally invasive technique

producing five 0.5-1cm incisions

• Hospital stay: 1-2 days• Recovery time: 2-3 weeks

Equipment

Liver Retractor Suction Harmonic ScalpelGrasping Forceps

Flexible Dissector Penrose Drain French Bougie

Needle Holder

Scissors

Operating Room Set-Up and Patient Position

• Patient’s position: • Supine with legs apart• 30° Reverse

Trendelenburg

• General anesthesia

• Endotracheal intubation

• Surgeon in between patient’s legs• Assistant to surgeon’s

left• Scrub nurse to

surgeon’s right

Trocar Placement• Midline—2/3 from xiphoid to

umbilicus, 10mm• Laparascope

• Immediately below Xiphoid Process, 5mm• Grasping forceps

• Anterior Axillary Line just below Costal Margin• Right, 10mm• Liver retractor around middle of

left lobe to retract ventrally

• Exposes anterior surface of the proximal stomach near the gastroesophageal junction

• Left, 5mm• Grasping forceps, suction, scissors

• Midclavicular Line, Left Upper Quandrant, 5mm• Dissecting and Suturing Devices

Procedure Steps

1. Crural Dissection

2. Circumferential Dissection of the Esophagus

3. Fundic Mobilization

4. Preparation of Crural Closure

5. Crural Closure

6. Fundoplication around the Lower Esophagus

Procedural Steps

1. Crural Dissection• Expose right crus of diaphragm by opening

the hepatogastric ligament (lesser omentum) over caudate lobe of liver• Avoid the hepatic branch of the vagus

nerve• Avoid left hepatic artery

• Incision of phrenoesophageal membrane on medial side of right crus of diaphragm • Use heat at first, then blunt dissection parallel

to crus • Blunt dissection helps avoid damage to the

anterior vagus nerve located tight against the anterior wall of the esophagus

• Rostral Border: At observation of the mediastinal pleura, appears as a glistening yellow fat pad

• Caudal Border: Posterior part of the crus

• The dissection is continued transversally towards the anterior surface of the left crus and caudally towards the crural arch

2. Esophagus Dissection

• Dissection of the posterior esophagus helps open the retroesophageal window

• Identify the posterior vagus nerve and protect it

3. Fundic Mobilization“Routine division of the shorts” to decrease dysphagia• Enter lesser sac one third of the way down

the greater curve of the stomach • Divide gastrosplenic ligament

• Isolate and divide short gastric vessels working towards the gastroesophageal junction• Harmonic scalpel can take vessels up to 5mm

in size• Do not partially divide vessels

• Stay close to stomach, being careful of spleen

• Within lesser omental sac, • Grab posterior of stomach to continue dividing

short gastric vessels

• Divide gastrophrenic ligament

• Gastric fundus completely immobilized

4. Preparation of Crural Closure

• Place flexible dissector into retroesophageal window, flip stomach to grab penrose drain• Penrose drain used to encircle and retract the

distal esophagus

• Ensure adequate intraesophageal mobilization (2-3 cm)• Grasping forceps in the opened position is

roughly 2 cm • In the process of opening peritoneum, the

diaphragm moves up

• Insert french bougie in patient’s mouth and guide into stomach• 52” for women, 54” for men• Greatest area for perforation is

gastroesophageal junction and at the curvature of stomach

• French bougie helps to determine tightness of hernia repair and fundoplication so patient does not get dysphagia post-surgery

5. Crural Closure

• Reconstruct esophageal hiatus by suturing the right and left crura behind the esophagus• Remove french bougie during

suturing• Stitch in left crus, dip into right

crus• Repeat twice

• No biological mesh required for Nissen Fundoplication crural closure, although it is used for more severe hiatal hernias

• Readvance french bougie to check tightness of reconstruction

6. Fundoplication• Bring the mobilized gastric fundus

through the retroesophageal window and around distal esophagus anteriorly• Find the cardiac angle where esophagus

meets stomach • Pull short gastric side of stomach out to

the right to find the true fundus

• 4-5cm distal from gastroesophageal junction

• Using grasping forceps, grab the posterior of the stomach • If the wrong area is wrapped, it may

cause poor reflux control (by twisting stomach) and/or a two compartment stomach, causing dysphagia

• Can test correct area with “shoe-shine” maneuver

6. Fundoplication

• Three sutures are placed with bites taking full thickness gastric fundus and partial thickness anterior esophageal wall • 1 cm bite of stomach, I muscular bite

around “10-o-clock position” of esophagus, 1 cm bite on other side of stomach

• Take Penrose Drain out after the 1st stitch

• Bottom stitch with no esophagus, just stomach bites

• When completed, wrap should be no greater than 2cm in length

• Advance French Bougie and check the tightness of the wrap • Be able to fit forceps in between the

wrap while the French Bougie is still in

Possible Complications

• Main Complications:• Bleeding• Perforation of esophagus• Perforation of stomach• Splenic injury.

• Approximately 5% of patients require conversion to open surgery because of bleeding, perforation or other complications. • About 95% of all cases can be performed

laparoscopically, while 5% of laparoscopic cases can result in a conversion to the open procedure.

Post-Operative Care

• Most patients are able to return home the first or second day after laparoscopic surgery

• Return to full activity usually takes 1 to 2 weeks

• Acid reducing medication is recommended for 2 weeks following surgery

• Follow up appointment should be made with the surgeon 7 to 10 days after discharge • Questions can be answered• Progress can be assessed• Patient can be examined

Post-Operative Care

• Operation creates a sphincter mechanism at the bottom of the esophagus to prevent reflux• May cause resistance to the passage of food, causing more air to be

swallowed

• Patients often experience periods of gas-bloat syndrome • Episodes can last up to 2 to 3 hours• Increase in swallowed air makes it difficult to belch or vomit• Patients often experience abdominal distention, nausea and an

increase in flatulence

• About 6 weeks after the laparoscopic repair, patients may experience dysphagia (difficulty swallowing) due a post-surgical swelling at the wrapped site• Although dysphagia is almost always temporary, 2% of patients

experience long term symptoms

Post-Operative Care

• Clear diet for three days following surgery, advance as tolerated

• Soft Diet after Nissen Fundoplication Surgery helps control diarrhea, excess gas, and dysphagia• Eat small frequent meals (4-6 meals per day), taking small bites and chewing

well before swallowing• Avoid foods that may cause stomach gas and distention: corn, dried beans,

peas, lentils, onions, broccoli, cauliflower and any food from the cabbage family

• Sweet foods should be eaten last to avoid quick digestion• Foods that are soft and moist are easier to digest. Avoid coarse grains, dried

fruits, nuts and seeds.

• Drink fluids between meals, and avoid drinking through a straw• Milk products should be slowly added to diet as tolerated• Avoid caffeine, carbonated drinks and alcohol

• Do not chew gum or tobacco, since it may increase the amount of air swallowed

References

• Dr. Roth’s Nissen Fundoplication Procedure (2010)

• Skandalakis JE, Skandalakis PN, Skandalakis LJ. Minimally Invasive Surgical Procedures and Anatomy. Year: Pages.

• Dallemagne B. Laparoscopic short floppy Nissen fundoplication for gastroesophageal reflux disease. Epublication: WeBSurg.com, Nov 2006;6(11). URL: http://www.websurg.com/ref/doi-ot02en331.htm

• Wykypiel H, Wetscher GJ, Klinger P, Glaser K (2004). The Nissen Fundoplication: Indication, Technical Aspects and Postoperative Outcome. Langenbecks Arch Surg 390:495-502