1. Laparoscopic Nissen Fundoplication
Jessica J. Siu
M1, University of Kentucky College of Medicine
Minimally Invasive Surgery Elective
20 April 2011

2. 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

3. 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.

4. 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

5. 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.

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 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

7. Open Procedure versus Laparoscopic
Incision of roughly 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

8. Equipment Liver Retractor Grasping Forceps Suction Harmonic Scalpel
Flexible Dissector
Penrose Drain
French Bougie
Needle Holder
Scissors

9. 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

10. 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

11. Procedure Steps Crural Dissection
Circumferential Dissection of the Esophagus
Fundic Mobilization
Preparation of Crural Closure
Crural Closure
Fundoplication around the Lower Esophagus

12. Procedural Steps

13. 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

14. 2. Esophagus Dissection
Dissection of the posterior esophagus helps open the retroesophageal window
Identify the posterior vagus nerve and protect it

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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

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: