Minimally invasive surgeries such as laparoscopic Nissen fundoplication can be used to treat gastroesophageal reflux disease (GERD). The laparoscopic procedure involves making several small incisions and using instruments and a camera to reconstruct the esophageal hiatus and wrap the gastric fundus around the lower esophagus. This restores the anti-reflux barrier. The procedure takes several hours and has a low risk of complications. Patients typically recover within a few weeks with some short-term difficulty swallowing. The fundoplication creates a new sphincter to prevent reflux and symptoms in most patients long-term.

1. Minimally Invasive
Surgeries
Chirurgicales Mini-Invasives
Celien Dubois, MD, PhD, DES, DESC
15.03.2009

2. Objectives
•
Laparoscopic vs. Open Procedure
•
Operating Room Set-up
• Equipment
• Patient Position
• Trocar Placement
•
Procedural Steps
•
Possible Complications
•
Post-Operative Care

3. Case
•
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

4. Management
•
Non-Surgical 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)

5. 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

6. Open Procedure v. Laparoscopy
•
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

7. 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

8. 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

9. 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

10. 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.

11. Esophagus Dissection
•
Dissection of the posterior esophagus helps open
the retroesophageal window
•
Identify the posterior vagus nerve and protect it

12. Fundal 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
•
Do not partially divide vessels
•
Stay close to stomach, being careful of spleen
• Within lesser omental sac, grab posterior of
stomach to continue dividing short gastric
vessels. Divide gastrophrenic ligament.

13. Preparation for the 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.

14. 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

15. 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

16. 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

17. 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.

18. 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

19. Post-Operative Care
●
Most patients return home the first or second day after surgery
●
Return to full activity usually takes 1 to 2 weeks
●
Acid reducing medication is recommended for 2 weeks
following surgery
•
Clear diet for three days following surgery, advance as tolerated
•
Sweet foods should be eaten last to avoid quick digestion
• Drink fluids between meals; 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.
Merci beaucoup!