Laparoscopic Nissen Fundoplication
All patients who are candidates for a laparoscopic fundoplication should undergo a preoperative evaluation that includes the following: (1) symptomatic evaluation, (2) an upper GI series, (3) endoscopy, (4) esophageal manometry, and (5) ambulatory pH monitoring.
The presence of both typical symptoms (heartburn, regurgitation, and dysphagia) and atypical symptoms of GERD (cough, wheezing, chest pain, and hoarseness) should be investigated, and symptoms should be graded with respect to their intensity both before and after operation. Nonetheless, a diagnosis of GERD should never be based solely on symptomatic evaluation. Many authorities assert that the diagnosis can be made reliably from the clinical history, so that a complaint of heartburn should lead to the presumption that acid reflux is present; however, testing of this diagnostic strategy demonstrates that symptoms are far less sensitive and specific than is usually believed. For instance, a study from the University of California, San Francisco (UCSF), found that of 822 consecutive patients referred for esophageal function tests with a clinical diagnosis of GERD (based on symptoms and endoscopic findings), only 70% had abnormal reflux on pH monitoring. Heartburn and regurgitation were no more frequent in patients who had genuine reflux than in those who did not; thus, symptomatic evaluation, by itself, could not distinguish between the two groups.
The response to proton pump inhibitors (PPIs) is a better predictor of abnormal reflux. For example, in the UCSF study just cited, 75% of patients with GERD reported a good or excellent response to PPIs, compared with only 26% of patients without GERD. Similarly, a study involving multivariate analysis of factors predicting outcome after laparoscopic fundoplication concluded that a clinical response to acid suppression therapy was one of three factors predictive of a successful outcome, the other two being an abnormal 24-hour pH score and the presence of a typical primary symptom (e.g., heartburn).
Upper Gastrointestinal Series
An upper GI series is useful for diagnosing and characterizing an existing hiatal hernia. The size of the hiatal hernia helps predict how difficult it will be to reduce the esophagogastric junction below the diaphragm. In addition, large hiatal hernias are associated with more severe disturbances of esophageal peristalsis and esophageal acid clearance. Esophagograms are also useful for determining the location, shape, and size of a stricture and detecting a short esophagus.
Endoscopy is typically the first test performed to confirm a symptom-based diagnosis of GERD. This approach has two pitfalls, however. First, even though the goal of endoscopy is to assess the mucosal damage caused by reflux, mucosal changes are absent in about 50% of GERD patients. Second, major interobserver variations have been reported with esophageal endoscopy, particularly for low-grade esophagitis. In one study, for instance, 60 (24%) of 247 patients with negative results on pH monitoring had been diagnosed as having grade I or II esophagitis. Accordingly, I believe that endoscopy is most valuable for excluding gastric and duodenal pathologic conditions and detecting the presence of Barrett's esophagus.
Esophageal manometry provides useful information about the motor function of the esophagus by determining the length and resting pressure of the lower esophageal sphincter (LES) and assessing the quality (i.e., the amplitude and propagation) of esophageal peristalsis. In addition, it allows proper placement of the pH probe for ambulatory pH monitoring (5 cm above the upper border of the LES).
Ambulatory pH Monitoring
Ambulatory pH monitoring is the most reliable test for the diagnosis of GERD, with a sensitivity and specificity of about 92%. It is of key importance in the workup for the following four reasons.
It determines whether abnormal reflux is present. In the UCSF study mentioned earlier, pH monitoring yielded normal results in 30% of patients with a clinical diagnosis of GERD, thereby obviating the continuation of inappropriate and expensive drugs (e.g., PPIs) or the performance of a fundoplication. In addition, pH monitoring prompted further investigation that in a number of cases pointed to other diseases (e.g., cholelithiasis and irritable bowel syndrome).
It establishes a temporal correlation between symptoms and episodes of reflux. Such a correlation is particularly important when atypical GERD symptoms are present because 50% of these patients experience no heartburn and 50% do not have esophagitis on endoscopy.
It allows staging on the basis of disease severity. Specifically, pH monitoring identifies a subgroup of patients characterized by worse esophageal motor function (manifested by a defective LES or by abnormal esophageal peristalsis), more acid reflux in the distal and proximal esophagus, and slower acid clearance. These patients more frequently experience stricture formation and Barrett metaplasia and thus might benefit from early antireflux surgery.
It provides baseline data that may prove useful postoperatively if symptoms do not respond to the procedure.
