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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
20 I. A. M. J. Broeders
a
b
Fig. 4.1 Trocar placement
Fig. 4.3 Opening pars flaccida of the gastrohepatic ligament (a), pre-
serving hepatic branch of the vagal nerve (b)
techniques are required. One may choose clips or advanced
haemostatic surgical equipment. Cutdown of this artery may
Fig. 4.2 Liver retractor position
result in postoperative liver enzyme rise and has incidentally caused liver necrosis in gastrectomy patients.
Start the cutdown of the pars flaccida distally, stick to
the pars flaccida and a better access to the right pillar of
the right crus. Cutdown of the hepatic branch may induce
slower emptying of the gallbladder. This does not give any
symptoms but may result in a higher chance of gallstone
formation in the long run.
the translucent area, and bent toward the patient’s left in the
vicinity of the dome of the oesophageal hiatus. Be aware of
the aberrant left hepatic artery in that upper part in case of
large hiatal hernia’s because the pars flaccida with its structures may be pulled upward.
One will often encounter a large arterial branch in the
pars flaccida running from the left gastric artery toward the
left liver lobe. This aberrant left hepatic artery will be found
in up to 30% of patients. The artery should preferably be
4.1.4 Incision of the Oesophago-Phrenic Ligament
saved together with the hepatic branch of the vagal nerve. In
case it hampers adequate surgical performance due to serious overweight or large hiatal hernia’s, the artery and vagal
nerve branch can be sacrificed but adequate hemostatic
The next step is to open the oesophago-phrenic ligament.
The assistant pulls the curvature minor to the patient’s left,
presenting the right pillar of the right crus. The ligament is
ab
Fig. 4.4 Incision (a) and section (b) of the oesophago-phrenic ligament
incised just medial to the rim of pillar (Fig. 4.4). This gives
access to the mediastinum. The incision is started dorsally
and continued upward up to the upper rim of the oesophageal hiatus. The left-hand instrument is placed in the mediastinum to push the pillar laterally, and the right-hand
instrument pushes the oesophagus with the dorsal vagal
nerve medially, resulting in blunt mobilization of the
oesophagus.
The incision of the oesophago-phrenic ligament is continued just below the upper rim of the hiatus toward the
patient’s left side (Fig. 4.4), while the left-hand instrument
pulls the gastro-oesophageal fat pad toward the patients left
side and assistant pulls the gastric fundus downward. The
gastro-phrenic ligament is then exposed and can be cut.
Little heat should be applied during dissection at the
level of the upper hiatal rim in order to avoid thermal damage to the anterior vagal nerve. The nerve is usually in close
vicinity of the oesophageal muscular tube, nevertheless
care should be taken not to cut it during mobilization of the
oesophagus in the upper area.
214 270 Degrees Fundoplication for Gastroesophageal …
a
b
4.1.5 Blunt Mobilization of the Oesophagus
Below the Dorsal Vagal Nerve
In other surgical textbooks, fundoplications are positioned between the oesophagus and the dorsal vagal nerve.
This requires dissection of the nerve, with a fair chance of
mechanical or thermal damage.
The oesophagus has to be lifted in an upward and medial
direction by the assistant, compressing the vagal nerve
to the oesophagus. This should be visualized to be certain
of the position of the vagal nerve. Subsequently the tissue layer between oesophagus and aorta can be cut with a
haemostatic surgical instrument to allow save dorsal mobilization of the oesophagus (Fig. 4.5). The surgeon has to
be aware of the margin of the right pleura which is close,
Fig. 4.5 Blunt mobilization of the oesophagus below the dorsal vagal
nerve (a) and dissection into the posterior mediastinum (b)
22 I. A. M. J. Broeders
a
certainly in large hiatal hernias. In case of a pleural tear,
increase end-respiratory pressure and do not attempt to
close. In will very rarely result in a postoperative pneumothorax. A thorax X-ray at the postoperative ward may be
advisable to be sure.
4.1.6 Division of the Short Gastric Vessels
and Gastrosplenic Ligament
The next step is to open the bursa omentalis at the upper
greater curvature and cut the short gastric vessels and the
spleno-gastric ligament (Fig. 4.6). This step is required to
allow a tension-free shift of the fundus behind the oesophagus. It also allows optimal exposition of the left pillar of
the right crus. Cutdown of this ligament is debated in literature, but performed by most surgeons in 270–360 degrees
fundoplications.
