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104
C. Clark
16.3 Positioning
Patient is placed supine on the operating table. The surgeon
stands at the end of the table for small infants, or to the right
of larger children. The camera person is on the left. The
patient requires a nasogastric (NG) tube.
Before preparation of the abdomen, the costal margin on
both sides should be marked out.
16.4 Surgical Technique
1. Infraumbilical 5-mm port is inserted using the Hassan
cut down technique.
2. Pneumoperitoneum is established, with typical pressure
settings 5–10 mmHg, depending on the size and weight
of the child.
3. The stomach is identified.
4. A small, 2-mm incision is made through the abdominal
wall under direct vision with the 11 blade scalpel over
the gastric area where you wish the button to sit, ensuring that there is enough space between the costal margin
and the button for comfort when the pneumoperitoneum
is released. Insert the atraumatic grasper directly though
the incision without port placement (Fig. 16.1).
5. Identify the pylorus, antrum, and body of the stomach
and decide on the best siting of the gastrostomy. Grasp
this area of the stomach and bring it up to the anterior
abdominal wall (Figs. 16.2 and 16.3). Problem shooting:
If the stomach does not easily reach the anterior abdominal wall, reduce the pneumoperitoneum pressure.
6. Using the MO45 round-bodied needle, place the 1–0
or 0 vicryl or PDS stay sutures through the anterior
abdominal wall and stomach, ensuring good bites of the
stomach. Make sure these bites are placed near the atraumatic grasper externally, as they will be used to secure
the button at the end of the procedure. Leave the stay
sutures long and place on a clip. As shown in Figs.
16.4,
16.5, and 16.6, this is done under direct vision. Top Tip:
Ensure the needle is at a right angle to the skin, to allow
easy suturing of the stomach wall.
7. For correct placement of the guide wire, the stomach is
inflated via the NG tube and then punctured with the
18G needle under direct vision. The stomach should
deflate through the needle to ensure good intragastric
needle placement. Place the guide wire into the stomach
and remove the needle (Fig. 16.7). Top Tip: To ensure
that the guide wire does not fall out, an assistant should
hold onto the wire externally at the entry point at all
times.
8. Dilation of the stomach now occurs over the guide
wire (under vision), starting with size 6 Fr and graduating up to size 18 Fr (Figs. 16.8 and 16.9). Hold the
stay sutures so the stomach is up against the anterior
abdominal wall.
9. Remove the dilators but keep the guide wire in place.
Place the gastrostomy measuring device over the guide
wire into the stomach and blow up the balloon to measure the size of MIC-KEY button required (e.g., 14 Fr,
1.5 cm MIC-KEY). Deflate the balloon and remove the
measuring device, leaving the guide wire in the stomach.
10. To place the MIC-KEY button, place the 8 Fr dilator
through the MIC-KEY button and then place it over the
guide wire and into the stomach under direct vision.
Blow up the balloon. To ensure correct intragastric
placement, insufflate the stomach via the NG tube again
(Fig. 16.10) and connect the MIC-KEY external tubing
to deflate the stomach via the button (Fig. 16.11). If the
stomach does not deflate easily, the button is not in the
correct place.
11. Once correct placement is confirmed, tie the stay sutures
over the button flanges (Fig. 16.12).
12. Release the pneumoperitoneum. Suture closed the infraumbilical port site.
Fig. 16.1 The atraumatic grasper is inserted directly though the
incision
Fig. 16.2 The best site for the gastrostomy is chosen
16 Primary Button Gastrostomy
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105
Fig. 16.3 This area is grasped and brought up to the anterior abdominal
wall
Fig. 16.4 Place the stay sutures through the anterior abdominal wall
and stomach, ensuring good bites of the stomach. The needle should be
at a right angle to the skin
Fig. 16.6 Leave the stay sutures long
Fig. 16.7 The guide wire is placed into the stomach
Fig. 16.5 Make sure these bites are placed near the atraumatic grasper
Fig. 16.8 Dilators of increasing size are now used
106
C. Clark
Fig. 16.9 During dilation, the stomach is held against the anterior
abdominal wall using the stay sutures
Fig. 16.10 The stomach is inflated to ensure correct intragastric
placement of the MIC-KEY button
Fig. 16.12 When correct placement is confirmed, tie the stay sutures
over the button flanges
13. Leave the sutures for 5 days. The button must not be
twisted during this time, so that good tract formation can
occur.
14. Remove the NG tube and place the button on free drainage overnight. The patient receives nothing by mouth
overnight, with essential medication given only through
the gastrostomy until the morning. Allow graduated use
of the gastrostomy as required.
Fig. 16.11 If the stomach is easily deflated via the button, the
placement is correct
16 Primary Button Gastrostomy
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107
16.5 Highlights and Pitfalls
• Always ensure correct intragastric placement of the needle and button by insufflating and deflating the stomach as
described above. If there is no deflation of the stomach,
reposition the needle and button until it occurs.
• Ensure that the guide wire is always in the stomach
throughout the procedure. If it comes out, replace it under
direct vision.
• Beware of overly vigorous insertion of the guide wire,
which may cause gastric perforation in unintended places.
• This technique can only be used if the stay suture needle
can be passed through the anterior abdominal wall easily.
In obese patients, a different primary button kit
(Gastrointestinal Anchor Set with Saf-T-Pexy T-Fasteners;
Kimberly- Clark, Roswell, GA, USA) can be used, via
upper gastrointestinal (UGI) endoscopy rather than
laparoscopy.
