Laparoscopic Nissen Fundoplication

CHAPTER 1

So today we're going to be doing a laparoscopic Nissen fundoplication. This is a 63-year-old gentleman who has a long-standing history of acid reflux or GERD, that's refractory to medical management with very high dose proton pump inhibitors so he is undergoing surgical management for his very debilitating disease. The preoperative workup consisted of an endoscopy that was normal, the barium swallow that shows no hiatal hernia, esophageal function test with manometry that showed normal peristalsis, and pH monitoring that shows an abnormal amount of acid reflux over 24 hours. So the way we're going to position the trocar is - the xiphoid process is right here, and this is the costal margin, on the left and on the right. So the first trocar will be an optical trocar that will be placed 14 centimeters from the xiphoid process, which is more or less here. The tendency is to put the trocar lower. That would be a mistake. We want to be as close to the gastroesophageal junction as possible so somewhere around here for the first trocar. And then we're going to place two trocars: one at the junction between the midclavicular line below the left costal margin, one at the junction between the midclavicular line and the right costal margin, and then one on the anterior axillary line, in the level of the umbilical port - somewhere here. We're going to place also somewhere on the left side of the xiphoid process a liver retractor, which will be secured to the patient's bed.

CHAPTER 2

Right here, on this portion. Okay. Incision. It's 1:17. Thank you. Good. Good job. Get after the scope. Right there, it's on your side. Right there. Perfect. Can I have a Kocher, please? Yeah, now you have to go with the cut because it's - just cut down, yeah, it's burned. Cut this piece right here. Okay, stop. S-retractors?

Now, you see the fascia there? The white stuff? Grasp the fascia with the Kocher. Big bite. Yeah, nice, perfect. Do you take it? No. Okay, maybe, no, Kocher. Okay, hold this. Pull it towards you - this guy. Okay. Again, so here is the same concept; so instead of grasping the skin and leaving the fascia at the level of the abdominal wall here, we have made an incision onto the skin, grasped the fascia, which is white, right here. So now we have at least one inch between the edge of the fascia and the abdominal contents. So we're going to make an incision and put a Veress needle in and insufflate. And insufflate the abdominal cavity. Okay, drop test. Don't worry, I'll hold this. Aspirate first. No gap, no blood, perfect. Go down. All right, take it out. Perfect. You see how everything goes down. High flow. Yeah, one second. Put it on your mask. Right there. Yeah so you can see. Do you feel it? Yep, okay. Okay. Perfect. It's okay. Don't worry. You can twist it. Okay. So the opening pressure is, okay, it’s 3. Yeah, 3 liters per minute. Take those out. Hold it. All right, and I think that's okay. Scott? That's yours.

Right into the hole that we made. See if you can feel it. Can you feel it? Yeah. Okay. Now, this one here. Use this guy. Okay. Twist. Twist like you mean it. Perfect. Okay, so let’s - gas, there - the black stuff, you see? It’s super easy. One second. Perfect. Can I have the local? This one here is just to see - take out. You can do this to clean it, okay? And put it in. This one here is very up in the chest. Okay, hold this for a second. Can you put the patient in reverse Trendelenburg now? Perfect, thank you. Okay, make an incision right here. Okay. Transverse incision.

Marking pen? Right below the costal margin. Right there. Perfect. That’s fine. You got it. For a 12 mm. Okay. That’s fine. Can I have a Kelly? I just want to make sure. Can you hold it for a second? Here. Can I have a knife? Okay, as you can see, you got to make the incision bigger. Okay. Okay.

Can I have a knife? A Schnidt, afterwards. Perfect. Okay, the snake retractor. Hold it-hold this. Okay. You have to go in the other side. Now we are inserting - the liver - what is going to become our liver retractor. Okay. Perfect. Yes, in the hole. Tighten this one here. Okay, now you tighten this one here. Yeah, good. Okay, harder, harder, harder. Perfect. And now you tie the end. Okay, now it’s fixed.

Now, this is one. We’re going to put another one somewhere there, okay? Knife? Knife back. Just... Yeah, yeah, give it to him. Open up the dermis. Yeah. Kelly? Yeah, Kelly just to stretch the skin. Perfect. Kelly back. Straight down. Release a little bit - perfect. Okay. Okay, make sure you didn’t cause any problems here. Nothing. Put it in, more. Perfect. Take this thing out. Okay.

Okay, can you make an incision here? Knife. Right here? Sure. Can I get a Kelly, please? Perfect. Okay, can we have the lights off?