The length of the cutdown should be limited to avoid
unnecessary devascularisation of the fundus. The ligament
is cut at about 0.5–1 cm from the gastric rim. This avoids
thermal damage of the gastric wall, but does not leave fatty
tissue on the dissected fundus. Also, dissection very close to
the splenic hilum is avoided as much as possible.
Dissection is performed with advanced bipolar or
ultrasonic laparoscopic dissection equipment. Five millimetre instruments perform adequate. Do not pull on the
fundus during activation of the instrument because vascular
branches may slip from the instrument tip before complete
coagulation.
b
c
4.1.7 Cut Oesophago-Phrenic Ligament on the
Left Side
Once the fundus is completely mobilized, dissection can be
continued upward, just medial to the muscular rim of the
left pillar of the right crus. The oesophagus can be mobilized on the patients left and left anterolateral side then,
merely blunt, with coagulation of small vessels (Fig. 4.7).
Care should be taken when mobilizing below the oesophagus, because exposure may lead to torsion of the oesophagus, with migration of the dorsal vagal nerve to the patients
left side.
4.1.8 Dissection of the Left Crus from the
patient’s Right Side
Once mobilization on the patient´s left side is finished, final
dissection below the oesophagus from the patient´s right
side can be performed (Fig. 4.8). The lower part left pillar
Fig. 4.6 Division the short gastric vessels, starting from caudal (a, b)
to cranial (c)
of the right crus is freed and complete circumferential cutdown of the oesopghago-phrenic ligament is verified. A
window is thereby created behind the oesophagus, allowing
easy passage of the fundus (Fig. 4.8).
ab
Fig. 4.7 Cut the oesophago-phrenic ligament (a) and blunt mobilization of the oesophagus from the left side (b)
a
4.1.9 Keep Track of the Vagal Nerves
The position of the vagal nerves should always be in the
mind of the surgeon in order to avoid damage (Fig. 4.9). In
case the position is not clear, the nerves should be sought
for carefully.
234 270 Degrees Fundoplication for Gastroesophageal …
4.1.10 Start of the Suturing of the Crus
The next step is to narrow the right crus to a size that pro-
b
c
vides complete covering of the oesophagus by the pillars of the right crus, without oesophageal compressing or
narrowing.
Suturing is usually started from below (Fig. 4.10). The
oesophagus with the adjacent dorsal vagal nerve is lifted
upward by the assistant using a blunt instrument. A sling to
stretch and position the oesophagus may be applied, broad
and atraumatic material should be used. An oesophageal
calibration tube may be used when checking the size of the
hiatal opening. Various reusable tubes are available for this
purpose. They should be positioned with great care under
laparoscopic control to avoid oesophageal damage or tears.
There is no conclusive evidence that these devices should
be used at all times to avoid dysphagia.
The crus has to be sutured with strong non-absorbable
sutures. 2.0 multifilament polypropylene sutures are used
most often. In case the surgeon wants to use running and
self-locking sutures, a high-quality clip at the distal end is
advised because of the repetitive strain on these sutures.
The pillars should be positioned with light compression;
gaps are not allowed. Excessive compression is not advised
because of the possibility of muscular necrosis or tearing
with subsequent widening of the hiatus.
Fig. 4.8 Dissection of the left crus from the patient’s right side (a, b)
and creation a window behind the oesophagus (c)
24 I. A. M. J. Broeders
ab
Fig. 4.9 Preservation of the anterior (a) and posterior (b) vagal nerves after esophageal dissection
The sutures should encompass the complete broad rim of
4.1.11 Fundus Pull Through
the pillars, with the peritoneum on the outside. Small bites
will result in muscular tears. The lower sutures should be
positioned with care because the aorta is just behind the
lower border of the right crus. In case of puncture of the
aorta, carefully remove the needle by pulling back the tread
and compress with an instrument on the crus. This gives
time to perform suction and position a gauze. Gauze compressing for a few minutes will usually solve the problem.
Suturing of the crus requires an adequate laparoscopic
suturing technique. The use of sliding knots is advised as
tension may be present when bringing the pillars together.
