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17 Nissen Fundoplication
11. Closed oesophageal hiatus 12. Creation of loose wrap behind oesophagus
115
Fig. 17.11 Closed oesophageal hiatus is seen after sufficient interrupted sutures are placed. An adequate space can be judged by gently
introducing a blunt instrument into the space (akin placing a little finger) to test tightness. The anterior and posterior vagi can be seen on the
relevant oesophageal walls
Fig. 17.12 The mobilised fundus is then passed through the window
posterior to the oesophagus and it is ensured that it can be loosely
wrapped around the oesophagus without tension. If released it should
not shoot back across
116
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13. Suturing of the wrap. 14. Final fundal suture
M. McHoney
Fig. 17.13 The wrap is then created by suturing the fundus anteriorly
over the oesophagus. The most superior (first) suture can incorporate
the oesophageal wall between the fundus. Usually three sutures are
needed to form the row of sutures
Fig. 17.14 The last of the three sutures is being placed to complete the
wrap. The natural line of the fundus can be seen. It allows for a natural
wrap
17 Nissen Fundoplication
117
15. Completed fundoplication The Nathenson’s retractor is first removed under vision,
followed by the other working ports, and closed under vision.
The abdomen is then desufflated and port closed.
17.6 Alternatives
Minimal mobilisation of the oesophagus has been highlighted by some as a technique to adopt to minimise the
risk of recurrence due to wrap herniation. This should not
be at the expense of identifying the appropriate anatomy
to allow an accurate construction of wrap and repair of
hiatus.
17.7 Highlights and Pitfalls
Fig. 17.15 The completed fundoplication is seen here
• Dissection in the lower thorax is kept to a minimal and is
carefully visualised to avoid incising the pleura and creating a capnothorax. This is usually asymptomatic and
sometimes only seen when a chest X-ray is performed for
another reason. Most can be managed conservatively as
the CO
is quickly absorbed. Symptoms may call for a
2
chest drain to be inserted temporarily.
• Positioning in the neurologically impaired or those with
musculoskeletal deformities may be difficult, while trying
to maintain ergonomic positioning of ports.
• The use of a wide bore nasogastric tube is not mandatory
to prevent a tight wrap. Ensuring the wrap is loose, and
not too tight a crural wrap is sufficient.
• Care is needed when suturing the hiatus to prevent trauma
to the liver with the needle, and bleeding.
Further Reading
1. Dingemann J, Ure BM. Systematic review of level 1 evidence for
laparoscopic pediatric surgery: do our procedures comply with the
requirements of evidence-based medicine? Eur J Pediatr Surg.
2013;23(6):474–9.
2. Siddiqui MR, Abdulaal Y, Nisar A, Ali H, Hasan F. A meta-analysis
of outcomes after open and laparoscopic Nissen’s fundoplication for
gastro-oesophageal reflux disease in children. Pediatr Surg Int.
2011;27(4):359–66.
3. St Peter SD, Barnhart DC, Ostlie DJ, Tsao K, Leys CM, Sharp SW,
et al. Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial. J Pediatr
Surg. 2011;46(1):163–8.
4. McHoney M, Wade AM, Eaton S, Howard RF, Kiely EM, Drake DP
et al. Clinical outcome of a randomized controlled blinded trial of
open versus laparoscopic Nissen fundoplication in infants and children. Ann Surg 2011;254(2):209–16.
Laparoscopic Thal Fundoplication
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Khaled Ashour, Alex C.H. Lee, and Hugh W. Grant
Abstract
The Thal fundoplication is a 180–270° anterior wrap. The basic dissection is similar to that
of any other fundoplication, except that it does not require a posterior window or posterior
mobilisation of the oesophagus and requires less dissection of the crus. It achieves the same
surgical objectives as other types of fundoplication, i.e., ensuring an intra-abdominal
oesophagus, creating an acute angle at the gastro-oesophageal junction, and creating a highpressure zone around the lower oesophagus [1]. Thal fundoplication has an equivalent success rate in neurologically normal children but has a higher failure rate in neurologically
impaired children when compared with the Nissen fundoplication. It also results in less
postoperative dysphagia [2].
18
Keywords
Laparoscopic • Thal • Fundoplication
18.1 General Information
The Thal fundoplication is a 180–270° anterior wrap.
The basic dissection is similar to that of any other fundoplication, except that it does not require a posterior window or posterior mobilisation of the oesophagus and
requires less dissection of the crus. It achieves the same
surgical objectives as other types of fundoplication, i.e.,
K. Ashour • H.W. Grant (*)
Department of Paediatric Surgery, John Radcliffe Hospital,
Oxford University, Oxford, UK
A.C.H. Lee
Department of Paediatric Surgery, Oxford University Hospitals
NHS Trust, Oxford Children’s Hospital, John Radcliffe Hospital,
Oxford, UK
ensuring an intra- abdominal oesophagus, creating an
acute angle at the gastro- oesophageal junction, and creating a high-pressure zone around the lower oesophagus
[1]. Thal fundoplication has an equivalent success rate in
neurologically normal children but has a higher failure
rate in neurologically impaired children when compared
with the Nissen fundoplication. It also results in less
postoperative dysphagia [2].
