Laparoscopic Nissen Fundoplication
The critical steps of this operation are (1) placing the ports, (2) dividing the short gastric arteries, (3) hiatal dissection, (4) mobilization of the fat pad and assessment of esophageal length, (4) hiatal closure, and (5) fashioning and securing the wrap. The procedure is performed under general anesthesia. EGD should be performed by the surgeon at the time of the operation to confirm the anatomic findings, in particular, esophageal length. The bladder is decompressed, antibiotics are given, and prophylactic measures to prevent pulmonary embolus are instituted. The procedure can be performed in the supine or lithotomy position, with both arms tucked in at the sides.
OR Setup and Trocar Placement
Our preference is to perform the operation with the patient in the lithotomy position. The surgeon stands between the patient's legs, and the first assistant is positioned to the left of the surgeon (Fig. 31-1).
With the patient in the lithotomy position, the surgeon stands between the patient's legs, and the first assistant is positioned to the left of the surgeon.
Typically, we create an 11-mm incision in the periumbilical region for the camera port using a modified Hassan technique to minimize inadvertent injury to the abdominal viscera. We then create a pneumoperitoneum by insufflating the abdomen with carbon dioxide to maximal pressure of 15–19 mm Hg. At our institution, we use a CO2 insufflator (Lexion Medical, Inc., St. Paul, MN), which humidifies and heats the peritoneum, improves visualization, and decreases hypothermia during surgery. Thereafter, we insert a fully adjustable 10-mm laparoscope with a deflectable tip to permit multiple planes of visualization; others use a 30-degree laparoscope. The table is positioned in a steep reverse Trendelenburg position for the duration of the procedure. Laparoscopy is performed to assess for the presence of adhesions. The remaining ports are placed sequentially under direct visualization in areas devoid of adhesions and are used, if needed, to perform further adhesiolysis until all five standard ports have been placed (see Fig. 31-1). All ports should be placed such that the instruments point naturally in the direction of the dissection (i.e., toward the gastroesophageal junction (GEJ)).
Dividing the Short Gastric Arteries to Mobilize the Fundus and Prevent Splenic Injury
The assistant raises the left lobe of the liver using a self-retaining liver retractor. A grasper is placed high on the greater curvature, retracting the greater curve caudally, anteriorly, and medially, whereas a second grasper elevates the gastrosplenic ligament laterally (Fig. 31-2). An avascular plane is identified along the greater curvature at the midlevel of the short gastric arteries. Using a 5-mm LigaSure™ (Valleylab, Boulder, CO) device, the gastrosplenic ligament is gradually divided all the way to the left crus. The two leaves should be divided separately. All lateral attachments to the upper portion of the greater curve of the stomach are completely divided to mobilize the stomach. It is important to completely mobilize the fundus to later enable a tension-free wrap of the esophagus.
The first grasper is placed high on the greater curvature, retracting the greater curve caudally, anteriorly, and medially, and a second grasper elevates the gastrosplenic ligament laterally.
After reaching the left crus, the left gastrophrenic ligament is opened, exposing the left crus down to its confluence with the right crus. Care must be taken to avoid injury to the anterior vagus, which courses between 3 and 12 o'clock. If a hiatal hernia is identified, as is extremely common in patients with GERD, its contents are reduced into the abdomen, and the peritoneal sac is amputated. Most often the hernia is of the sliding type (see Chap. 29), and the sac is very small. If the hernia is larger than 4 cm, special attention should be given to ensuring adequate esophageal length.
