Presentation on theme: "Laparoscopic Nissen Fundoplication"— Presentation transcript:
1 Laparoscopic Nissen Fundoplication Jessica J. SiuM1, University of Kentucky College of MedicineMinimally Invasive Surgery Elective20 April 2011
2 Objectives Indications for Nissen Fundoplication Laparoscopic vs. Open ProcedureOperating Room Set-upEquipmentPatient PositionTrocar PlacementProcedural StepsPossible ComplicationsPost-Operative Care
3 Case Study25 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.
4 Case StudyPatient diagnosed with Gastroesophageal Reflux Disease (GERD)GERD affects more than 10% of the adult populationSymptoms of GERDHeartburn from reflux of gastric acidRegurgitation of gastric contents up into the mouthSevere epigastric pain with sudden onset
5 Case Study Conservation Treatment: Lifestyle modificationWeight loss, effective only if patient is overweightReduced high fat food intakeElevation of upper body for 30 minutes following mealsCessation of smokingMedicationsAntacids for improving heartburn symptomsProton pump inhibitors (PPI)Conservative treatment may improve symptoms but may not treat underlying cause of GERD.
6 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 peristalsisPPI’s fail to control GERD long term, especially in the presence of large hiatal hernias, poor esophageal peristalsis, regurgitation of large volumes, or dysphagiaNissen Fundoplication Surgical therapy:Addresses the functional nature of GERDRestores anti-reflux barrier, strengthens esophageal peristalsis, speeds gastric emptying, and improves gastric clearanceCurative in 85-93% of patientsResearch of post-operative Nissen Fundoplication patients have supported good long term results, with low morbidity and mortality
7 Open Procedure versus Laparoscopic Incision of roughly cm in the abdomenHospital stay: Several daysRecovery time: 4-6 weeksIndicated in patients who have had multiple abdominal surgeryLaparoscopic:Minimally invasive technique producing five 0.5-1cm incisionsHospital stay: 1-2 daysRecovery time: 2-3 weeks
9 Operating Room Set-Up and Patient Position Patient’s position:Supine with legs apart30° Reverse TrendelenburgGeneral anesthesiaEndotracheal intubationSurgeon in between patient’s legsAssistant to surgeon’s leftScrub nurse to surgeon’s right
10 Trocar Placement Midline—2/3 from xiphoid to umbilicus, 10mm LaparascopeImmediately below Xiphoid Process, 5mmGrasping forcepsAnterior Axillary Line just below Costal MarginRight, 10mmLiver retractor around middle of left lobe to retract ventrallyExposes anterior surface of the proximal stomach near the gastroesophageal junctionLeft, 5mmGrasping forceps, suction, scissorsMidclavicular Line, Left Upper Quandrant, 5mmDissecting and Suturing Devices
11 Procedure Steps Crural Dissection Circumferential Dissection of the EsophagusFundic MobilizationPreparation of Crural ClosureCrural ClosureFundoplication around the Lower Esophagus
13 1. Crural DissectionExpose right crus of diaphragm by opening the hepatogastric ligament (lesser omentum) over caudate lobe of liverAvoid the hepatic branch of the vagus nerveAvoid left hepatic arteryIncision of phrenoesophageal membrane on medial side of right crus of diaphragmUse heat at first, then blunt dissection parallel to crusBlunt dissection helps avoid damage to the anterior vagus nerve located tight against the anterior wall of the esophagusRostral Border: At observation of the mediastinal pleura, appears as a glistening yellow fat padCaudal Border: Posterior part of the crusThe dissection is continued transversally towards the anterior surface of the left crus and caudally towards the crural arch
14 2. Esophagus DissectionDissection of the posterior esophagus helps open the retroesophageal windowIdentify the posterior vagus nerve and protect it
15 3. Fundic Mobilization“Routine division of the shorts” to decrease dysphagiaEnter lesser sac one third of the way down the greater curve of the stomachDivide gastrosplenic ligamentIsolate and divide short gastric vessels working towards the gastroesophageal junctionHarmonic scalpel can take vessels up to 5mm in sizeDo not partially divide vesselsStay close to stomach, being careful of spleenWithin lesser omental sac,Grab posterior of stomach to continue dividing short gastric vesselsDivide gastrophrenic ligamentGastric fundus completely immobilized