Suturing devices such as the Endo Stitch™ can be applied
but standard needles will allow optimal tailoring of the
After tailoring of the hiatus, the fundus is pulled behind the
oesophagus (Fig. 4.11). First, omentum between fundus and
spleen is pulled downward, and the fundus is positioned
infero-lateral to the oesophagus. Then the oesophagus and
dorsal vagal nerves are lifted, exposing the passage behind
the oesophagus. The fundus is grabbed with an atraumatic
instrument and pulled behind the oesophagus.
The pull through should be relatively tension free, and
a fair amount of the upper fundus should be passed. The
fundus may be grabbed both on the right and left side and
moved from side to side, to check for tension and to be sure
that the fundus is not rotated.
stitches.
In small hiatal hernia’s one or two stitches behind the
oesophagus may be sufficient. In larger hernia’s more
stitches are needed and closure above and below the
4.1.12 Suturing of the Fundus and Creation of the Fundoplication
oesophagus is advised. Suturing below the oesophagus only
will result in kinking of the oesophagus and may induce
unfavourable spread of forces applied on the right crus.
When suturing above the oesophagus, start high, just below
the diaphragm vein, to alter the shape of the upper dome
from oval to triangular, and to avoid excessive force on subsequent upper hiatal sutures (Fig. 4.10).
Calibration of the size of the hiatus strongly depends on
experience. The hiatal size should be checked without any
pulling on oesophagus or stomach. The pillars should completely cover the oesophagus, but tailoring or narrowing is
not allowed. When using a bougie, this should be checked
again after removal. A laparoscopic instrument has to be
passed along the oesophagus into the mediastinum with
ease.
The fundus should be fixed to the diaphragm at multiple
sites to avoid fundus slippage and recurrence of reflux.
Suturing to the oesophagus only induces a fair chance of
failure at long term. The muscular fibres of the oesophagus
are fragile and the fundus has a tendency to return to its natural position.
Suturing of the fundus starts at the patient’s right side
(Fig. 4.12). The first suture takes the oesophagus muscular
wall, the right pillar close to the upper rim of the hiatus, and
the backside of the pulled-through fundus. Subsequently,
two sutures are placed along the right side of the abdominal part of the oesophagus. The goal is to cover a stretch
as long as possible along the abdominal oesophagus. This
implies that the first suture should be placed as high as
254 270 Degrees Fundoplication for Gastroesophageal …
ab
cd
ab
Fig. 4.10 Posterior (a, b) and anterior (c, d) hiatus closure
Fig. 4.11 Fundus is pulled behind the oesophagus (a, b)
possible, and the lowest suture as close as possible to the
GE junction at the lesser curvature. Be aware not to take
branches of the anterior vagal nerve at that point.
After finishing the right side of the fundoplication,
the fundus is pulled a bit from left to right, and a stitch is
positioned from the backside of the fundus to the crus, in
between the crural sutures. This stitch releases tension
on the fundoplication and fixes the fundus to the crus
once more, in an attempt to provide long-term success
(Fig. 4.13).
The final part of the procedure is the suturing of the
fundoplication on the patient’s left side (Fig. 4.14). The
first stitch takes the fundus, close to the diaphragm and
close to the oesophagus, then the left pillar of the right
26 I. A. M. J. Broeders
a
a
b
b
c
Fig. 4.12 Suturing the fundus. Schematic (a) and close view (b, c)
c
Fig. 4.13 Suturing of the backside of the fundus to the crus.
Schematic (a) and close view (b, c)
274 270 Degrees Fundoplication for Gastroesophageal …
a
a
b
b
c
Fig. 4.15 Final result of the 270 degrees fundoplication. Schematic
(a) and close view (b)
Care should be taken to avoid the anterior vagal nerve
when suturing the fundus to the oesophagus. The final two
stitches fix the fundus to the left lateral wall of the oesophagus. Again, a stretch as long as possible should be covered.
The most distal stitch is positioned in the oesophagus just
above the initiation of the gastro-oesophageal fat pad. Take
Fig. 4.14 Left side of the fundoplication. Schematic (a) and close
view (b, c)
the fundus at its projected rim, close to the oesophagus.
crus just lateral to the upper rim and then the oesophageal
muscular wall as high as possible. The gastro-oesophageal
fatpad should be pulled downward and slightly to the
patient’s right side to expose the structures as mentioned.