With the stomach retracted laterally, the lesser curvature is opened in an avascular region near the liver, exposing the caudate lobe, until the right crus of the hiatus is seen. Care is required to avoid the left gastric artery, a possible replaced hepatic artery, and vagal branches. Occasionally, a small branch from the left gastric artery to the left hepatic artery is divided without consequence to improve the exposure. The right crus is identified, and the overlying peritoneum is opened, exposing its edge. Because of the risk of perforation, we do not attempt to directly identify the esophagus before opening the crus. The right crus is dissected from its confluence to the median arcuate ligament, where it joins the left crus (Fig. 31-3). This dissection is done meticulously taking only a thin layer of peritoneum, and the esophagus is revealed by its orientation, longitudinal muscle fibers, and position of the posterior vagus nerve, which courses between 9 and 6 o'clock. Using blunt dissection with traction and countertraction, the peritoneum and phrenoesophageal ligament are divided, proceeding in a plane perpendicular to the esophagus. We divide the esophagophrenic attachments and peritoneum in a semicircular fashion down to the median arcuate ligament, with all due caution to avoid injury to the anteroposterior branches of the vagus. Great care is taken to avoid perforating the esophagus or stomach when mobilizing the GEJ. The esophagus is retracted upward, and a window is bluntly opened and widened to reveal the left side of the abdomen.
The right crus is dissected from its confluence to the median arcuate ligament, where it joins the left crus.
Mobilization of the Fat Pad and Assessment of Esophageal Length
The fat pad is medialized proceeding from the patient's left side to center, thereby exposing the true GEJ. The GEJ is identified by recognizing the confluence of the longitudinal muscles of the esophagus merging with the sling muscles of the stomach. The GEJ is not perpendicular. In approximately 85% of patients, there is adequate length of the abdominal esophagus (≥2 cm), and a lengthening procedure is not required. If a foreshortened esophagus is encountered (i.e., if the esophagus retracts into the mediastinum and there is less than 1 cm of abdominal esophagus), we perform a Collis extension (see Chap. 34) before the hiatus is closed.
The esophagus is retracted using an endoscopic Kittner retractor (Ethicon Endo-Surgery, Cincinnati, OH). The hiatal confluence then is visualized and closed by sewing the left crus to the right crus beginning at the confluence. Using the Endostitch device (Auto Suture, Norwalk, CT) inserted through the epigastric port, the crura are sewn to each other (1 cm of crus) moving from the patient's left side to the right side using Tevdek 0 suture. A Ti-rite knot (Ti-rite Knot Device, Wilson-Cook Medical, Winston-Salem, NC) then is placed to secure the suture. We prefer tying the sutures extracorporeally using a Ti-rite knot because it provides a more consistent and secure set of knots than manual intracorporeal tying. Additional stitches are placed in the same way at half- to three-quarter-centimeter intervals. The hiatus is usually repaired with three to five such sutures. As the opening narrows, the prospective last suture is placed but not tied. The retraction is relaxed, the nasogastric tube is removed, and a 58 bougie (range 52–60, with size depending on patient factors) is slowly and carefully introduced into the esophagus to a depth of 50 cm (10 cm below the GEJ). The bougie helps the surgeon to properly gauge the hiatal closure (Fig. 31-4). The esophagus then is retracted in an upward direction, tension is placed on the suture, and a visual assessment is made to determine if the prospective suture should be tied or removed. When the caliber of the hiatus with the bougie in the esophagus is deemed snug but not constricted, the bougie is retracted to 25 cm. If the hiatus is still lax, the bougie is withdrawn, and an extra suture is placed.
The bougie is introduced into the esophagus to a depth of 50 cm (10 cm beyond the GEJ).
The GEJ is elevated, and a reticulating grasper is brought under the esophagus to pull the apical tip of the greater curvature to the right of the right side. The inverted stomach is grabbed with an endoscopic grasper. The surgeon aids by pushing the gastric fundus behind the esophagus, enabling the surgeon to assess the configuration of the wrap. After bringing the gastric fundus behind the esophagus, we choose the most apical point along the line of the greater curvature (the line of the short gastric vessels). Choosing the correct region of the stomach to wrap is essential for the success of the fundoplication.
Babcock clamps are applied to both sides of the stomach that now encircles the esophagus, and the 58 bougie is carefully readvanced into the stomach. Using the Babcock clamps, the stomach is “shoeshined” at both ends around the distal esophagus to ensure correct alignment, correct tension, lack of excess redundancy, and correct placement of the wrap (Fig. 31-5). The fat pad is now pulled caudad from the greater curvature in the area of the GEJ to enable better adhesion of the stomach to the esophagus.
