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MMCTS
(December 5, 2008). doi:10.1510/mmcts.2007.002931 Copyright © 2008 European Association for Cardio-thoracic Surgery
Procedure Laparoscopic Nissen fundoplicationDepartment of Thoracic Surgery, UZ Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium * Corresponding author: Tel.: +3216346822; fax: +3216346821. Philippe.Nafteux{at}uzleuven.be
The dissection is started performing a crural dissection with visualization and preservation of both vagus nerves, followed by circumferential dissection of the esophagus at the gastro-esophageal junction. Adequate intra-mediastinal mobilization of the esophagus is performed to obtain 3–4 cm of intra-abdominal esophagus without undue downward traction on the cardia or stomach. The gastric fundus is then mobilized through adequate short gastric vessel division. The left and right pillars of the right diaphragmatic crus are approximated using interrupted sutures. A short (<2 cm), floppy 360° fundoplication anchored to the esophagus is created.
Key Words: Antireflux procedure • Fundoplication • Gastro-esophageal reflux (GER) • Laparoscopic Nissen
The Nissen fundoplication is the gold standard for the operative treatment of gastro-esophageal reflux disease (GERD). This well-established procedure has proved itself to be both durable and safe after follow-up periods of 20 years and beyond. Since its introduction by Rudolf Nissen in 1956, this procedure has undergone many modifications. The laparoscopic Nissen fundoplication was first reported by Dallemagne et al. in 1991.
Position After induction of general anesthesia and introduction of a bladder catheter, the patient is placed in supine position, legs in split position with both arms alongside the body, secured to the operating table (Photo 1).
The surgeon stands between the patient's legs with the first assistant to the patient's left and the second assistant to the patient's right. Two monitors stand at the level of the patient's head, on the right and left side, respectively.
Ports placement
A 5-mm liver retractor is placed through the right hypochonder port so as to retract the liver anteriorly and medially to expose the hiatus. The lesser omentum left of the stomach is incised until visualization of the right crus is obtained. During the dissection of the pillars, great care is taken not to damage the hepatic branches of the vagus nerve (Video 1). The next part of the procedure consists in the dissection of the esophageal hiatus. The hiatus is formed by the division of the right crus in two anatomically distinct parts: the left part turning below the esophagus to form the left border of the esophageal hiatus (left pillar), the right part forming the right border of the hiatus (right pillar) (Video 2).
Dissecting both pillars will prepare these muscular structures for an appropriate narrowing of the esophageal hiatus and will open a window behind and lateral to the left of the esophagus (Video 3).
A Penrose drain is placed around the abdominal esophagus and secured with an endoloop (Video 4).
During the dissection of the inferior part of both pillars, great care is taken not to damage the posterior vagal nerve (Video 5).
The next step is to complete the dissection of the esophagus within the esophageal hiatus and to further extend the peri-esophageal dissection into the mediastinum in order to mobilize enough length of it thereby avoiding upward retraction of the gastro-esophageal junction and fundoplication (Videos 6 and 7).
A tension-free abdominal esophageal segment to be surrounded by the fundoplication is essential as it will limit the risks of subsequent intrathoracic migration of the fundoplication or migration of the gastro-esophageal junction through the hiatus. At least 3–4 cm tension-free abdominal esophagus must be present within the abdomen at the end of the dissection. If not, this might be an indication to perform a Collis-Nissen gastroplasty. During the upper dissection of the hiatus, great care is taken not to damage the anterior vagus nerve (Video 8).
Mobilization of the upper part of the fundus of the stomach is the next step; this is achieved by dividing the gastrophrenic adhesions and the medial short gastric vessels until the upper part of the fundus is completely liberated (Video 9).
The dissection and division of these vessels is greatly facilitated by using the harmonic scalpel. When dissection is finished, the reconstruction begins by approximating the two pillars in order to narrow the opening of the esophageal hiatus (Video 10).
The narrowing of the esophageal hiatus should be calibrated to a size that allows supple passage of a 10 mm scope alongside the esophagus. One can also introduce a bougie inside the esophagus (size 52–56) to assist in calibrating the narrowing of the hiatus. The fundus is then passed behind the esophagus (Video 11) to initiate the fundoplication.
One can introduce a bougie (56- to 60-French) into the esophagus to calibrate the fundoplication but most of the time performing a de visu floppy fundoplication will suffice to achieve a correct fundoplication. The fundoplication is performed by stitching both sides of the gastric fundus together in front of the esophagus (Video 12). Anchoring the fundoplication to the esophagus using an additional suture completes the intervention (Video 13).
The procedure is finished by removing the Penrose drain and controlling the fundoplication and hiatal narrowing (Video 14).
The ports are removed de visu and the pneumoperitoneum is removed. The fascia perforated by the 10-mm port is closed using interrupted sutures, the skin is then closed. Dressings are applied.
Anti-emetics are administered to avoid forceful vomiting the first hours postoperatively as this may cause early disruption of the sutures and intrathoracic migration of the fundoplication. A nasogastric tube is routinely kept in place for 24 h after the surgery. At day one a contrast study is performed to check for leaks and the correct location of the fundoplication and the easy passage of the contrast material through the fundoplication. If satisfactory, fluids and soft diet are allowed. The patient is usually discharged at day two after the surgery. Although outpatient laparoscopic Nissen fundoplication has been performed, patient satisfaction in such a setting is rather low since the management of nausea or pain during the first 24 h after the surgery may be difficult without parenteral access. All patients are again seen at the outpatient clinic one month after the procedure. Further follow-up is arranged on individual basis.
The overall short-term results in appropriately selected patients are excellent [3, 4]. Minor self-limiting symptoms may occur in the postoperative period. However, up to 50% of the patients will present transient dysphagia caused by postoperative edema secondary to surgical manipulation. This will improve typically within six weeks. Endoscopic dilation may be necessary in case of persistent dysphagia. Occasionally this may require redo surgery. Other common symptoms are bloating, early satiety, nausea and diarrhea. Those symptoms again tend to improve within weeks and respond usually to appropriate medication. Long-term results in correctly selected patients are excellent [5, 6]; more than 90% of patients report satisfaction with their laparoscopic Nissen fundoplication. A minority of patients report persistent dysphagia, bloating and/or recurrent reflux. The cause of failed reflux control is mostly due to (1) total disruption of the wrap, (2) a slipped Nissen fundoplication (with a part of the stomach above and below the fundoplication), (3) herniation of the wrap into the chest [7]. Surgical failure may require reoperation. When re-intervention is required a laparoscopic approach is technically feasible in the hands of experienced surgeons. The overall results of redo surgery however being somewhat inferior as compared to those obtained after primary surgery [8].
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