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392 Atlas of Gastrointestinal Surgery: Esophagus
Liver
retracted
Vasa brevia
divided
1
A measurement is made 16 cm caudal to the xiphoid process and 3 to
4 cm to the left of midline for insertion of the
laparoscope. An auxiliary 5-mm port is placed
for retraction of the left lateral segment of the liver.
This is generally placed in the anterior axillary line at the
right costal margin. Two prime operative ports are placed
fairly high along each costal margin on the right and left side.
Stomach
Spleen
Finally, an additional working laparoscopic port is placed in the anterior axillary line slightly below the left costal margin.
Initially, the abdomen is explored for other pathology. Then, with the left lateral segment of the liver retracted in a cephalad direction, the lesser sac is entered by dividing
the vasa brevia from the mid-greater curvature of the stomach towards the hiatus (1). As this dissection
progresses, the structures of the retroperitoneum can be visualized in the lesser sac (pancreas, hilum of the spleen, and
splenic artery). As the dissection progresses, the vasa brevia become ever shorter. At the superior pole of the spleen they
often can be quite short, making this dissection difficult. Often the final few vessels are divided adjacent to and close to
the splenic capsule. Retraction forces during this portion of the procedure must be carefully applied, as tearing of the splenic
capsule can cause problematic bleeding. Once the last few vessels at the superior pole of the spleen are divided, the spleen
falls away to the patient’s left revealing the left crus of the diaphragm (2).
Anterior vagus n.
Laparoscopic Nissen Fundoplication 393
Left cras
Esophagus
retracted
medially
Divided
vasa brevia
Spleen
Posterior
stomach
2
At this point, the angle of His, the gastroesophageal junction, and the distal esophagus are
carefully dissected free. The surgeon begins this
retro-esophageal dissection from the left-hand side.
The more that can be safely accomplished from this
side during this portion of the procedure, the
easier the dissection will subsequently
Gastrohepatic
ligament divided
be when dissecting from the right.
Next, the lesser sac is
opened from the right by dividing the filmy gastrohepatic ligament with the hook cautery
(3). This is initiated in a clear
spot where the tissue can be
Stomach
3
Caudate lobe
safely divided.
394 Atlas of Gastrointestinal Surgery: Esophagus
Retraction of the stomach to the left reveals the caudate
lobe of the liver, the right crus of the diaphragm, and the
posterior esophagus. The anterior (left) vagus nerve and its
branches are often visible at this juncture. Care must be
taken during this dissection to avoid inadvertent division of
a replaced left hepatic artery. When this anomaly occurs
(4), the primary arterial blood flow to the left lobe
of the liver traverses this tissue.
The dissection is carried from this point anteriorly to release the anterior esophageal tissue
from the arch of the crus. The anterior vagus
nerve can be seen at this point, usually directly on the surface of the anterior esophagus. As
the dissection is continued posteriorly (5), the
stomach is lifted in an anterior direction.
Dissecting only tissue that is filmy and safe, the
surgeon can work posterior to the gastroesophageal junction and completely encircle it by connecting to the dissection previously performed along the
left side of the esophagus.
Replaced left
hepatic a.
4
Anterior
vagus n.
R. and
l. crura
Stomach
lifted
anteriorly
Connection
to previous
dissectioin
5
An umbilical tape or Penrose drain is placed around the
gastroesophageal junction (6) and locked with an endoloop.
This provides a handle for retraction of the gastroe-
Laparoscopic Nissen Fundoplication 395
sophageal junction in all directions (7). This dissection also allows the surgeon to clearly identify the
anterior and posterior vagus nerves and to mobilize a significant length of intra-abdominal esophagus (5 to 7 cm).
With the gastroesophageal junction isolated
and elevated, both the right and left crura
should be visible behind the stomach, looking
from the patient’s right side toward the left.