The patient is placed under general anesthesia and intubated with a single-lumen endotracheal tube. Abdominal wall relaxation is ensured by the administration of a nondepolarizing muscle relaxant, the action of which is rapidly reversed at the end of the operation. Adequate muscle relaxation is essential because increased abdominal wall compliance allows increased pneumoperitoneum, which yields better exposure. An orogastric tube is inserted at the beginning of the operation to keep the stomach decompressed; it is removed at the end of the procedure.
The patient is placed in a steep reverse Trendelenburg position, with the legs extended on stirrups. The surgeon stands between the patient's legs. To keep the patient from sliding as a result of the steep position used during the operation, a bean bag is inflated under the patient, and the knees are flexed only 20º to 30º. A Foley catheter is inserted at the beginning of the procedure and usually is removed in the postoperative period. Because increased abdominal pressure from pneumoperitoneum and the steep reverse Trendelenburg position decrease venous return, pneumatic compression stockings are always used as prophylaxis against deep vein thrombosis.
The equipment required for a laparoscopic Nissen fundoplication includes five 10 mm trocars, a 30º laparoscope, a hook cautery, and various other instruments (see Table 1 ). In addition, we use a three-chip camera system that is separate from the laparoscope.
In all patients except those with very poor esophageal motility -- for whom partial fundoplication (see "Laparoscopic Partial (Guarner) Fundoplication") is preferable -- we advocate performing a 360º wrap of the gastric fundus around the lower esophagus as described by Nissen, but we always take down the short gastric vessels to achieve what is called a floppy fundoplication. This type of wrap is very effective in controlling gastroesophageal reflux.[19,20] The operation can be divided into nine key steps as follows.
Step 1: Placement of Trocars
Five 10 mm trocars are used for the operation (see Figure 1). Port A is placed about 14 cm below the xiphoid process; it can also be placed slightly (2 to 3 cm) to the left of the midline to be in line with the hiatus. This port is used for insertion of the scope. Port B is placed at the same level as port A but in the left midclavicular line. It is used for insertion of the Babcock clamp; insertion of a grasper to hold the Penrose drain once it is in place surrounding the esophagus; or insertion of the clip applier, the ultrasonic coagulating shears, or both to take down the short gastric vessels. Port C is placed at the same level as the previous two ports but in the right midclavicular line. It is used for insertion of the fan retractor, the purpose of which is to lift the lateral segment of the left lobe of the liver and expose the esophagogastric junction. I do not divide the left triangular ligament. The fan retractor can be held in place by a self-retaining system fixed to the operating table. Ports D and E are placed as high as possible under the costal margin and about 5 to 6 cm to the right and the left of the midline so that they are about 15 cm from the esophageal hiatus; in addition, they should be placed so that their axes form an angle of 60º to 120º. These ports are used for insertion of the graspers, the electrocautery, and the suturing instruments.
Laparoscopic Nissen fundoplication. Illustrated is the recommended placement of the trocars.
Troubleshooting. If the ports are placed too low in the abdomen, the operation is made more difficult. If port C is too low, the fan retractor will not retract the lateral segment of the left lobe of the liver well, and the esophagogastric junction will not be exposed. If port B is too low, the Babcock clamp will not reach the esophagogastric junction, and when the ultrasonic coagulating shears or the clip applier is placed through the same port, it will not reach the upper short gastric vessels. If ports D and E are too low, the dissection at the beginning of the case and the suturing at the end are problematic.
Other mistakes of positioning must be avoided as well. Port C must not be placed too medially, because the fan retractor may clash with the left-hand instrument; the gallbladder fossa is a good landmark for positioning this port. Port A must be placed with extreme caution in the supraumbilical area: its insertion site is just above the aorta, before its bifurcation. Accordingly, I recommend initially inflating the abdomen to a pressure of 18 mm Hg just for placement of port A; increasing the distance between the abdominal wall and the aorta reduces the risk of aortic injury. I also recommend directing the port toward the coccyx. Once port A is in place, the intraperitoneal pressure is reduced to 15 mm Hg. A Hasson cannula can be used in this location, particularly if the patient has already had one or more midline incisions. Maintaining the proper angle (60º to 120º) between the axes of the two suturing instruments inserted through ports D and E is also important: if the angle is smaller, the instruments will cover part of the operating field, whereas if it is larger, depth perception may be impaired. Finally, if a trocar is not in the ideal position, it is better to insert another one than to operate through an inconveniently placed port.