4.1.13 Checking and Ending
The final result is checked (Fig. 4.15). The fundoplica-
tion should be tension free and should cover at least a few
centimetres of intra-abdominal oesophagus on both sides.
28 I. A. M. J. Broeders
The hiatus should cover but not tailor the oesophagus.
A blunt instrument may be passed along the upper rim of
the oesophagus into the mediastinum, to be sure of a good
hiatal size. The area is checked for any bleeding sources,
and the liver retractor and trocars are removed under laparoscopic control. As much as possible CO2 is removed by
suction before removing the last trocar.
References
1. Nissen R. Eine einfache operation zur beeinflussung der refluxoesophagitis. Schweiz Med Wochenschr. 1956;86:590–2.
2. Broeders JA, Bredenoord AJ, Hazebroek EJ, et al. Reflux and belching after 270 degree versus 360 degree laparoscopic posterior fundoplication. Ann Surg. 2012 Jan; 255(1):59–65.
3. Kellokumpu I, Voutilainen M, Haglund C, et al. Quality of life following laparoscopic Nissen fundoplication: assessing short-term
and long-term outcomes. World J Gastroenterol. 2013;19:3810–8.
4. Xing Du, Zhiwei Hu, Yan C, et al. A meta-analysis of long follow-up outcomes of laparoscopic Nissen (total) versus Toupet
(270°) fundoplication for gastro-esophageal reflux disease based
on randomized controlled trials in adults. BMC Gastroenterol.
2016;16:88.
5. Broeders JA, Roks DJ, Ahmed Ali U, et al. Laparoscopic anterior
180-degree versus nissen fundoplication for gastroesophageal reflux
disease: systematic review and meta-analysis of randomized clinical
trials. Ann Surg. 2013;257:850–9.
Laparoscopic Nissen Fundoplication
Bernard Dallemagne
5
5.1 Introduction
Surgical procedures to treat gastroesophageal reflux are
indicated in well-studied patients. Nowadays, different
techniques are performed like an antireflux procedure, with
no clear differences in functional results. Nissen fundoplication is one of these options. The first laparoscopic Nissen
fundoplication was performed in 1991 [1]. Today this procedure is the most common antireflux technique and many
variations have been used to improve surgical results.
Nissen fundoplication is associated with potential complications: dysphagia, gas bloating, reflux symptoms
recidive, etc. [2]. For this reason, this procedure must be
indicated in selected patients and it must be performed by
an experienced surgeon [3].
5.2 Description of the Surgical Technique
The key steps to perform a laparoscopic Nissen fundoplication include the following (Video 5.1) [4].
5.2.1 Patient and Trocars’ Position
5.2.2 Exposure of Operative Field
A good exposure of the principal structures is required at
the beginning of the surgery. To do enough retraction of the
left lobe of the liver a Nathason retractor is placed.
30 degrees laparoscope is used at this time to identify
pars flaccida of the gastrohepatic ligament and the crura
(Fig. 5.2).
5.2.3 Start the Intervention
This step includes:
– Division of pars fláccida from inferior to superior
(Fig. 5.3). It is important to preserve the nerve branch
(from the vagus) and the left hepatic arterial branch from
the left gastric artery.
– Exposure of the crura. By traction of the stomach the
phreno-esophageal membrane is open. After the dissec-
tion of the right crus, the esophagus is dissected into the
mediastinum (Fig. 5.4).
– Dissect the esophagus from the left crus by blunt dissec-
tion (Fig. 5.5).
Patient is placed in french position, the surgeon is located
between patient´s legs and five trocars are placed (Fig. 5.1)
5.2.4 Circumferential Exposure of the Distal
Esophagus
Abdominal esophagus must be dissected completely, making a posterior window. In this step, it is necessary to take
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_5) contains
supplementary material, which is available to authorized users.
care of and preserve the integrity of the right pleura and
vagal nerves (Fig. 5.6).
5.2.5 Taping of the Esophagus for Retraction
B. Dallemagne (*)
L’Hopital and IRCAD, 67000 Strasbourg, France
e-mail: bernard.dallemagne@ircad.fr
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_5
An umbilical tape is placed around the esophagus to do a
correct retraction (Fig. 5.7).
29