CHAPTER 3

Okay. So, this one here is the left lobe of the liver with the triangular ligament right there, right? This is the greater omentum and the spleen - it's right there, you see? Yep, almost - almost - anyway, it's there - I don't want to bust it. So, this one here is the stomach, okay, and the greater omentum is here. Somewhere around here should be the right pillar and the left pillar of the crus. Okay - so that’s the greater omentum, we're going to go down. Perfect. So this is the left - lesser curvature of the stomach. Okay, so the esophagus should be - and the GE junction should somewhere in there. Okay, I'm going to ask you to open traction here, and this transparent stuff is the hepatogastric ligament. We're going to cut it, and we're going to go into the lesser sac. The patient has an NG tube inside, okay. Has no Foley catheter. Okay, so you can see the stomach that goes all the way down - this one here - the branches, the first, the second, and the third branch of the less - left gastric artery. Okay so I’m going to ask you to do this, okay, and pull gently like this, okay?

Okay. Pull now. Pull. So… So this one here is the caudate lobe of the liver. Okay. Good. You have to do this kind of movement, right here, right here. Hold it. Pull it down, so I can see center here because that's where we're going. Come closer with the camera. Perfect. Okay. This one here, right here is the diaphragm.

Okay, now, you can see this part here - this is the right pillar of the crus, and esophagus is somewhere in there. Okay. Come closer. Come closer with the camera. If you can’t see, I can’t see. Okay. Perfect. You see, this is the esophagus. Pull - Scott - pull. You’re pulling? Thank you. Now we’re disconnecting the esophagus. From the right pillar of the crus. Okay. Okay, like this. Those are the attachments, and they are not attached there anymore. Okay. And right here is the apex of left pillar of the crus. Okay? So we went circumferential, from here up to here. So we went - start from the left. We start - we took down the - hepatogastric ligament. We found the apex - sorry, the border of the right pillar of the crus, cut it out, disconnect the esophagus - the right side of the esophagus from the right pillar of the crus. And went all the way around, cutting down the phrenoesophageal membrane. Perfect. There are some attachments that we will take down later.

Okay, so now, let's change - you hold those things. Okay, I may see this. No major problems are there. Okay, over here. So this one here is where the short gastrics are, okay? So you have to come here and grasp as much as you can from there. You want to go on the - okay, grasp. And then keep pushing it a little bit more? Yep, perfect, perfect. Great, perfect. Nice. Sorry, my fault. And then... Go ahead. Push a little bit more. Hey, hold it. Sorry, I know it’s difficult for the first time. It’s okay, don’t worry. Perfect. See if you can hold it like this. Perfect. Okay, so this one here is the lesser - lesser sac from the other side. Yeah. Perfect, okay. Now, Scott. Release what you’re doing. Okay. Release. Perfect. And grab - one goes below and one goes above, right there. Open more. This thing? No. Hold the camera like this. I'll show you. Why is this not opening? Okay. Okay, perfect. Hold this. Okay. Push it - no, down, down, down. Perfect, perfect, perfect, okay. That's okay. See the tip of the NG? See the tip of the NG? Yep. Okay. Okay, now as you can see, this one here is tilted - just keep it this way, okay? Now you are there. Now release, and let’s do the same thing on top, okay? You have to grasp the anterior and posterior wall of the stomach. No, go above. Go above me. Perfect. Perfect. Nice, take it. Okay, perfect. Hold the camera. Now you - it's like, you’re going to do this movement of pulling towards you, because you see, you’re going to open at this angle. Back up - a little more. Back up a little bit. Okay. Back up with the camera. Uh huh. You’re doing fantastic. Come closer. Let me see. Perfect. Those are the short gastrics, okay? Now, stop for a second. You can see that that's where we did the dissection - that's the apex of the left pillar of the crus, you see? So we’re going to connect this to that. Okay, so that’s the spleen. Back up - Uh huh, go in. One second. Uh huh, go in, so I can see. Back up. Mm hmm. Okay, so that’s apex of the fundus. That's a pillar of the crus.