If the surgeon spears the epigastric vessels with a trocar, bleeding will occur, in which case there are two options. The first option is to pull the port out, insert a 24 French Foley catheter with a 30 ml balloon through the site, inflate the balloon, and apply traction with a clamp. The advantage of this maneuver is that the vessel need not be sutured; the disadvantage is that the surgeon must then choose another insertion site. At the end of the case, the balloon is deflated. If some bleeding is still present, it must be controlled with sutures placed from outside under direct vision. The second option is to use a long needle with a suture, with which one can rapidly place two U-shaped stitches, one above the clamp and one below. The suture is tied outside over a sponge and left in place for 2 or 3 days.
Step 2: Division of Gastrohepatic Ligament; Identification of Right Crus of Diaphragm and Posterior Vagus Nerve
Once the ports are in place, the gastrohepatic ligament is divided. Dissection begins above the caudate lobe of the liver, where this ligament usually is very thin, and continues toward the diaphragm until the right crus is identified. The crus is then separated from the right side of the esophagus by blunt dissection, and the posterior vagus nerve is identified. The right crus is dissected inferiorly toward the junction with the left crus.
Troubleshooting. An accessory left hepatic artery originating from the left gastric artery is frequently encountered in the gastrohepatic ligament. If this vessel creates problems of exposure, it may be divided; in my experience, doing so has not caused problems. When dissecting the right crus from the esophagus, the electrocautery should be used with particular caution. Because the monopolar current tends to spread laterally, the posterior vagus nerve may sustain damage simply from being in proximity to the device, even when there is no direct contact. The risk of neuropraxia can be reduced by using the cut mode rather than the coagulation mode when the electrocautery is close to the nerve. The cut mode has problems of its own, however, and is not recommended in most laparoscopic procedures. A better alternative is to use the ultrasonic coagulating shears.
Step 3: Division of Peritoneum and Phrenoesophageal Membrane above Esophagus; Identification of Left Crus of Diaphragm and Anterior Vagus Nerve
The peritoneum and the phrenoesophageal membrane above the esophagus are divided with the electrocautery, and the anterior vagus nerve is identified. The left crus of the diaphragm is dissected downward toward the junction with the right crus.
Troubleshooting. Care must be taken not to damage the anterior vagus nerve or the esophageal wall. To this end, the nerve should be left attached to the esophageal wall, and the peritoneum and the phrenoesophageal membrane should be lifted from the wall by blunt dissection before they are divided.
Step 4: Creation of Window between Gastric Fundus, Esophagus, and Diaphragmatic Crura; Placement of Penrose Drain around Esophagus
The esophagus is retracted upward with a Babcock clamp applied at the level of the esophagogastric junction. Via blunt and sharp dissection, a window is created under the esophagus between the gastric fundus, the esophagus, and the diaphragmatic crura. The window is enlarged with the ultrasonic coagulating shears, and a Penrose drain is passed around the esophagus. This drain is then used for traction instead of the Babcock clamp to reduce the risk of damage to the gastric wall.
Troubleshooting. The two main problems to watch for during this part of the procedure are (1) creation of a left pneumothorax and (2) perforation of the gastric fundus.
A left pneumothorax is usually caused by dissection done above the left crus in the mediastinum rather than between the crus and the gastric fundus. This problem can be avoided by properly dissecting and identifying the left crus.
Perforation of the gastric fundus is usually caused by pushing a blunt instrument under the esophagus and below the left crus without having done enough dissection. Care must be exercised in taking down small vessels from the fundus when the area behind the esophagus is approached from the right: the anatomy is not as clear from this viewpoint, and perforation can easily occur. Sometimes, perforation is caused by the use of a monopolar electrocautery for dissection. An electrocautery burn can go unrecognized during dissection and manifest itself in the form of a leak during the first 48 hours after operation.
Step 5: Division of Short Gastric Vessels
The ultrasonic coagulating shears or the clip applier is introduced through port B. A grasper is introduced by the surgeon through port D, and an assistant applies traction on the greater curvature of the stomach through port E. Dissection begins at the level of the middle portion of the gastric body and continues upward until the most proximal short gastric vessel is divided and the Penrose drain is reached.
Troubleshooting. Again, there are two main problems to watch for during this part of the procedure: (1) bleeding, either from the gastric vessels or from the spleen, and (2) damage to the gastric wall.
