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Laparoscopic floppy Nissen fundoplication
LAPAROSCOPY
Laparoscopic Floppy Nissen Fundoplication William S. Richardson, MD, New Orleans, Louisiana, John G. Hunter, MD, Atlanta, Georgia
Good results for antireflux surgery are obtained when proper patients are selected, trained surgeons perform the operation, and proper techniques are used. As our prior results showed higher rates of dysphagia without fundus mobilization (Nissen-Rossetti fundoplication), we now perform complete mobilization on all patients. Full fundus mobilization requires take-down of the short gastric vessels to reveal the base of the left crus, take-down of all posterior gastropancreatic adhesions and the peritoneal fold that is cauded to the crus and superior to the pancreas. Proper division of these attachments will allow an untethered fundoplication and may reduce the risk of dysphagia and slip of the fundoplication onto the stomach. Am J Surg. 1999; 177:155–157. © 1999 by Excerpta Medica, Inc.
N
issen fundoplication was first described in 1936.1 Since then many surgeons have adopted modifications and perform the short “floppy” Nissen fundoplication as described by DeMeester et al2 and Donahue et al.3 Controversy exists on the routine mobilization of the fundus by dividing the short gastric vessels and the posterior gastric vessels, and mobilizing the gastric fundus off the left hemidiaphragm. Early in our laparoscopic experience we performed the Nissen-Rossetti fundoplication (no take-down of the short gastric arteries) in selected cases, and we found a higher rate of early and persistent dysphagia when the fundus was not mobilized.4 After this review of our data we started routinely mobilizing the greater curvature of the stomach by taking down all the short gastric arteries and posterior gastric attachments until the stomach is mobilized off the left hemidiaphragm. Mobilization of the gastric fundus adds complexity to laparoscopic fundoplication and is often omitted by the neophyte (Figure 1). This can be intimidating dissection because the stomach is often very close to the spleen near its upper pole. Indeed, others have shown that in 92% of cases one of the upper short gastric arteries passes directly from the surface of the stomach to the interior of the upper pole of the spleen with no hilar connection.5 Because of this, the superior pole of the spleen is occasionally infarcted by greater curvature dissection. Many surgeons stop
From the Department of Surgery (WSR), Ochsner Clinic, New Orleans, Louisiana, and the Emory University School of Medicine (JGH), Atlanta, Georgia. Requests for reprints should be addressed to William S. Richardson, MD, Ochsner Clinic, 1514 Jefferson Highway, New Orleans, Louisiana 70121. Manuscript submitted April 17, 1998, and accepted in revised form October 16, 1998.
© 1999 by Excerpta Medica, Inc. All rights reserved.
the fundus dissection at this point, neglecting to divide the posterior gastric artery and other retrogastric attachments. The speed and safety of this dissection has been improved with the use of both bipolar electrocautery and harmonic scalpel for this part of the procedure.6,7 The purpose of this study is to describe the technique of complete fundus mobilization learned from more than 700 laparoscopic fundoplication procedures.
METHODS Our technique of fundoplication has been previously described.8 Briefly, the patient is placed on a modified fracture table in the supine position with the legs abducted to a 45° angle at the hip. The surgeon operates from between the patient’s legs and a five-port system is used (Figure 2). The patient is placed in the reverse Trendelenburg position. A 45° laparoscope is placed through the periumbilical port. A liver retractor is placed through the rightmost port and elevates the left lobe of the liver off the hiatus. The surgeon operates through the upper middle ports, and the assistant retracts through the left subcostal port. The operation begins by dividing the phrenoesophageal ligament anterior to the hiatus preserving the vagus nerve to the liver. The crura are then identified and bluntly dissected away from the esophagus by placing two closed blunt graspers between the esophagus and crura, then spreading transversely toward 3 and 8 o’clock with respect to the video monitor. The phrenoesophageal and phrenogastric attachments are “cleaned” off the crura as far posteriorly as is readily visualized with the 45° scope. Posterior dissection of the esophagogastric (EG) junction is not performed until the fundus is completely mobilized. What was once a difficult dissection is made much easier by approaching the posterior esophagus after fundus mobilization allows complete dissection of the left crus to the median arcuate ligament. Short gastric vessel division starts approximately one third of the way down the greater curvature. An atraumatic bowel grasper is used in the surgeons left hand to retract the stomach near the area of initial dissection holding it laterally and posteriorly. The assistant uses an atraumatic bowel grasper and retracts the short gastric mesentery anteriorly and laterally. A hole into the lesser sac is created in an area that is avascular. Either a mixture to monopolar and bipolar electrocautery or the harmonic scalpel (Ultracision, Smithfield, Rhode Island) may be used. Once a passage to the lesser sac is created, the surgeon’s grasper is placed on the greater curve and the assistant’s grasper is placed in the opening. Again, the surgeon retracts laterally and inferiorly and the assistant retracts laterally and anteriorly, gradually mobilizing the stomach away from the spleen. As one moves up the greater curvature, optimal visualization is often achieved by allowing gravity to retract the 0002-9610/99/$–see front matter PII S0002-9610(98)00324-9
155
LAPAROSCOPIC FLOPPY NISSEN FUNDOPLICATION/RICHARDSON AND HUNTER
Figure 1. Dividing the higher short gastric vessels.
while the surgeon retracts the anterior gastric wall medially and anteriorly (Figure 1). This move splays out the remaining short gastric mesentery and pulls it away from the spleen. A fatty, heavy greater omentum will not stay away from the superior pole with gravity alone, an extra trocar (5 mm) is inserted between the telescope and the left costal margin. With his left hand, the first assistant grasps the omentum with an atraumatic grasper and retracts it inferiorally. Next a decision has to be made regarding the best way to separate the stomach from the spleen. Usually there is room for the harmonic scalpel blades to perform this division without burning the fundus. If not, the mesentery may be taken in layers with scissors or with an “L” hook bipolar and/or the harmonic scalpel. Make sure when performing this with the harmonic scalpel to lift anteriorly before coagulating or running a risk of causing bleeding with the unshielded posterior blade of the scalpel. If there is insufficient room for the harmonic scalpel blade in this layering approach, a right angle may be used to separate the layers first. The uppermost layer is the peritoneum, and once it is divided, the stomach and spleen usually separate enough to use the harmonic scalpel. This layer may be safely divided with the monopolar cautery (hook cautery). The dissection is similar when using the bipolar cautery. If hemorrhage occurs from the splenic side and there is too little to grasp with the harmonic scalpel, a hemoclip is applied or alternatively the bipolar cautery is used. If there is a hemorrhage from the stomach and there is too little tissue for the harmonic scalpel to grasp (the harmonic scalpel may cause lateral burning) an intracorporeal figure-of-eight suture may be applied. Next, the posterior gastrophrenic attachments are detached (Figure 3). This is easily performed with the harmonic scalpel or monopolar and bipolar cautery. The surgeon retracts the greater curve of the stomach anteriorly and laterally, and the assistant retracts the posterior stomach toward the spine. There is a fold of peritoneum caudad to the posterior attachment of the crura and superior to the body of the pancreas. In this fold is the posterior gastric artery and vein, which are branches of the splenic vessels. This is divided with the harmonic scalpel, and the dissection continues to the base of the left crus. Care is taken to preserve the splenic artery and the left gastric artery. Next the esophagus is bluntly dissected into the mediastinum until 2 to 3 cm of esophagus easily is brought into the abdomen. The crura are reapproximated if the hiatal opening is enlarged and a 2 cm Nissen fundoplication is performed over a 60-French dilator. Instruments are removed from the abdomen, and the skin is reapproximated.
COMMENTS
Figure 2. Port placement for laparoscopic fundoplication.
greater omentum inferiorly. The first assistant may best expose the very short superior pole vessels by retraction of the posterior wall of the stomach medially and posteriorly 156
Routine mobilization of the greater curvature added 45 minutes in operating time during the first year. Since we began using the harmonic scalpel routinely, the median time for greater curvature mobilization has fallen below 20 minutes.9 Full mobilization of the stomach is important for decreasing the risk of dysphagia. Fundic mobilization is often difficult owing to the close proximity of the spleen to the greater curve. Using specific retraction techniques, bipolar cautery or harmonic scalpel, and layered dissection,
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999
LAPAROSCOPIC FLOPPY NISSEN FUNDOPLICATION/RICHARDSON AND HUNTER
clips. One splenic hilar injury was controlled with microfibrillar collagen (Lavitene, MedChem Products, Woburn, Massachusetts), but splenectomy has not been required. There have been no gastric injuries. Significant prolonged (.6 weeks) solid food dysphagia was seen in 11% of patients before we started taking down the greater curvature routinely, but fell to 3% to 4% when this became routine.8 Efficacy remains excellent, with 93% of patients relieved of their heartburn and 97% of patients satisfied with their operation.