The wrap is “shoeshined” at both ends around the distal esophagus to ensure proper placement.
Securing the Nissen Fundoplication
Using the Endostitch device, sutures are passed from the left side of the wrap to the esophagus and then to the right side of the wrap, taking 1 cm of stomach on each side, and the sutures are tied with a Ti-rite knot (Fig. 31-6). Additional stitches are placed in the same way at 5-mm intervals. The length of the fundoplication is 2–2.5 cm and typically consists of four nonabsorbable Tevdek 2-0 stitches. The first three stitches are taken through all three layers: stomach-esophagus-stomach. The last stitch is made from stomach to stomach. It is important to take small bites of serosa and muscularis without mucosa because the latter can lead to necrosis and leak if tied too tightly. After removing the bougie, an 18F nasogastric tube is placed by the anesthesiologist, and its entrance into the stomach and positioning are confirmed visually. The repair then is examined visually to ensure that the wrap is configured correctly. Hemostasis is ensured, and the fasciae underneath the large ports are closed, as is the skin.
A Ti-rite knot then is placed to secure the suture.
Open Nissen Fundoplication
At one time, the open Nissen fundoplication, developed by Rudolph Nissen in the 1950s,2 was the “gold standard” of antireflux surgery. It was simple, easy to learn, yielded excellent outcome with an overall 10-year success rate of better than 90%, and was technically less challenging than other operations for reflux. However, after Dallemagne and colleagues adapted the technique laparoscopically in 1991,3 high patient demand for the minimally invasive procedure quickly followed. As a consequence, the open approach is now indicated only in the diminishing circumstances where a laparoscopic approach is not possible. In experienced hands, these circumstances are rare. Frankly, the laparoscopic approach is easier to perform and safer because of its better visualization and access. In our practice, we try to accomplish the wrap first laparoscopically, even when we plan to open the abdomen subsequently for another reason. We recommend that the equipment required for conversion be readily available and a system set up for rapid conversion. It is important for the staff to periodically discuss and simulate the conversion sequence.
The open procedure is performed with the patient in the supine position with the right arm extended or tucked and the left arm tucked in at the side. The bed is placed in a shallow reverse Trendelenburg position. A nasogastric tube is inserted for drainage and decompression of the stomach.
The abdomen is explored through an upper midline incision (Fig. 31-7). (If needed, the incision can be extended below the umbilicus.) Lysis of adhesions can be carried out in the left upper quadrant as needed. The falciform suspensory ligament is divided, and the triangular ligament (hepatophrenic ligament) is excised. An upper-hand retractor is placed to elevate the costochondral portion of the chest. A moist laparotomy pad is placed behind the spleen, and a liver retractor is positioned to retract the left lobe, exposing the esophageal hiatus.
Midline incision for open technique.
Mobilization of the Distal Esophagus and Proximal Stomach
As with the laparoscopic approach, three or four short gastric arteries are ligated either with clamps or with the LigaSure device (Valleylab, Boulder, CO) to avoid splenic injury. The phrenoesophageal ligament is opened using Metzenbaum scissors to make a semicircular incision. The anterior vagus is identified on the left and the posterior vagus is identified on the right side of the esophagus (Fig. 31-8). The gastrohepatic ligament is opened close to the liver, with vigilance to avoid injury to the left gastric artery, a replaced hepatic artery, or branches of the vagus. A finger is placed behind the esophagus, and then a Penrose drain is passed behind the esophagus to enable caudal retraction.
The anterior vagus is identified on the left and the posterior vagus is identified on the right side of the esophagus.
The right crus is identified and dissected from its confluence to the median arcuate ligament, where it joins the left crus. As with the laparoscopic approach, attention is given to ensuring adequate esophageal length, and hiatal hernia, if present, is reduced into the abdomen and the peritoneal sac amputated. Consideration also should be given to reconstruction and repair of the hiatus with mesh if warranted. The assistant pulls the Penrose drain in a caudal direction as the surgeon pushes the gastric fundus behind the esophagus, enabling assessment of the region where the wrap will lie.