Back up with the camera. Let go - what you’re taking. Perfect. You and I are going here. Zoom in? Come closer. So you can see, this is the pillar the crus, this is the other pillar of the crus. So if you do the dissection in the mediastinum, then you're going to end up in the aorta, okay, but you got to make sure that you make the dissection there. Okay. Hold this. Okay, let's go on the other side. I can’t see where it is. It’s somewhere there. Okay, very good. Let go. Okay. Uh huh, like this - you got to pull really hard. Okay? Okay. Flip it up. flip it, flip it, like... So you are there. You see? Good. Can I have the Penrose? And can you give us also one of those endoloops - no, endo… No, the thing you tie - the loops. The ligating loops? Yeah, yeah. Do you want a quarter inch or a 3/8 inch Penrose? Hold this. Quarter inch. I'm going to follow it to the other side. Yes. Guys, one second. Okay, back up. Perfect, yep. Okay, that’s esophagus, make sense? And now we’re going to use this for traction. Okay, Scott, grab it. Grab the loop. Put it inside. Okay. Now, break it. Break this, okay? Okay. And pull it a little bit. Just pull it a little bit. Not too much. So this now goes inside, okay? One second, hold the entire thing. Can I have a grasper? Oh, okay. Now the tip goes right there where you want to put it, okay? Okay. So pull. Uh huh. Pull, pull, pull, pull. Pull. Pull, pull - tight, tight, tight. Okay. Okay, scissor. Okay, that's it. Now. Your Scissors are on the Mayo. Okay. Just hold it. Scissors. Mm hmm. Pick it up. Perfect. Okay. This is what you're going to lead, okay? You're going to lead with this. So the movement is left, right, down, okay? Because you have the esophagus. Okay. One second, okay, it's not locking. Let me get it. Thank you. Now, pull up towards the patient's shoulder. No, we are going to work here.

Perfect. Pull towards you. Perfect, let’s see if we can work this way. Okay, turn around. That means flip it over. Okay. No, you stay like - you stay like this. The only thing you can do is you can move the stem left and right. Okay, now flip it over on the other side - you back up with the camera. Perfect. Okay. Grasper. Uh huh, like that. You got to squeeze hard because that's unfortunate the way it is. Okay, come closer. Perfect. Good, thank you. Okay, what is this white stuff here? This is… Let's call it aorta. Yes, that is aorta. Okay. Okay, back up, back up. Stop for a second. Hold this. Okay. Flip it over. Okay, let’s do something. Hold the camera like this. Uh huh. Back up. If not, I'm going to crutch. Uh huh. Let’s get in there - Uh huh. More. I’m trying to watch to see what’s going on here. Okay, hold this. Okay, can you hold it like this? Thank you. Back up the camera. Now, flip it over on the other side like we did before. Perfect. Let’s see if we can see much better now. Perfect. Okay. Okay, let’s do it again from the other side. Hold it. Now go in with the camera. Go in. Perfect. Okay, let’s flip it over again. Perfect. Oh, okay. First of all, this is the view that we need to work in because… okay? Okay, this is the right - right pillar of the crus - left pillar of the crus. This one here is the aorta, okay? Come closer, can you go in. That’s the pleura - a hole in the pleura. Do you see lung? No. Okay. Are you pulling, Scott? Okay. Yep. Okay. Okay, let's flip it over on the other side. Okay, no - now we’re going here, okay? Perfect. Okay, hold this. Now, hold this. So, this one here - now you can see the esophagus so that these are like nice and taut. Yep. Okay? I just want you to pull as hard as this. Okay? Squeeze. Okay. Okay, hold this now. Mm hmm, let’s go in again, you and I. Okay, on top. Pull down, down. Uh huh. On the other side - right there, slowly. Okay, hold this. Hold this. So you can see here, this guy here is the anterior vagus, okay? Somewhere there. Okay, hold it like this. Hard. Perfect. Perfect. Uh huh. Go in. That's a lymph node. Okay, can you clean them? Flip it over on the other side. Perfect, up - if you can put it up. Perfect, so those are the attachments on this side. Flip it over on the other side. Perfect. Okay, whatever - go on the other side. Perfect. Okay, so now, can I have, open Ray-Tec? Okay, so forget about this stuff. It’s a small vessel. It’s going to… Can I have the 0 silk? 0 silk on the endostitch. Okay, let go. See now there is at least one inch. of esophagus in the abdomen. Now, you're going to do this. The anterior vagus is there. The posterior vagus is somewhere there - you should not see it. Go ahead. One second. Now grasp it with the tip. The tip is the one that grasps. Uh huh.