Tissue around the crura is carefully dissected away
revealing the point where the crura come together. Care must be taken with this dissection, as the
aorta is immediately deep to the crura. The gastroesophageal junction is then retracted to the
patient’s left, and the laparoscope moved to the
Esophagus
encircled
6
R. and l.
crura
patient’s right. The angulation of the scope is
adjusted so that the view is from the left. From
this perspective, the left crus is further
dissected away from the esophagus
(7), creating additional intraabdominal length.
Esophagus
7
Aorta
Left crus
Stomach
396 Atlas of Gastrointestinal Surgery: Esophagus
Crural
closure
The next objective is closure of the crura. Many surgeons
advocate the placement of a sizer passed by the anesthe-
siologist, either an inflatable orogastric tube or a
Maloney dilator, within the esophagus to help
judge how tightly the diaphragmatic crura
should be closed. Teflon pledgets are usu-
ally used to buttress the crural closure
(8). The sutures are placed laparo-
scopically and tied either intracorpo-
really or extracorporeally. With the
sizer in place, the crura are approx-
imated until closed snugly around
the esophagus. One should check
the adequacy of the crural closure
by visualizing the amount of space
anterior to the esophagus and the arch
8
of the crura. If there is too much space,
another stitch should be placed. If the
anterior esophagus is impinged by the arch
of the crura, the closure is too tight.
With the crural closure accomplished, the wrap is
Posterior
fundus
constructed. The gastroesophageal junction is once
again retracted anteriorly and an atraumatic
grasper is carefully placed behind the esoph-
Esophagus
Closed
crura
agus from left to right. The posterior fundus
is then grasped, and pulled posterior to
the esophagus (9). This should be car-
ried out under direct vision by placing
the angled telescope behind the gastroe-
sophageal junction to view the posterior
fundus. In some obese individuals, this can
be very difficult. In these circumstances, the
fundus can be “pushed” from the left side to
the right side, or a suture can be placed in the
9
posterior fundus on the left side which is then
passed posterior and used to pull the posterior
fundus around to the patient’s right side. With
the posterior fundus in position, a spot on the
anterior fundus on the patient’s left is chosen,
which will create an appropriately floppy
esophageal wrap.
With the posterior fundus on the right of the
esophagus and the anterior fundus on the left, each
held by atraumatic graspers, the wrap is “rocked”
back and forth to be sure it is not twisted, or too
Laparoscopic Nissen Fundoplication 397
tight, or too loose.
The sutures are then placed, with pledgets.
Each bite also includes a superficial bite of anterior esophagus to help avoid “slipping” of the fundoplication (10). Usually the fundoplication is
constructed with three or four stitches, each
approximately 1 cm apart, to create a wrap 3 to 5
cm in length (11). Following construction of the
wrap, the sizer is removed from the esophagus. The
abdomen is examined laparoscopically for bleeding,
tissue injury, or other problems, prior to removal
of trocars and closure of port sites.
10
Crural
closure
Completed
Nissen
fundoplcation
11
Toupet Fundoplication:
Open and Laparoscopic
Operative Indications
The Toupet procedure was proposed in 1963 when the Nissen fundoplication was emerging as the preferred approach
for the surgical treatment of gastroesophageal reflux. Indications and evaluation are similar to that for any antireflux procedure, however, most feel that the Toupet method should be reserved for those patients with weak esophageal motility to
avoid postoperative dysphagia since the wrap is only 270˚ rather than circumferential.
Operative Technique
Open Technique
The preparation, position and exposure are similar to that described previously for the
Nissen fundoplication. The procedure is performed through an upper midline incision
and can be broken down into three main steps. The first is reduction of the hiatal hernia and mobilization of the abdominal esophagus. Similar to the Nissen, the esophageal
hiatus is exposed by dividing the left triangular ligament of the liver with electrocautery,
and dividing the peritoneum overlying the esophagus. The diaphragmatic crura are mobi-
lized away from the esophagus, and a long right-angle clamp is used to pass a Penrose
drain around the back side of the distal esophagus to facilitate downward retraction. The esophagogastric junction is
inspected and the two vagus nerves identified.