© 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_18
119
120
K. Ashour et al.
18.2 Working Instruments
• For children <7 kg:
– A 5-mm 30° short scope placed via the umbilicus
– One working 3-mm port in the right upper quadrant
– One working 5-mm port in the left upper quadrant
(with reducer for 3-mm instruments)
– Nathanson retractor placed via the epigastrium
(Fig. 18.1).
• For children >7 kg:
– A 5- or 10-mm 30° scope and 5-mm ports should be
used
– Hook (monopolar) diathermy usually is sufficient for
dissection, but an ultrasonic dissector (Thunderbeat
[Olympus, Southborough, MA] or Harmonic [Ethicon,
Somerville, NJ]) or LigaSure (bipolar; Covidien,
Mansfield, MA) may be used, although they usually
are not required because division of the short gastric
vessels seldom is necessary for a Thal fundoplication.
18.3 Positioning, Port Siting,
Ergonomic Considerations
and
If the child is <7 kg, he/she should be positioned supine with
the head up and the legs abducted at the foot of the operating
table. If the patient is >7 kg, the Lloyd-Davies position with
the hips abducted and minimal flexure of the hip and knees is
helpful (Fig. 18.2). The surgeon should stand between the
patient’s legs with the monitor over the patient’s head for the
best ergonomics.
Fig. 18.1 Port sites
Fig. 18.2 Patient position
18 Laparoscopic Thal Fundoplication
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18.4 Surgical Technique
18.4.1 Entry
Empty the bladder with a catheter; use an umbilical or supraumbilical “Hasson” entry. Subsequent ports should be placed
under laparoscopic vision in the right upper quadrant and left
upper quadrant (for maximum triangulation), and a Nathanson
retractor should be inserted at the level of (or just below) the
edge of the liver, through the linea alba in the epigastrium.
18.4.2 Retraction
Good liver retraction is crucial; the Nathanson is a very useful retractor because it lifts the liver up and away from the
operative field and is one less instrument to get tangled with
the surgeon’s instruments (Fig. 18.3).
18.4.3 Exposure
121
Fig. 18.3 Ergonomics
Start the dissection over the caudate lobe by dividing the
zona pellucida of the lesser omentum (Fig. 18.4). This opens
a window that leads to the gastro-oesophageal junction
(Fig. 18.5). Dissection should proceed superiorly towards
the oesophageal hiatus. Accessory vessels from the left gastric vessels to the left lobe of the liver are common, and these
may be ligated or diathermised as required.
18.4.4 Dissection
Identify and mobilise the phreno-oesophageal ligament; it
usually is apparent in children as there is little fat.
Occasionally in overweight children, it is difficult to identify
this location, so look for lymph nodes that often lie over the
gastro-oesophageal junction and are a useful landmark.
It is easier to start the dissection of the phrenoligament at the “9 o’clock” position (when looking towards
the oesophageal hiatus). A superficial incision should be
made vertically between the right leaflet of the right crus and
the oesophagus (Fig. 18.6), and the oesophagus should be
pushed to the patient’s left. This usually opens the window
and exposes the intra-abdominal oesophagus and the oesophageal hiatus. If the area is inflamed, some minor bleeding
may be present.
Minimum dissection of the crus is important to minimise
the risk of inducing a hiatus hernia or causing recurrence of
a hiatus hernia [3]. The oesophagus should not be “stripped.”
In a Thal fundoplication the crural fibres have to be sufficiently dissected on the anterior aspect of the oesophagus to
enable the surgeon to place secure sutures on the anterior
part of the intra-abdominal oesophagus (Fig.
oesophageal
18.7).
Fig. 18.4 Exposure of the operative field
Fig. 18.5 Division of the zona pellucida of the lesser omentum
122
K. Ashour et al.
It is important in a Thal fundoplication to mobilise the
greater curve of the stomach as far as the short gastric vessels, because the fundus is folded across the anterior aspect
of the oesophagus in a Thal fundoplication. If the fundus is
not mobilised sufficiently, there is too much tension to make
a Thal fundoplication feasible.
Fig. 18.6 Dissection of phreno-oesophageal ligament at the 9 o’clock
position
18.4.5 Placing the Sutures
Interrupted 2–0 polyester (nonabsorbable and easy to tie) on
a “ski” needle works well; intra- or extracorporeal suturing
may be used.
Thal fundoplication originally was described as a 180°
anterior wrap [1]; however, a 270° wrap is preferable. The
sutures in the oesophagus are placed in an inverted “U” starting at the gastro-oesophageal junction and running up the
left side of the patient’s oesophagus, across the top of the
intra-abdominal oesophagus, and down the right-hand side.