16 4. Preparation of Crural Closure Place flexible dissector into retroesophageal window, flip stomach to grab penrose drainPenrose drain used to encircle and retract the distal esophagusEnsure adequate intraesophageal mobilization (2-3 cm)Grasping forceps in the opened position is roughly 2 cmIn the process of opening peritoneum, the diaphragm moves upInsert french bougie in patient’s mouth and guide into stomach52” for women, 54” for menGreatest area for perforation is gastroesophageal junction and at the curvature of stomachFrench bougie helps to determine tightness of hernia repair and fundoplication so patient does not get dysphagia post-surgery
17 5. Crural ClosureReconstruct esophageal hiatus by suturing the right and left crura behind the esophagusRemove french bougie during suturingStitch in left crus, dip into right crusRepeat twiceNo biological mesh required for Nissen Fundoplication crural closure, although it is used for more severe hiatal herniasReadvance french bougie to check tightness of reconstruction
18 6. FundoplicationBring the mobilized gastric fundus through the retroesophageal window and around distal esophagus anteriorlyFind the cardiac angle where esophagus meets stomachPull short gastric side of stomach out to the right to find the true fundus4-5cm distal from gastroesophageal junctionUsing grasping forceps, grab the posterior of the stomachIf the wrong area is wrapped, it may cause poor reflux control (by twisting stomach) and/or a two compartment stomach, causing dysphagiaCan test correct area with “shoe-shine” maneuver
19 6. FundoplicationThree sutures are placed with bites taking full thickness gastric fundus and partial thickness anterior esophageal wall1 cm bite of stomach, I muscular bite around “10-o-clock position” of esophagus, 1 cm bite on other side of stomachTake Penrose Drain out after the 1st stitchBottom stitch with no esophagus, just stomach bitesWhen completed, wrap should be no greater than 2cm in lengthAdvance French Bougie and check the tightness of the wrapBe able to fit forceps in between the wrap while the French Bougie is still in
20 Possible Complications Main Complications:BleedingPerforation of esophagusPerforation of stomachSplenic 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.
21 Post-Operative CareMost patients are able to return home the first or second day after laparoscopic surgeryReturn to full activity usually takes 1 to 2 weeksAcid reducing medication is recommended for 2 weeks following surgeryFollow up appointment should be made with the surgeon 7 to 10 days after dischargeQuestions can be answeredProgress can be assessedPatient can be examined
22 Post-Operative CareOperation creates a sphincter mechanism at the bottom of the esophagus to prevent refluxMay cause resistance to the passage of food, causing more air to be swallowedPatients often experience periods of gas-bloat syndromeEpisodes can last up to 2 to 3 hoursIncrease in swallowed air makes it difficult to belch or vomitPatients often experience abdominal distention, nausea and an increase in flatulenceAbout 6 weeks after the laparoscopic repair, patients may experience dysphagia (difficulty swallowing) due a post-surgical swelling at the wrapped siteAlthough dysphagia is almost always temporary, 2% of patients experience long term symptoms
23 Post-Operative CareClear diet for three days following surgery, advance as toleratedSoft Diet after Nissen Fundoplication Surgery helps control diarrhea, excess gas, and dysphagiaEat small frequent meals (4-6 meals per day), taking small bites and chewing well before swallowingAvoid foods that may cause stomach gas and distention: corn, dried beans, peas, lentils, onions, broccoli, cauliflower and any food from the cabbage familySweet foods should be eaten last to avoid quick digestionFoods 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 strawMilk products should be slowly added to diet as toleratedAvoid caffeine, carbonated drinks and alcoholDo not chew gum or tobacco, since it may increase the amount of air swallowed
24 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:Wykypiel H, Wetscher GJ, Klinger P, Glaser K (2004). The Nissen Fundoplication: Indication, Technical Aspects and Postoperative Outcome. Langenbecks Arch Surg 390: