Indications

  • Symptomatic reflux esophagitis refractory to medical therapy

  • Barrett’s esophagus (consider mucosal ablation)

Preoperative Preparation

  • Pass a nasogastric tube to decompress the stomach.

  • See Chap. 19.

Pitfalls and Danger Points

  • Injury to the esophagus.

  • Tension pneumothorax due to unrecognized entry into the mediastinal pleura. Even a relatively small tear can allow CO2 to enter the pleural space and compromise ventilation.

  • Injury to spleen or stomach.

  • Failure to create a sufficiently floppy wrap.

Operative Strategy

Several laparoscopic fundoplications have been devised. We prefer the laparoscopic Nissen fundoplication because it is intended to be virtually identical to a well-established open procedure when completed. The steps in the dissection are necessarily a bit different from those for the open procedure, and several additional features should be noted.

First, the hiatus is accessed by elevating the left lobe of the liver without dividing its attachments. Second, the esophagus is exposed and mobilized by dissecting the crura with minimal manipulation of the esophagus. The resulting extensive mediastinal dissection that accompanies esophageal mobilization makes approximation of the crura mandatory. Postoperative herniation of the stomach or small intestine may complicate the laparoscopic procedure when this step is omitted. Finally, several short gastric vessels must be divided to ensure creating a floppy wrap.

The operation has been adapted to a robotic approach. See references at the end for this and other adaptations to newer laparoscopic approaches.

Documentation Basics

  • Findings

  • Position of wrap relative to vagus nerves

  • Associated paraesophageal hernia?

Operative Technique

Room Setup and Trocar Placement

Position the patient with the legs slightly spread and supported on padded stirrups (Fig. 20.1). Position the monitors at the head of the table. We place the primary monitor at the patient’s left shoulder, with a secondary monitor at the patient’s right, as shown. Some surgeons use a single monitor placed over the head of the operating table. We prefer to stand in the usual position, at the patient’s side, for the initial puncture and entry into the abdomen. During dissection and suturing, the surgeon should stand between the patient’s legs, directly facing the hiatus (Fig. 20.2). When choosing an initial puncture site (to be used for the laparoscope), recall that the hiatus is quite high and deep. The normal umbilical port site may therefore be too low. A trocar pattern must be individualized according to the patient’s body habitus. A 30° angled laparoscope is mandatory for easy visualization.

Fig. 20.1
figure 1

(Reprinted with permission, from Scott-Conner CEH, editor. The SAGES manual: fundamentals of laparoscopy and GI endoscopy. New York: Springer; 1999)

Full size image
Fig. 20.2
figure 2

(Reprinted with permission, from Scott-Conner CEH, editor. The SAGES manual: fundamentals of laparoscopy and GI endoscopy. New York: Springer; 1999)

Full size image

Exposure of the Hiatus

Pass a liver retractor through the right lateral port site. A variety of liver retractors are available, and which one is chosen is largely a matter of the surgeon’s preference. We prefer a flexible retractor that becomes rigid and assumes the shape shown in Fig. 20.3 when a screw is turned. The particular retractor shown is composed of many short segments with an internal cable. When the tension on the cable is released, the retractor becomes limp and may be straightened out to pass it through a trocar. Once the retractor is inside the abdomen, the cable is tightened by twisting a knob on the handle. Increasing tension on the internal cable forces the articulations to bend into the shape shown. The retractor is bent into shape by tightening the cable in the commodious right subphrenic space and is then passed underneath the liver.

figure 3

Fig. 20.3

The liver retractor is properly placed when stable exposure is obtained, and the diaphragmatic surface is seen behind the left lobe of the liver. It may not be possible to distinguish the actual hiatus at this point. This exposure generally requires that the retractor be “toed in” so the part of the retractor closest to the hiatus has maximal lift applied. The laparoscope and instruments are then insinuated underneath the left lobe of the liver in the working space thus created.

Generally, the stomach and some omentum partially or completely obscure the hiatus even with the liver retracted. Therefore the second part of obtaining exposure entails placing an endoscopic Babcock clamp on the stomach and pulling toward the left lower quadrant (Fig. 20.4).

figure 4

Fig. 20.4

Dissecting the Hiatus

The esophagus is dissected by clearing the peritoneum off the hiatus and carefully exposing the muscular crura. Properly performed, this maneuver automatically exposes the esophagus and creates a posterior window.

Begin the dissection by exposing the right crus. Start by opening the peritoneum just to the right of the probable hiatus. The first step involves dividing the lesser omentum. A grasper is used to elevate the flimsy lesser omentum close to the hiatus, and ultrasonic dissecting scissors are used to divide the omentum (Fig. 20.4).

It is tempting to begin this dissection by opening the transparent part of the omentum farther to the right. If you begin your omental window high, however, near the hiatus, you are less likely to encounter a hepatic artery. This has the additional advantage of keeping the window in the lesser omentum relatively small, which helps anchor the wrap and prevents slipping.

Do not try to identify and dissect the esophagus at this stage. To do so risks perforation. A far safer approach is to dissect and clearly define the muscular hiatus and both crura. First identify the right crus after dividing the peritoneum. Next carry the dissection up over the arch of the crura, concentrating on exposing the muscle fibers of the diaphragm. During this dissection, the esophagus becomes obvious by its orientation, longitudinal muscle, and overlying vagus nerve; it may also be gently displaced downward (Fig. 20.5) and to the left. The esophagus has a light pink to reddish pink color and characteristic longitudinal striations. If there is uncertainty as to the location of the esophagus, the nasogastric tube may be palpable to light touch with a grasper, or an esophagogastroduodenoscopy (EGD) scope may be passed and used to elevate and transilluminate the esophagus. These maneuvers are rarely needed.

figure 5

Fig. 20.5

A closed grasper is used to push the esophagus down. This grasper is introduced parallel to the esophagus through one of the left-sided trocars and is used to probe into the mediastinum by gently pushing the esophagus down.