The “mirror image” sutures are placed in the greater curve of
the stomach starting at the gastro-oesophageal junction and
extending laterally along the crest of the greater curve
(Fig. 18.8). Approximately seven to nine sutures are required.
The first suture should be placed at the gastro-oesophageal
junction between the greater curve of the stomach and the
left side of the descending oesophagus (Fig. 18.9). Sequential
stitches are placed as described earlier (Fig.
geon continues the fundoplication by suturing the top of the
fundus to the top of the intra-abdominal oesophagus
(Fig. 18.11). The wrap is completed by suturing the lateral
aspect of the fundus to the right side of the descending
oesophagus. At this point, the posterior vagus usually is seen
(indicating that the wrap is around the back of the oesophagus). Once completed, the Thal fundoplication looks a like a
pancake across the front of the oesophagus (Fig. 18.12).
There is no need for a wide-bore nasogastric tube as a
partial wrap is not likely to be too tight.
18.10). The sur-
Fig. 18.7 Mobilising the oesophagus (minimal dissection)
18.4.6 Closure
The Nathanson retractor should be removed under laparoscopic vision, the ports removed under vision, additional
local anaesthetic instilled around the port-sites, and the port
sites closed.
18 Laparoscopic Thal Fundoplication
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123
Fig. 18.10 Suturing the fundus to the left side of the oesophagus
Fig. 18.8 Thal fundoplication
Fig. 18.9 Starting the Thal fundoplication: suturing the lower part of
the fundus to the lower part of the oesophagus
Fig. 18.11 Suturing the top of the fundus to the top of the intraabdominal oesophagus
Fig. 18.12 Completed Thal fundoplication
124
K. Ashour et al.
18.5 Highlights and Pitfalls
• If the surgeon is right-handed, position the main working
port high in the patient’s left upper quadrant, just below
the costal margin, with the (inner) tip lying at the level of
the transverse colon and greater curve of stomach. This
allows good triangulation, and instruments can be inserted
and removed easily without too much movement of the
camera, saving time and making the surgery easier.
• Make sure the (inner) tip of the right upper quadrant port
is to the (patient’s) left of the falciform ligament. This
keeps the instruments from snaring in the falciform ligament each time they are inserted.
• Do not start dissection until there is good exposure and
liver retraction. Spend an extra few minutes optimising
the access to the oesophagus; this saves time and effort
during the operation.
• If access and visibility deteriorate during the operation,
check for leaks, pressure settings, patient position, and
muscle paralysis. Discourage the anaesthetist from using
nitrous oxide.
References
1. Ashcraft KW, Holder TM, Amoury RA, McGill CW, Holder
Thal fundoplication: a simple and safe operative treatment for
TM.
gastroesophageal reflux. J
2. Kubiak R, Andrews J, Grant H. Long-term outcome of laparoscopic Nissen fundoplication versus laparoscopic Thal fundoplication: comparison of long-term outcomes. Ann Surg.
2011;253(1):44–7.
3. St. Peter SD, Barnhart DC, Ostlie DJ. Minimal vs extensive esophageal mobilisation during laparoscopic fundoplication: a prospective
randomised trial. J Pediatr Surg. 2011;46(1):163–8.
Pediatr Surg. 1978;13(6D):643–7.
Pyloric Stenosis
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Merrill McHoney
Abstract
The laparoscopic approach for pyloromyotomy is gaining in popularity, mainly as a result
of its cosmetic advantage, ease of operation, and good outcome [1, 2]. It requires very basic,
inexpensive instrumentation, which probably helps make it cost-effective compared with
open surgery [3]. Whatever the reasons for the increasing popularity of laparoscopic pyloromyotomy, the approach may be embarked upon safely by those with suitable skills and
resources, and is taught easily.
Keywords
Pyloric stenosis • Ramstedt’s operation • Pyloromyotomy • Laparoscopy
19
19.1 General Information
The laparoscopic approach for pyloromyotomy is gaining in
popularity, mainly as a result of its cosmetic advantage, ease
of operation, and good outcome [1, 2]. It requires very basic,
inexpensive instrumentation, which probably helps make it
cost-effective compared with open surgery [3]. Whatever the
reasons for the increasing popularity of laparoscopic pyloromyotomy, the approach may be embarked upon safely by
those with suitable skills and resources, and is taught easily.
M. McHoney, MD, PhD
Department of Paediatric Surgery,
Royal Hospital for Sick Children,
9 Sciennes Road, Edinburgh EH9 1LF, UK
19.2 Working Instruments
• 5-mm port
• 30° telescope
• 3-mm blade for pyloromyotomy (e.g., Conmed Linvatec
[Largo, FL] or Smith and Nephew [London, UK] disposable
3-mm menisectomy knife)
• Two 3-mm Johan forceps
• 3-mm pyloromyotomy (Tan) spreader (optional)
© 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_19
125
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