REFERENCES
Figure 3. Division of the peritoneal fold posterior to the stomach.
this dissection is safe. Improved surgical results favor routine application of these techniques. Without full mobilization of the fundus, tethering of the stomach on the esophagus may result.10,11 This may cause twisting and kinking of the gastroesophageal junction and foregut obstruction. Spiral valves and two compartment stomachs result when the anterior gastric wall is used to fashion a fundoplication. In either case, the obstruction is difficult to dilate and may require redo fundoplication. Although bleeding from short gastric vessels has occurred, it has been easily controlled with the harmonic scalpel or
1. Nissen R. Die(transpleural resektion der kardia). Dtsch Chir. 1937;249:311–316. 2. DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease: evaluation of primary repair in 100 consecutive patients. Ann Surg. 1986;204:9 –20. 3. Donahue PE, Samuelson S, Nylus LM, Bombeck CT. The floppy Nissen fundoplication effective long term control of pathologic reflux. Arch Surg. 1985;120:663– 667. 4. Hunter JG, Swanstrom L, Waring JP. Dysphagia after laparoscopic antireflux surgery. The impact of operative technique. Ann Surg. 1996;224:51–57. NLM citation ID:96289476. 5. Farag A, Shoukry A, Nasr SE. A new option for splenic preservation in formal sized spleen based on preserved histology and phagocytic function of the upper pole using upper short gastric vessels. Am J Surg. 1994;168:257–261. 6. Swantrom LL, Pennings JL. Laparoscopic control of short gastric vessels. J Am Coll Surg. 1995;181:347–351. 7. McKernan JB, Champion JK. Laparoscopic antireflux surgery. Am Surg. 1995;61:530 –536. 8. Hunter JG, Trus TL, Branum GD, et al. A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg. 1996;223:673– 685. 9. Laycock WS, Trus TL, Hunter JG. New technology for the division of short gastric vessels during laparoscopic Nissen fundoplication. A prospective randomized trial. Surg Endosc. 1996;10: 71–73. NLM citation ID:96263791. 10. Wo JM, Trus TL, Richardson WS, et al. Evaluation and management of post-fundoplication dysphagia. Am J Gastroenterol. 1996;91:2318 –2322. 11. Dallemagne B, Weertz JM, Jegaes C, Markiewicz S. Causes of failures of laparoscopic antireflux operations. Surg Endosc. 1996;10: 305–310.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999
157
Laparoscopic Floppy Nissen Fundoplication William S. Richardson, MD, New Orleans, Louisiana, John G. Hunter, MD, Atlanta, Georgia
Good results for antireflux surgery are obtained when proper patients are selected, trained surgeons perform the operation, and proper techniques are used. As our prior results showed higher rates of dysphagia without fundus mobilization (Nissen-Rossetti fundoplication), we now perform complete mobilization on all patients. Full fundus mobilization requires take-down of the short gastric vessels to reveal the base of the left crus, take-down of all posterior gastropancreatic adhesions and the peritoneal fold that is cauded to the crus and superior to the pancreas. Proper division of these attachments will allow an untethered fundoplication and may reduce the risk of dysphagia and slip of the fundoplication onto the stomach. Am J Surg. 1999; 177:155–157. © 1999 by Excerpta Medica, Inc.
N
issen fundoplication was first described in 1936.1 Since then many surgeons have adopted modifications and perform the short “floppy” Nissen fundoplication as described by DeMeester et al2 and Donahue et al.3 Controversy exists on the routine mobilization of the fundus by dividing the short gastric vessels and the posterior gastric vessels, and mobilizing the gastric fundus off the left hemidiaphragm. Early in our laparoscopic experience we performed the Nissen-Rossetti fundoplication (no take-down of the short gastric arteries) in selected cases, and we found a higher rate of early and persistent dysphagia when the fundus was not mobilized.4 After this review of our data we started routinely mobilizing the greater curvature of the stomach by taking down all the short gastric arteries and posterior gastric attachments until the stomach is mobilized off the left hemidiaphragm. Mobilization of the gastric fundus adds complexity to laparoscopic fundoplication and is often omitted by the neophyte (Figure 1). This can be intimidating dissection because the stomach is often very close to the spleen near its upper pole. Indeed, others have shown that in 92% of cases one of the upper short gastric arteries passes directly from the surface of the stomach to the interior of the upper pole of the spleen with no hilar connection.5 Because of this, the superior pole of the spleen is occasionally infarcted by greater curvature dissection. Many surgeons stop
From the Department of Surgery (WSR), Ochsner Clinic, New Orleans, Louisiana, and the Emory University School of Medicine (JGH), Atlanta, Georgia. Requests for reprints should be addressed to William S. Richardson, MD, Ochsner Clinic, 1514 Jefferson Highway, New Orleans, Louisiana 70121. Manuscript submitted April 17, 1998, and accepted in revised form October 16, 1998.