When the upper part of the hiatus has been cleaned thoroughly, elevate the esophagus gently with a closed grasper and clean the lower part of the left crus from the right side by working underneath the esophagus (Fig. 20.6). This maneuver produces a window behind the esophagus while minimizing the risk of perforating the esophagus. The esophagus is never actually grasped; rather, it is gently displaced to one side or the other using a closed grasper. Frequently the anterior vagus nerve is seen on the right side of the esophagus.

figure 6

Fig. 20.6

It is fairly common to encounter a sizable vessel next to the esophagus on the right side (Fig. 20.7).

figure 7

Fig. 20.7

The vessel is smaller than it appears; it looks large because it is closer to the scope than the esophagus. This vessel is usually a branch of the inferior phrenic artery. It must be carefully secured with ultrasonic shears (Fig. 20.8). A replaced hepatic artery, sometimes encountered in this region, is usually larger and is seen to curve away toward the liver rather than pass cephalad toward the diaphragm. If a replaced hepatic artery is encountered, gently displace it to the right (out of the field of surgery) and protect it.

figure 8

Fig. 20.8

Mobilizing the Esophagus

If the crura have been carefully dissected to create an adequate posterior window, there should be a clear space behind the esophagus and retractors should pass easily. The retractors we prefer are curved and paired. They are designed to be inserted from the left and right sides.

Pass the first retractor from the left side. The design of the retractor shown is similar to that of the liver retractor. It is passed into the abdomen limp, and the cable is tightened to make it assume its working configuration. Once the curve is set, the retractor is rigid and ready for use.

Follow the arc of the circle while passing the retractor. Gently swing it from behind. Do not attempt to create a window with the retractor—the window should already be there. Do not attempt to “hook up” under the esophagus; to do so risks posterior perforation. When the tip of the retractor is seen to emerge from the right side of the space behind the esophagus, lift the esophagus with the retractor (Fig. 20.9).

figure 9

Fig. 20.9

Pass the second esophageal retractor from the right. Follow the first retractor around, concentrating on the feel of metal on metal as the second retractor “rides” along parallel to the first. Maintain traction on the stomach to help generate a sufficient length of esophagus (Fig. 20.10).

figure 10

Fig. 20.10

Move the two retractors apart in a spreading movement, parallel to the long axis of the esophagus (Fig. 20.11) to enlarge the window behind the esophagus if needed. Generally only one of the retractors is needed for the remainder of the procedure.

figure 11

Fig. 20.11

Closing the Hiatus

The hiatus must be closed to avoid herniation of the stomach or small intestine. Place one or two simple sutures of 0 or 2-0 silk and tie them (Fig. 20.12). Leave a gap to avoid overtightening the hiatus, which may cause postoperative dysphagia.

figure 12

Fig. 20.12

Dividing the Short Gastric Vessels

The short gastric vessels tether the fundus of the stomach to the spleen (Fig. 20.13a). Begin dividing these vessels at a convenient point high on the fundus and work cephalad (Fig. 20.13b). We prefer ultrasonic shears for this division. Test the mobility of the fundus by passing it back and forth anterior to the esophagus (Fig. 20.14a, b).

figure 13

Fig. 20.13

figure 14figure 14

Fig. 20.14

If at any time there has been concern about injury to the esophagus or stomach, have the anesthesiologist instill methylene blue into the nasogastric tube and look for staining. Repair any areas of concern at this time. Use the wrap to buttress any esophageal repair.

Creating the Wrap

Remove the esophageal retractors and allow the esophagus to return to its normal anatomic position. Pass Maloney dilators from above. For most adults, sequentially pass dilators until a 56–60F dilator is in place (Fig. 20.15a).

figure 15

Fig. 20.15

Replace the left esophageal retractor and elevate the esophagus. Use an angled grasper to reach behind the esophagus from right to left. Grasp the fundus and pull it behind the esophagus. It should pass easily (Fig. 20.15b, c, d).

Bring additional fundus over from the left side to meet the portion that has been passed behind (Fig. 20.16). The wrap should meet easily and feel “floppy.” Avoid the error of creating a twist by pulling the posterior part of the wrap too far to the right. Such a twist may contribute to postoperative dysphagia.

figure 16

Fig. 20.16

Place three sutures to complete the wrap. Catch a bit of the esophagus with the first suture or two to anchor the wrap well above the stomach (Fig. 20.17). Take care not to take an excessively deep bite and create a perforation. Some surgeons place clips on the knots to mark the location of the wrap. It facilitates postoperative evaluation with barium swallow. The completed wrap should lie easily below the diaphragm (Fig. 20.18).

figure 17

Fig. 20.17

figure 18

Fig. 20.18

Postoperative Care

We keep the nasogastric tube in place for the first 24 h to avoid gastric dilatation. A Hypaque swallow the first postoperative day should demonstrate free passage of Hypaque without extravasation. This is particularly important if there is any question of the integrity of the wrap or esophagus.

Complications

  • Esophageal perforation

  • Herniation of viscera through the hiatal opening

  • Slipped wrap

  • Dysphagia