Okay. One second, I want to see something. Okay, come closer. Okay, so the posterior vagus is right there. Ting! See? This thing here. So anteriorly - see? Posterior vagus. So anterior and posterior vagus nerves were preserved. Ready? Yes. You see that the - this thing forms a “V.” Hold this guy. The hands. Okay. The “V” like this? Hold the camera now. Okay. You have to show me because… Now... See how close the aorta is? Yeah. Don’t move with the camera - don’t move, don't move. Okay, can I have- Thank you. Just leave it like this. I’ll take another. The next one - cut it shorter. It was too long. How long was the first one? Get me 12. 12 cm. So one cent - big bite, because this one here is a centimeter - one centimeter apart and one centimeter from each other. Yeah. Hunter, Hunter, yes. Okay, so there are two stitches placed there, okay? Should we put another one? No, because look at this, okay? There is at least a good centimeter. Okay. So I'm happy with this.

So I'll explain to you what we're going to do. We're going to get - we’re going to get the fundus of the stomach, okay? So stay there - don't move. That’s the fundus right there. Okay. Easy. Okay. Okay, those are the grasp - the stumps of the short gastric vessels, okay? Okay. Now drop this down, Scott, towards the - no, I’ll do it, I’ll do it. Okay, like this. You see? Okay. Perfect. Do it. This one here - they call it shoeshine maneuver. This one here is a small gastroesophageal fat pad. Okay, just - we can do - use the - the fundoplication will be like this. And we want to do the shoeshine maneuver to make sure that all the fundus is - all the fundus is - is free, okay?

CHAPTER 4

So I grasp the shor - the - the stump of the short gastrics on the, here on the right. And this one here on the left, okay? And this one we’re going to do together like this. Now, you got to get rid of this one here. Okay. Get the Babcock. Grasp right below what I have on my right hand, right below. The fundus of the stomach on there... Lower, lower, lower, lower. Perfect, there. Okay. Can you show - flip it over like this? Perfect. I want to see this part here. Perfect. Okay, let go. Okay, so this is the way that we’re going to do, make sense? Like this. Okay. Now, Scott, grasp left and right part of the fundoplication. Perfect. Go in. Push down, and grasp everything. Squeeze. No. You can squeeze with the paddles. I want the paddles in between - perfect! Perfect. Squeeze hard because they’re going to - okay, do you have the endostitch? Zero? Whatever you have ready.

Yes. Come closer so you can see. Uh huh. Scott, now let go. Perfect. Get the scissors, Scott. And cut this thing. Back up with the camera. Back up a little more? Come closer now. Right there is okay. Come closer. Scott, you have to twist the scissors. Perfect. Good. Two graspers. Okay. All right. Hold this. Penrose is back and intact, okay? Can I have that 0? Scott. Scissors, please. Back up with the camera a little bit? Okay, can I teach you a trick? Yep. Hey, look at where the tip of the camera is. Uhh, okay. Oh, okay! Okay? Perfect. And then you cut yourself. Oh, that’s good. Cut. Yeah. Perfect. Can I have the 0? One second. Hey, I need to see. Ah, perfect. Okay. Okay, can you cut this? Again, see where the tip is? Up, up, up. Hold this. Okay. Okay, so... the fundoplication is here and here. Okay, you may want to put maybe a stitch on top right there just to close it. And see how it works. Okay, can I have another one? Now, I don't know - I have not decided if I want to put this or not, because the thing is that we don't - don’t put the Bougie to calibrate. Okay so, this one here kind of looks nice if you put a superficial stitch. Hold this. Come closer. Perfect. Scissors. No. Okay. Perfect. Fundoplication is done. Okay. Looks super good. It's not too tight. Okay. See? It's not tight at all there. Yeah. See? Agree? Perfect. Okay. Yep.

CHAPTER 5

Can you flatten the patient, please? I'm going to move the bed.

Hold it like this - put it inside, I have to go there. Can I have a Carter-Thomason with a- can you lower the table, please? Okay. Is it down? It’s all the way down, yes. Okay. Can I have the Carter-Thomason? With those 0 Ethibond. Don’t worry about this - perfect. The 0 Ethibond? You want the house lights up? Not yet. Take off the needle. And then you put it there. I don't want you to... Perfect, thank you. Okay. Okay, now lights on in the room. Take this out. Take this port out. Don’t pull it - just take this. If I put the valve in, it’s going to release the... The air. Can we have the room - spotlights. Scissors, please. Okay to turn the tower off? Yes, we’re done. One sec - don’t cut. 4 by 4? Pull them. Okay. Cut this. Perfect, and you'll do the rest. Okay. Do we have a... Okay. The operation is concluded.

