Plate 43

Symptomatic gastroesophageal reflux disease is the most common indication for laparoscopic fundoplication using the floppy 360-degree Nissen technique. The clinical presentation and diagnostic workup are described in detail with Plate 41, Fundoplication. Repeated episodes of aspiration pneumonia or asthma triggered by reflux are significant indications. Intolerance to medical management with proton pump inhibitors, noncompliance with recommended medication regimens, and the cost of lifelong medications may also be additional indications for this procedure.

A full general medical evaluation is performed and the usual preanesthesia testing is obtained. Esophageal function studies such as manometry or video esophagography are necessary in order to plan for a 360-degree wrap or a partial fundoplication and to detect underlying dysmotility not related to reflux. Special emphasis is placed upon the pulmonary workup. Pulmonary function studies are needed in high-risk patients, especially if recurrent episodes of aspiration pneumonia or asthma have occurred. Antacids, acid blockers, and proton pump inhibitors are continued. Perioperative antibiotic coverage is optional.

General anesthesia with endotracheal intubation is used. An orogastric (OG) tube is placed for gastric decompression.

The patient is placed in the supine position with the arms out on arm boards for anesthesia access or with the arms containing the blood pressure cuff, pulse oximeter, and intravenous access tucked in at the sides. Many surgeons prefer the semilithotomy position using Allen stirrups to support the feet and legs (Figure 1). The legs are spread sufficiently for the surgeon to be positioned, but the thighs are only partially elevated. Elastic stockings or pneumatic sequential compression stockings are put on the lower legs. The patient is placed in a reverse Trendelenburg position, with about 30 degrees of elevation to the head of the table.

The area from the nipples to the pubic symphysis is shaved. Routine skin preparation is performed.

A combination of 5- and 10-mm ports are placed as shown if the patient is in the semilithotomy position (Figure 1). The size of each port is determined by the instruments used. In general, 10-mm ports are used for the Hasson with its videoscope and the endoscopic suturing instrument. The size of the grasping Babcock clamp and the ultrasonic dissector determines whether a 5- or 10-mm port is placed for these instruments. Larger ports may also be indicated if a 5-mm videoscope is not available.

The supraumbilical 10-mm port is placed first, using the open Hasson technique described in Plate 91. After the abdomen is entered and the port secured with the lateral stay sutures, the intraperitoneal space is inflated with carbon dioxide to 15 mm Hg. The surgeon observes the intra-abdominal pressure and total volume of gas infused as the abdomen distends and becomes tympanitic. The videoscope is white-balanced and focused. After the optical end is coated with antifog solution, the scope is advanced into the abdomen under direct vision. All four quadrants of the abdomen are explored visually. Placement of each of the other selected port sites begins with skin infiltration using a local anesthetic. The local needle can then be passed perpendicularly through the abdominal wall and its entry site verified. A 10-mm port is placed in the left midsubcostal position. Five-mm ports are placed in the right lateral subcostal, in the epigastrium just to the right of the midline falciform ligament, and in the far left subcostal positions.

A flexible fan or loop-shaped liver retractor is introduced through the right lateral subcostal port. The left lobe of the liver is retracted superiorly and laterally (Figure 2) and the external portion of this liver retractor is secured to its bracket on the side rail of the operating table. In general, the surgeon uses the epigastric and left midsubcostal ports for the two instruments. The assistant guides the videoscope through the umbilical site while providing additional traction and exposure with an instrument passed through the left lateral subcostal port. The dissection begins with the surgeon grasping the greater curvature of the stomach with an atraumatic clamp that retracts the stomach anteriorly and to the patient's right. The assistant grasps the lateral gastrosplenic ligament and retracts this ligament and spleen to the patient's left. The area of the gastrosplenic ligament is clearly visualized. A suitable zone is chosen and opened with blunt dissection. The ultrasonic dissector begins sequential division of the short gastrics about 1 cm out from the stomach so as to minimize thermal injury (Figure 3). The tissue grasped by the ultrasonic dissector must be clearly visualized, especially in its tip, so as not to partially transect the next short gastric vessel. A partially cut vessel results in bleeding that is difficult to isolate and control without conversion to an open abdominal operation. A better visualization of the lesser sac space and the path of the gastrosplenic ligament can be obtained if the stomach is sequentially grasped along its posterior wall beneath the cut short gastrics (Figure 4). This ultrasonic dissection continues to divide the short gastrics superiorly until the spleen is free and the left crus of the diaphragm is visualized. With further Babcock retraction near the top of the greater curvature, a few posterior peritoneal adhesions to the back of the stomach may need division. Care must be taken in this region to avoid the left gastric artery.

The peritoneum over the left crus muscle is carefully dissected and divided until the crus muscle bundle is clearly seen (Figure 5). This visualization may be improved by gentle anterior elevation of the esophagus with the assistant's instrument. The dissection next mobilizes the lesser curve of the stomach using the ultrasonic dissector in the gastrohepatic ligament (Figure 6).

Next >