Nissen Fundoplication
Merrill McHoney
17
17.1 General Information
The laparoscopic approach to fundoplication may offer
advantages over the open approach. It offers good access to
the hiatus, oesophagus and stomach, while minimising the
surgical wound. There is less postoperative need for use of
high dependency units, less respiratory depression due to
pain, less postoperative adhesions, better cosmesis and at
least equal efficacy. There is less morbidity and equal efficacy with the laparoscopic approach.
17.2 Working Instruments
• 5 mm Hasson port
• 30° telescope (length proportionate to patient size)
• 3 or 5 mm instruments depending on patient size
• needle holders
• hook diathermy
• scissors
• Maryland and/or Yohan forceps
• Natheson’s liver retractor (size depending on patient
weight) with table attachment
• Ultrasonic scalpel or ligasure (optional for dissection and
dealing with short gastric vessels)
17.3 Positioning, Port Siting
Ergonomic Considerations
and
The patient is positioned at the end of the table in frog legged
position (the operating surgeon will be between the legs
during the procedure). Patients with severe contractures secondary to neuro-muscular disorders may have to be placed
with legs together, which are then placed on one side of
the patient. Primary port is placed in the umbilical fold
(the upper or lower fold may be chosen depending on patient
size and body habitus to maximise ergonomics). Two further
working ports are placed in the left and right upper abdomen
under vision. The port in the right side of the patient may
need to be slightly long to be beyond the falciform ligament,
thereby avoiding catching it on introducing instruments.
Slight head up positioning may be useful in allowing the
intestines to fall away from the operating field.
A Natheson’s retractor is placed through an epigastric
incision under vision. The size is chosen appropriate to
patient size. It is positioned to allow the left lobe of the liver
to be lifted out of the operative field of the oesophagus.
M. McHoney, MD, PhD
Royal Hospital for Sick Children,
9 Sciennes Road, Edinburgh EH9 1LF, UK
© Springer-Verlag Berlin Heidelberg 2017
M. McHoney et al. (eds.), Color Atlas of Pediatric Anatomy, Laparoscopy, and Thoracoscopy,
DOI 10.1007/978-3-662-53085-6_17
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110
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M. McHoney
17.4 Relevant Anatomy
1. View of the oesophageal hiatus
Fig. 17.1 This view shows the initial view seen in-situ. The zona pellucida of the lesser omentum overlying the caudate lobe of the liver is
seen. The left lobe of the liver is seen (beneath the Natheson’s liver
retractor), ending in the left triangular ligament. The oesophagus and
stomach is seen with the gastro-epiloic vessels along the lesser
curvature
2. View of the anatomy of the hiatus
Fig. 17.2 The zona pellucuda has been opened and the right (and left)
crus of the diaphragm is seen, creating the oesophageal hiatus. The posterior vagus can be seen on the oesophagus
17 Nissen Fundoplication
3. Another view of anatomy of the hiatus 17.5 Surgical Technique
4. Exposure of the oesophagus
Fig. 17.3 In this figure the left crus is more visible. The posterior
vagus is again seen applied to the back of the oesophagus and an
oesophageal vessel is also seen going through the hiatus
Fig. 17.4 An initial incision is made in the zona pellucida of the lesser
omentum overlying the caudate lobe of the liver. Hook diathermy dissection is useful, and care is taken when approaching a small vessel
bundle in the otherwise relatively avascular structure. The dissection is
continued caudally to expose the oesophagus
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M. McHoney
5. Exposure of the oesophagus GOJ and crus 6. Mobilisation of the lower oesophagus to create intraabdominal length
Fig. 17.5 The lower oesophagus and GOJ are now seen, and further
exposed by dividing the phreno-oesophageal ligament and other attachments of the oesophagus to the diaphragm, some of which may represent inflammatory reaction to oesophagitis. Blunt and hook/bipolar
dissection is used. The anterior and posterior vagi are identified and if
possible preserved on the oesophageal wall
Fig. 17.6 Further adhesions of the lower oesophagus to the diaphragm
and abdominal wall may need to be divided. Care is taken to avoid the
pleura in the lower part of the chest. The aorta is also in close proximity
behind the crura
17 Nissen Fundoplication
7. Creation of window behind oesophagus for fundal wrap 8. Completed posterior window and crural exposure
113
Fig. 17.7 The oesophagus is lifted forward and the space behind it
developed by dividing the tissue behind using a combination of blunt
(mostly) and diathermy dissection of the mainly loose areolar tissue
behind it. Be aware and cautious of the vessels encountered towards the
back of the space. The posterior vagus nerve should be sought and kept
intact along the posterior wall of the oesophagus
Fig. 17.8 The window has been created and developed. Note the posterior vagus nerve. The fundus is visible through the window and can
then be grasped and mobilisation of the stomach begun
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9. Mobilisation of the fundus 10. Repairing the crura
a
M. McHoney
Fig. 17.9 Mobilisation of the fundus is then performed by dividing the
adhesion between it and the abdominal wall and spleen. The loose
adhesions can be seen here and are divided using hook diathermy. Very
small vessels (vasa brevis) between fundus and spleen can be encountered and divided using hook diathermy. The short gastrics need not be
routinely divided if not needed to create a loose wrap. If needing dividing a harmonic scalpel or ligasure bipolar is useful
b
Fig. 17.10 (a) A non absorbable suture (on a ski needle) is introduced
into the abdomen. The crura is approximated using one or two stitches
to close the oesophageal hiatus, without closing too tightly (which can
cause dysphagia). The ski needle is shown in this figure to be entering
the left crus. (b) The ski needle is seen here exiting the right crus. The
suture is tied using intracorporeal sutures. One or two are usually
needed
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