© 1999 by Excerpta Medica, Inc. All rights reserved.
the fundus dissection at this point, neglecting to divide the posterior gastric artery and other retrogastric attachments. The speed and safety of this dissection has been improved with the use of both bipolar electrocautery and harmonic scalpel for this part of the procedure.6,7 The purpose of this study is to describe the technique of complete fundus mobilization learned from more than 700 laparoscopic fundoplication procedures.
METHODS Our technique of fundoplication has been previously described.8 Briefly, the patient is placed on a modified fracture table in the supine position with the legs abducted to a 45° angle at the hip. The surgeon operates from between the patient’s legs and a five-port system is used (Figure 2). The patient is placed in the reverse Trendelenburg position. A 45° laparoscope is placed through the periumbilical port. A liver retractor is placed through the rightmost port and elevates the left lobe of the liver off the hiatus. The surgeon operates through the upper middle ports, and the assistant retracts through the left subcostal port. The operation begins by dividing the phrenoesophageal ligament anterior to the hiatus preserving the vagus nerve to the liver. The crura are then identified and bluntly dissected away from the esophagus by placing two closed blunt graspers between the esophagus and crura, then spreading transversely toward 3 and 8 o’clock with respect to the video monitor. The phrenoesophageal and phrenogastric attachments are “cleaned” off the crura as far posteriorly as is readily visualized with the 45° scope. Posterior dissection of the esophagogastric (EG) junction is not performed until the fundus is completely mobilized. What was once a difficult dissection is made much easier by approaching the posterior esophagus after fundus mobilization allows complete dissection of the left crus to the median arcuate ligament. Short gastric vessel division starts approximately one third of the way down the greater curvature. An atraumatic bowel grasper is used in the surgeons left hand to retract the stomach near the area of initial dissection holding it laterally and posteriorly. The assistant uses an atraumatic bowel grasper and retracts the short gastric mesentery anteriorly and laterally. A hole into the lesser sac is created in an area that is avascular. Either a mixture to monopolar and bipolar electrocautery or the harmonic scalpel (Ultracision, Smithfield, Rhode Island) may be used. Once a passage to the lesser sac is created, the surgeon’s grasper is placed on the greater curve and the assistant’s grasper is placed in the opening. Again, the surgeon retracts laterally and inferiorly and the assistant retracts laterally and anteriorly, gradually mobilizing the stomach away from the spleen. As one moves up the greater curvature, optimal visualization is often achieved by allowing gravity to retract the 0002-9610/99/$–see front matter PII S0002-9610(98)00324-9
155
LAPAROSCOPIC FLOPPY NISSEN FUNDOPLICATION/RICHARDSON AND HUNTER
Figure 1. Dividing the higher short gastric vessels.
while the surgeon retracts the anterior gastric wall medially and anteriorly (Figure 1). This move splays out the remaining short gastric mesentery and pulls it away from the spleen. A fatty, heavy greater omentum will not stay away from the superior pole with gravity alone, an extra trocar (5 mm) is inserted between the telescope and the left costal margin. With his left hand, the first assistant grasps the omentum with an atraumatic grasper and retracts it inferiorally. Next a decision has to be made regarding the best way to separate the stomach from the spleen. Usually there is room for the harmonic scalpel blades to perform this division without burning the fundus. If not, the mesentery may be taken in layers with scissors or with an “L” hook bipolar and/or the harmonic scalpel. Make sure when performing this with the harmonic scalpel to lift anteriorly before coagulating or running a risk of causing bleeding with the unshielded posterior blade of the scalpel. If there is insufficient room for the harmonic scalpel blade in this layering approach, a right angle may be used to separate the layers first. The uppermost layer is the peritoneum, and once it is divided, the stomach and spleen usually separate enough to use the harmonic scalpel. This layer may be safely divided with the monopolar cautery (hook cautery). The dissection is similar when using the bipolar cautery. If hemorrhage occurs from the splenic side and there is too little to grasp with the harmonic scalpel, a hemoclip is applied or alternatively the bipolar cautery is used. If there is a hemorrhage from the stomach and there is too little tissue for the harmonic scalpel to grasp (the harmonic scalpel may cause lateral burning) an intracorporeal figure-of-eight suture may be applied. Next, the posterior gastrophrenic attachments are detached (Figure 3). This is easily performed with the harmonic scalpel or monopolar and bipolar cautery. The surgeon retracts the greater curve of the stomach anteriorly and laterally, and the assistant retracts the posterior stomach toward the spine. There is a fold of peritoneum caudad to the posterior attachment of the crura and superior to the body of the pancreas. In this fold is the posterior gastric artery and vein, which are branches of the splenic vessels. This is divided with the harmonic scalpel, and the dissection continues to the base of the left crus. Care is taken to preserve the splenic artery and the left gastric artery. Next the esophagus is bluntly dissected into the mediastinum until 2 to 3 cm of esophagus easily is brought into the abdomen. The crura are reapproximated if the hiatal opening is enlarged and a 2 cm Nissen fundoplication is performed over a 60-French dilator. Instruments are removed from the abdomen, and the skin is reapproximated.