The second step involves mobilization of the posterior fundus. This is performed in the same fashion as for the Nissen
fundoplication. The important maneuver is to expose the inferior aspect of both diaphragmatic crura. The mobilization is
completed by dividing the phrenogastric ligament. The preaortic adhesions between the peritoneal fold of the left gastric
Toupet Fundoplication: Open and Laparoscopic 399
artery and the inferior aspect of the esophageal hiatus fixing the fundus are divided with great care. By doing so, the posterior aspect of the fundus can be pulled behind the esophagus.
The final step is the esophagogastroplasty with phrenogastropexy. The posterior aspect of the fundus is pulled behind
the esophagus carefully with a Babcock clamp or pushed manually from the patient’s left to right. The vagus nerves are
identified, taking care not to incorporate them in the sutures. The fundus is fixed first to the right border of the esophagus
with interrupted 2-0 silk sutures (1). The fundus is then fixed to the right crus of the diaphragm with four or five sutures.
The superior suture incorporates the esophagus, the fundus, and the crus. The lowest suture fixes the fundus to the aortic
fibrous orifice and should be placed without tension (2).
Anterior
vagus n.
Posterior
fundus
sutured to
right border
of espohagus
1
Fundus
sutured
to right crus
2
400 Atlas of Gastrointestinal Surgery: Esophagus
This same technique is used on the left side with the same number of sutures approximating the fundus to the left crus
of the diaphragm (3), starting with the inferior suture. Then the left border of the esophagus is attached to the fundus
(4). The procedure is completed by suturing the superior aspect of the fundus to the phrenoesophageal membrane. The
enlarged esophageal hiatus can be closed with 0-silk sutures on a large Ferguson needle over a 46 French Maloney dilator and nasogastric tube, as with the Nissen fundoplication.
Fundus
sutured
to left crus
3
Completed Toupet
fundoplication
Dilator
NG tube
4
Toupet Fundoplication: Open and Laparoscopic 401
Laparoscopic Technique
The patient is placed in the prone position with arms on arm boards. The appropriate
site for the camera port is approximately 16 cm caudal to the xiphoid process and 3
to 4 cm to the left of the patient’s midline. With a 30˚ angled laparoscope, this position affords the best opportunity to view the esophagus from both sides and from
behind when necessary. In order to obtain such a position, the site can be accessed
directly using the Hasson technique. Alternatively, a simple stab just above the umbilicus can be used to place a Veress needle carefully at the umbilicus, which is the safest
spot for blind placement of the Veress needle. Once the abdomen is insufflated, the
patient is placed in a fairly steep reverse Trendelenburg’s position. It is important to
make the appropriate measurements and mark potential port sites after this has been accomplished because the abdominal
dimensions change, and the surface anatomy is altered relative to bony structures.
A measurement is made 16 cm caudal to the xiphoid process and 3 to 4 cm to the left of midline for insertion of the
laparoscope. An auxiliary 5-mm port for retraction of the left lateral segment of the liver is generally placed in the anterior axillary line at the right costal margin. Two prime operative ports are placed fairly high along each costal margin on the
right and left side. Finally, an additional working laparoscopic port is placed in the anterior axillary line slightly below the
left costal margin.
Initially, the abdomen is explored for other pathology. The left lobe of the liver is lifted anteriorly to expose the esophageal
hiatus. The gastrohepatic ligament is divided using electrocautery. Any hiatal hernia is reduced with downward traction after
incising the peritoneal covering. The right crus of the diaphragm is identified and dissected down to its confluence with the
left crus. Using blunt dissection, a space posterior to the esophagus is created. The esophagus is encircled with a Penrose
drain, retracted downward and further mobilized to allow a 3- to 4-cm segment of intra-abdominal esophagus.
The enlarged esophageal hiatus can be closed with 0 silk. A 46 French Maloney dilator and nasogastric tube within
the esophagus help judge how tightly the diaphragmatic crura should be closed. Teflon pledgets are usually used to buttress the crural closure. The sutures are placed laparoscopically and tied either intracorporeally or extracorporeally.