Bleeding from the gastric vessels is usually caused by excessive traction or by division of a vessel that is not completely occluding with clips on both sides. Vessels up to 5 mm in diameter can be taken down with the ultrasonic coagulating shears; this process requires about half of the amount of time needed when only clips are used. The lower blade has a sharp, oscillating inferior edge that must always be kept in view to prevent damage to other structures (e.g., the pancreas, the splenic artery and vein, and the spleen). Damage to the gastric wall can be caused by a burn from the electrocautery used to dissect between vessels or by traction applied via the graspers or the Babcock clamp.
Step 6: Closure of Crura
The diaphragmatic crura are closed with interrupted 2-0 silk sutures on a curved needle; the sutures are tied intracorporeally. Exposure is provided by retracting the esophagus upward and toward the patient's left with the Penrose drain. The lens of the 30º laparoscope is angled slightly to the left by moving the light cable of the scope to the patient's right. The first stitch should be placed just above the junction of the two crura. Additional stitches are placed 1 cm apart, and a space of about 1 cm is left between the uppermost stitch and the esophagus.
Troubleshooting. Care must be taken not to spear the posterior wall of the esophagus with either the tip or the back of the needle. So as not to limit the space available for suturing, the bougie is not placed inside the esophagus during this part of the procedure.
Step 7: Insertion of Bougie into Esophagus and through Esophagogastric Junction
The esophageal stethoscope and the orogastric tube are removed, and a 56 French bougie is inserted by the anesthesiologist and passed through the esophagogastric junction under laparoscopic vision. The crura must be snug around the esophagus but not too tight: a closed grasper should slide easily between the esophagus and the crura.
Troubleshooting. The most worrisome complication during this step is perforation of the esophagus. This can be prevented by lubricating the bougie and instructing the anesthesiologist to advance the bougie slowly and to stop if any resistance is encountered. In addition, it is essential to remove any instruments from the esophagogastric junction and to open the Penrose drain; these measures prevent the creation of an angle between the stomach and the esophagus, which can increase the likelihood of perforation. The position of the bougie can be confirmed by pressing with a grasper over the esophagus, which will feel full when the bougie is in place.
Step 8: Wrapping of Gastric Fundus around Lower Esophagus
The gastric fundus is gently pulled under the esophagus with the graspers. The left and right sides of the fundus are wrapped above the fat pad (which lies above the esophagogastric junction) and held together in place with a Babcock clamp introduced through port B. (The Penrose drain should be removed at this point because it is in the way.) Usually, three 2-0 silk sutures are used to secure the two ends of the wrap to each other. The first stitch does not include the esophagus and is used for traction; the second and the third include a bite of the esophageal muscle. The bougie is passed into the stomach after the first stitch to assess the size of the wrap. If the wrap seems at all tight, the stitch is removed and repositioned more laterally. Two coronal stitches are then placed between the top of the wrap and the esophagus, one on the right and one on the left. Finally, one additional suture is placed between the right side of the wrap and the closed crura.
To avoid the risk of injuring the inferior vena cava at the beginning of the dissection, some surgeons use a different method -- the so-called left crus approach. In this approach, the operation begins with identification of the left crus of the diaphragm and division of the peritoneum and the phrenoesophageal membrane overlying it. The next step is division of the short gastric vessels, starting midway along the greater curvature of the stomach and continuing upward to join the area of the previous dissection. When the fundus has been thoroughly mobilized, the peritoneum is divided from the left to the right crus, and the right crus is dissected downward to expose the junction of the right and left crura. With this technique, the vena cava is never at risk. In addition, the branches of the anterior vagus nerve and the left gastric artery are less exposed to danger. This technique can be very useful, particularly for management of very large paraesophageal hernias and for second antireflux operations (see "Reoperation for GERD").
Troubleshooting. To determine whether the wrap is going to be floppy, the surgeon must deliver the fundus under the esophagus, making sure that the origins of the short gastric vessels that have been transected are visible. Essentially, the posterior wall of the fundus is being used for the wrap. If the wrap remains to the right of the esophagus without retracting back to the left, then it is floppy, and suturing can proceed. If not, the surgeon must make sure that the upper short gastric vessels have been transected. If tension is still present after these maneuvers, it is probably best to perform a partial wrap (see "Laparoscopic Partial (Guarner) Fundoplication").