COMMENTS
Figure 2. Port placement for laparoscopic fundoplication.
greater omentum inferiorly. The first assistant may best expose the very short superior pole vessels by retraction of the posterior wall of the stomach medially and posteriorly 156
Routine mobilization of the greater curvature added 45 minutes in operating time during the first year. Since we began using the harmonic scalpel routinely, the median time for greater curvature mobilization has fallen below 20 minutes.9 Full mobilization of the stomach is important for decreasing the risk of dysphagia. Fundic mobilization is often difficult owing to the close proximity of the spleen to the greater curve. Using specific retraction techniques, bipolar cautery or harmonic scalpel, and layered dissection,
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999
LAPAROSCOPIC FLOPPY NISSEN FUNDOPLICATION/RICHARDSON AND HUNTER
clips. One splenic hilar injury was controlled with microfibrillar collagen (Lavitene, MedChem Products, Woburn, Massachusetts), but splenectomy has not been required. There have been no gastric injuries. Significant prolonged (.6 weeks) solid food dysphagia was seen in 11% of patients before we started taking down the greater curvature routinely, but fell to 3% to 4% when this became routine.8 Efficacy remains excellent, with 93% of patients relieved of their heartburn and 97% of patients satisfied with their operation.
REFERENCES
Figure 3. Division of the peritoneal fold posterior to the stomach.
this dissection is safe. Improved surgical results favor routine application of these techniques. Without full mobilization of the fundus, tethering of the stomach on the esophagus may result.10,11 This may cause twisting and kinking of the gastroesophageal junction and foregut obstruction. Spiral valves and two compartment stomachs result when the anterior gastric wall is used to fashion a fundoplication. In either case, the obstruction is difficult to dilate and may require redo fundoplication. Although bleeding from short gastric vessels has occurred, it has been easily controlled with the harmonic scalpel or
1. Nissen R. Die(transpleural resektion der kardia). Dtsch Chir. 1937;249:311–316. 2. DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease: evaluation of primary repair in 100 consecutive patients. Ann Surg. 1986;204:9 –20. 3. Donahue PE, Samuelson S, Nylus LM, Bombeck CT. The floppy Nissen fundoplication effective long term control of pathologic reflux. Arch Surg. 1985;120:663– 667. 4. Hunter JG, Swanstrom L, Waring JP. Dysphagia after laparoscopic antireflux surgery. The impact of operative technique. Ann Surg. 1996;224:51–57. NLM citation ID:96289476. 5. Farag A, Shoukry A, Nasr SE. A new option for splenic preservation in formal sized spleen based on preserved histology and phagocytic function of the upper pole using upper short gastric vessels. Am J Surg. 1994;168:257–261. 6. Swantrom LL, Pennings JL. Laparoscopic control of short gastric vessels. J Am Coll Surg. 1995;181:347–351. 7. McKernan JB, Champion JK. Laparoscopic antireflux surgery. Am Surg. 1995;61:530 –536. 8. Hunter JG, Trus TL, Branum GD, et al. A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg. 1996;223:673– 685. 9. Laycock WS, Trus TL, Hunter JG. New technology for the division of short gastric vessels during laparoscopic Nissen fundoplication. A prospective randomized trial. Surg Endosc. 1996;10: 71–73. NLM citation ID:96263791. 10. Wo JM, Trus TL, Richardson WS, et al. Evaluation and management of post-fundoplication dysphagia. Am J Gastroenterol. 1996;91:2318 –2322. 11. Dallemagne B, Weertz JM, Jegaes C, Markiewicz S. Causes of failures of laparoscopic antireflux operations. Surg Endosc. 1996;10: 305–310.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999
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