The hiatus is repaired using Tevdek 0 sutures. The left crus is sewn to the right, taking 1.5 cm of the crus on each side. After placing the first two sutures, a bougie (58–60 depending on patient size) is introduced into the esophagus, and the hiatus is closed with a few additional sutures to correctly gauge the closure. Note that insertion of the bougie is a critical step. If performed incorrectly, this maneuver can lead to esophageal or gastric perforation. It must be done under direct vision in a controlled manner to minimize potential complications.
After the gastric fundus has been brought behind the esophagus, the apical-most point along the line of the greater curvature (the line of the short gastric vessels) is identified. The apex of the stomach is brought behind the esophagus. Babcock clamps are applied to both sides of the stomach, and the bougie is reintroduced. Using the Babcock clamps, the stomach is “shoeshined” at both ends around the distal esophagus to ensure correct alignment, contour, tension, and placement of the wrap. One should see a straight line between both upper edges of the wrap. The fat pad is removed well away from the greater curvature in the area of the GEJ to prevent vagal injury in a medial-to-lateral direction to enable better adhesion of the stomach to the esophagus. We routinely wrap the stomach around a bougie to ensure that the wrap is not too tight. The length of our fundoplication is 2–2.5 cm and typically consists of three or four nonabsorbable Tevdek 2-0 stitches (Fig. 31-9). The first three stitches to close the wrap traverse all three layers: stomach-esophagus-stomach. Full-thickness bites of esophagus that incorporate the underlying mucosal layer are avoided. Avoiding the mucosal layer when stitching is important because the latter, if tied too tightly, can necrose and leak. The last stitch is made from stomach to stomach. To gauge the tightness of the wrap after the bougie is removed, we place an 18F nasogastric tube through the reinforced esophagus. If the fit is proper, the surgeon should be able to pass the fifth digit under the wrap (Fig. 31-10). Proper esophageal length prevents the wrap from slipping into the chest. Proper patient selection (adequate esophageal length), good technique, and correct placement of stomach and esophageal sutures will prevent the wrap from slipping in the caudal direction. If caudal slippage occurs, the stomach will constrict and assume an “hourglass” appearance, producing a partial obstruction (Fig. 31-11). This can be avoided by adhering to the aforementioned principles.
A 2- to 2.5-cm fundoplication is created.
A finger is slipped under the wrap to test it.
Caudal slippage produces an “hourglass” appearance to the stomach and partial obstruction.
After assuring hemostasis, the retractors are removed, and pads and instruments are counted. The abdominal fascia is closed with two 1-0 PDS loop sutures, with attention to the corners of the incision and 1 × 1 cm bites of fascia. The subcutaneous layer is not closed. The skin is closed with a stapler or a running 3-0 Vicryl intracuticular stitch. The patient is aroused, extubated, and taken to the postoperative recovery room.
With adequate knowledge of the operative pitfalls, many technical errors can be avoided. These are summarized in Table 31-3.
Table 31-3. Operative Pitfalls |Favorite Table|Download (.pdf)
Table 31-3. Operative Pitfalls
- Splenic laceration usually involving traction injuries (uncommon with laparoscopic approach).
- Injury to the vagus nerve or to vagal branches near the stomach in the gastrohepatic ligament.
- Vascular injury to the left gastric artery or injury to a replaced hepatic artery.
- Unidentified perforation of the stomach or the esophagus during retraction or dissection.
- Improper hiatal closure owing to incomplete hiatal dissection. Loose hiatal closure may lead to postoperative hiatal hernia, whereas tight hiatal closure may lead to esophageal obstruction and consequently achalasia.
- Inadequate mobilization of gastric fundus and distal esophagus leading to suboptimal position of the fundoplication and, as a result, inadequate function.
- A fundoplication that is too long or too tight will result in dysphagia, gas bloating, and a functional obstruction.
- A fundoplication that is too short or too loose will not alleviate GERD.