Damage to the gastric wall may occur during the delivery of the fundus. Atraumatic graspers must be used, and the gastric fundus must be pulled gently and passed from one grasper to the other. Sometimes, it is helpful to push the gastric fundus under the esophagus from the left. The wrap should measure no more than 2 to 2.5 cm in length and, as noted, should be done with no more than three sutures. The first stitch is usually the lowest one; it must be placed just above the fat pad where the esophagogastric junction is thought to be.
If the anesthesiologist observes that peak airway pressure has increased (because of a pneumothorax) or that neck emphysema is present (because of pneumomediastinum), the pneumoperitoneum should be reduced from 15 mm Hg to 8 or 10 mm Hg until the end of the procedure. Pneumomediastinum tends to resolve without intervention within a few hours of the end of the procedure. Small pneumothoraces (usually on the left side) tend to resolve spontaneously, rendering insertion of a chest tube unnecessary. Larger pneumothoraces (> 20%), however, call for the insertion of a small (18 to 20 French) chest tube.
Step 9: Final Inspection and Removal of Instruments and Ports from Abdomen
After hemostasis is obtained, the instruments and the ports are removed from the abdomen under direct vision.
Troubleshooting. If any areas of oozing were observed, they should be irrigated and dried with sponges rolled into a cigarettelike shape before the ports are removed. In addition, if some grounds for concern remain, the oozing areas should be examined after the pneumoperitoneum is decreased to 7 to 8 mm Hg to abolish the tamponading effect exerted by the high intra-abdominal pressure.
All the ports should be removed from the abdomen under direct vision so that any bleeding from the abdominal wall can be readily detected. Such bleeding is easily controlled, either from inside or from outside.
A feared complication of laparoscopic Nissen fundoplication is esophageal or gastric perforation, which may result either from traction applied with the Babcock clamp or a grasper to the esophagus or the stomach (particularly when the stomach is pulled under the esophagus) or from inadvertent electrocautery burns during any part of the dissection. A leak will manifest itself during the first 48 hours. Peritoneal signs will be noted if the spillage is limited to the abdomen; shortness of breath and a pleural effusion will be noted if spillage also occurs in the chest. The site of the leak should always be confirmed by a contrast study with barium or a water-soluble contrast agent. Optimal management consists of laparotomy and direct repair. If a perforation is detected intraoperatively, it may be closed laparoscopically.
About 50% of patients experience mild dysphagia postoperatively. This problem usually resolves after 4 to 6 weeks, during which period patients receivepain medications in an elixir form and are advised to avoid eating meat and bread. If, however, dysphagia persists beyond this period, one or more of the following causes is responsible.
A wrap that is too tight or too long (i.e., > 2.5 cm).
Lateral torsion with corkscrew effect. If the wrap rotates to the right (because of tension from intact short gastric vessels or because the fundus is small), a corkscrew effect is created.
A wrap made with the body of the stomach rather than the fundus. The relaxation of the LES and the gastric fundus is controlled by vasoactive intestinal polypeptide and nitric oxide[22,23]; after fundoplication, the two structures relax simultaneously with swallowing. If part of the body of the stomach rather than the fundus is used for the wrap, it will not relax as the LES does on arrival of the food bolus.
Choice of the wrong procedure. In patients who have severely abnormal esophageal peristalsis (as in end-stage connective tissue disorders), a partial wrap is preferable. A 360º wrap may cause postoperative dysphagia and gas bloat syndrome.
If the wrap slips into the chest, the patient becomes unable to eat and prone to vomiting. A chest radiograph shows a gastric bubble above the diaphragm, and the diagnosis is confirmed by means of a barium swallow. This problem can be prevented by using coronal sutures and by ensuring that the crura are closed securely.
Paraesophageal hernia may occur if the crura have not been closed or if the closure is too loose. In my opinion, closure of the crura not only is essential for preventing paraesophageal hernia but also is important from a physiologic point of view, in that it acts synergistically with the LES against stress reflux. Sometimes, it is possible to reduce the stomach and close the crura laparoscopically. More often, however, because the crural opening is very tight and the gastric wall is edematous, laparoscopic repair is impossible and laparotomy is preferable.
Postoperative care and outcome evaluation of laparoscopic Nissen fundoplication are considered elsewhere in conjunction with the discussion of partial fundoplication (see "Laparoscopic Partial (Guarner) Fundoplication, Postoperative Care and Outcome Evaluation").
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