CHAPTER 6

Today we did a laparoscopic Nissen fundoplication in a patient who complained about heartburn and regurgitation for several years. He was a placed on anti- antisecretory medications like proton pump inhibitors, 20 milligrams twice a day, and a dose of H2 blockers at night for breakthrough reflux. The patient was still symptomatic, so he underwent the workup for the - the proper workup to be considered for laparoscopic Nissen fundoplication as he could not get medical control of his symptoms. The preoperative workup has been well codified by a - a panel of surgeons and gastroenterologists who got together in 2013 at the Digestive Disease in Dublin. The preoperative workup consisted of esophageal function testing like esophageal manometry and pH monitoring. The esophageal manometry aims at ruling out the presence of achalasia, whose symptoms can be reported also by patients who have gastroesophageal reflux. There is a certain degree of symptomatic overlap, but the treatment of achalasia is completely opposite from the patients with gastroesophageal reflux disease. The second test was a pH monitoring that allows us to detect the pathological amount of reflex. The pH monitoring consists in placing a wire with a tip placed 5 centimeters above the lower esophageal junction, and the tip contains a sensor that detects acid over 24 hours. This test was positive in this patient. That means that over 24 hours, he had an excessive amount of reflux compared - acid reflux - compared to the normal individual. So this was the second test. The third test was an endoscopy. The endoscopy was done to rule out any other causes for the patient’s symptoms. As well as the patient had a barium swallow. The barium swallow gives us an understanding of the anatomy of the foregut, which is the esophagus and stomach. It can rule out the presence of a hiatal hernia or other pathology like esophageal diverticulum or so fourth, so on. So all these tests that were performed according to the general guidelines that were set forth in 2013 by these panel of experts, and after the workup was complete, we took this patient to the operating room. We placed the patient supine on this pink foam. And the most important thing for us was to provide support for the patient in order for him to be placed in almost a sitting up position because if - when a patient is in a sitting position, all the organs try to - tend to fall down, and the surgeon has a great access to the operative field - in this case the gastroesophageal junction, the esophagus, and the stomach. The first portion of the procedure was actually the correct patient positioning. A good patient positioning has allowed us to to perform the operation easier, faster, and better. The portal site placement is straightforward, or conventional. We started the operation by taking down the gastrohepatic ligament. We identified the right pillar of the crus, we went from the apex of the right pillar of the crus to the apex of the left pillar of the crus. Then we identified the right esophageal window, and this was important for us because we wanted to pass this Penrose drain. And the Penrose drain, around the esophagus that incorporates the anterior and posterior vagus nerve, had the purpose of applying an atraumatic traction to the distal esophagus. So we were able to move the esophagus left and right without causing any problems or any trauma or bleeding. By applying traction to the esophagus, we were able to pull the esophagus down by doing the dissection of the esophagus in the posterior mediastinum. So we brought the gastroesophageal junction down in the abdomen for at least 2-2.5 centimeters. Once this was done, we had already prepared the short gastric vessels and the fundus of the stomach. And here, the challenging thing is to perform a complete mobilization of the fundus of the stomach. That means taking down all the short gastric vessels, the posterior gastric artery, and making sure that the esophagus and the fundus of the stomach are free of any connection because in this case we decided to perform a 360, or Nissen, fundoplication or a total wrap. And a complete mobilization of the fundus is essential to perform the wrap. There are several different kinds of fundoplications. There are partial anterior, partial posterior, or total fundoplication. In the United States, we prefer to do a 360 degree or total fundoplication unless the patient has a defect in peristalsis or the peristalsis is extremely weak or almost none / absent such as patients with achalasia. But we had the preoperative assessment through manometry that allowed us to understand that the peristalsis of the esophagus was strong and was normal, so we decided to do total fundoplication, which provided a good balance between control of reflux and prevention of difficulty swallowing in case we did this too tight. The operational was not difficult. There was no hiatal hernia. The dissection was okay. We put a nasogastric tube to decompress the stomach in order to manipulate the stomach better. Then we took it out at the end - almost at the beginning of the operation once we decompressed the stomach. We did not place a Foley in this patient. The operation took 1 hour and 30 minutes. The patient will be taken to the room, on just a regular floor. He will be placed on nothing to eat or drink for tonight. He will be given a regular diet tomorrow morning. He will have no barium swallow, no labs. We didn't have much of bleeding, so labs are - won’t tell us anything that we will do different otherwise. Same thing for the barium swallow. And he will be discharged home after breakfast tomorrow morning with a hospital stay of less than 24 hours. And he will be expected to be seen in clinic in a week. The only of change in the medication that we provided for this patient was to discontinue the proton pump inhibitors that he has been taking for the past year. So that's the reason why we did the operation: to control the reflux, so he will not need the proton pump inhibitors any longer.