Laparoscopic
Nissen Fundoplication
Jessica J. Siu
M1, University of Kentucky College of Medicine
Minimally Invasive Surgery Elective
20 April 2011
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
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.
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
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.
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
Open Procedure versus
Laparoscopic
•
Open Procedure:
• Incision of roughly 20-25 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
Equipment
Liver Retractor
Flexible Dissector
Grasping Forceps
Suction
Penrose Drain
Needle Holder
Harmonic Scalpel
French Bougie
Scissors
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
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
Procedure Steps
1.
Crural Dissection
2.
Circumferential Dissection
of the Esophagus
3.
Fundic Mobilization
4.
Preparation of Crural
Closure
5.
Crural Closure
6.
Fundoplication around the
Lower Esophagus
Procedural Steps
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
2. Esophagus Dissection
• Dissection of the posterior esophagus helps open the
retroesophageal window
• Identify the posterior vagus nerve and protect it
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
•
•
•
Stay close to stomach, being careful of spleen
Within lesser omental sac,
•
•
Do not partially divide vessels
•
Grab posterior of stomach to continue dividing short
gastric vessels
•
Divide gastrophrenic ligament
Gastric fundus completely immobilized
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
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
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
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
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.
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
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
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
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:
http://www.websurg.com/ref/doi-ot02en331.htm
• Wykypiel H, Wetscher GJ, Klinger P, Glaser K (2004). The
Nissen Fundoplication: Indication, Technical Aspects and
Postoperative Outcome. Langenbecks Arch Surg 390:495-502