LAPAROSCOPIC NISSEN FUNDOPLICATION

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LAPAROSCOPIC NISSEN FUNDOPLICATION

B. Dallemagne

Département de Chirurgie Digestive, CHC – Les Cliniques Saint Joseph, Liege, Belgium

Introduction

The idea of fundoplication to prevent gastroesophageal reﬂux was born in 1937 in Istanbul, when Rudolf Nissen performed a transpleural cardia resection and protected the anastomosis within a gastric fold. The ﬁrst fundoplication without resection was performed in 1955, with a short publication appear- ing in 1956 [1].

Nissen’s technique initially consisted of the invag- ination of the esophagus into a sleeve of the gastric wall obtained from the upper portion of the stom- ach. (Fig. 1). The gastrosplenic vessels and the dia- phragmatic hiatus were untouched. The functional importance of the vagus trunks were ignored and neglected: many branches were transected, although without dramatic consequences.

Together with the development of modern tools to study the physiology of the foregut and review of the experience, adaptations were made to the original technique.

Marco Rossetti, coworker of Rudolf Nissen, was at the origin of these adaptations. His technique, the anterior wall technique, is still widely applied. The

important technical changes included a more exten- sive mobilization of the posterior wall of the stomach from the left crus and diaphragm and use of the anterior wall of the fundus to create the total wrap.

In this technique, the detachment of the fundus from the crus and diaphragm enables a complete loose wrap without the need for division of the short gastric vessels [2].

The most commonly performed total wrap nowa- days was introduced by Donahue and Bombeck in 1977 and validated by DeMeester in 1986. The technique involves full mobilization of the gastroesophageal junction and posterior fundus with division of the upper short gastric vessels and a crural repair [3]–[5].

Over the years, the length of the wrap has been reduced to the current 2.0 cm. This operation is com- monly referred to as the short ﬂoppy Nissen.

Surgical technique The short ﬂoppy Nissen Technique

The operation is performed under general anesthesia with endotracheal intubation; the patient is placed in the lithotomy position. The surgeon stands between the legs of the patient with, at his right, the surgical assistant and on his left, the scrub nurse, or another assistant.

Pneumoperitoneum is established in normal fash- ion, with usual precautions. A maximal intraperi- toneal pressure of 14 mmHG is allowed.

The table is maintained in a steep, head-up position: gravity displaces the abdominal viscera from the subdiaphragmatic area.

The ﬁrst trocar, 10 mm caliber, is placed in the supra-umbilical midline, at the junction of the upper

Fig. 1. Original Nissen’s fundoplication (Reprint from Gastro esophageal reﬂux disease: back to surgery? Büchler, Farth- mann (eds) Karger 1997)

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174 Chapter 16

The GE junction is place under traction using a gra- sping forceps from the left lateral port. The lesser omentum is divided, beginnig above the hepatic branch of the vagus nerve to the level of the right crus (Fig. 3).

The phreno-esophageal membrane is then divided in a transverse direction, on the anterior aspect of the hiatal orifice. Then, along the inner side of the right crus, the right esophageal wall is freed by dis- secting the cleavage plane (Fig. 4). This dissection is carried out using ultrasonic scissors. Attention is turned next to the left anterolateral aspect of the esophagus: at its lefts border, the left crus is identi- fied. The clivage plane between it and the left aspect of the esophagus is freed. The gastric fundus is then pulled inferiorely and to the right. The proximal gastrophrenic ligament is divided, beginning the mobilization of the gastric pouch. Extending the dissection the length of the right diaphragmatic crus starts the liberation of the posterior aspect of the esophagus. The pars flacida of the lesser omentum is opened, preserving the hepatic branches of the vagus nerve. This allows access to the crura, left and right, the right posterior aspect of the esophagus and the posterior vagus nerve (Fig. 5). Careful dissection of the meso esophagus and the left crus reveals a clivage plane between this crus and the posterior gastric wall. Confirmation of having opened the cor- rect plane is obtained by visualizing the fatty tissue of the gastrosplenic ligament or the spleen itself, when looking behind the esophagus. A drain is two-thirds and lower one-third between the um-

bilicus and the xyphoid process. The laparoscope is introduced through this port. Visual inspection of the entire peritoneal cavity is carried out.

Under direct vision, four other 5 mm trocars are inserted: their location is shown in (Fig. 2). In our set- up, the surgeon manipulates the subxyphoid and the left mid-clavicular canulas for most of the procedure.

The operation begins with retraction of the left lobe of the liver using a liver retractor introduced through the right trocar.

The remainder of the procedure follows the clas- sical sequence of the operation performed through laparotomy.

Fig. 2. Trocars placement for laparoscopic fundoplication

Fig. 3. Division of the pars condensa of the lesser omentum, pre- serving the branches of the vagus nerve and a left hepatic artery

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passed through this channel and will be held by the left sided assistant and his left sub costal instrument.

This retroesophageal channel is enlarged to allow easy passage of the anti reﬂux valve.

With the traction on the drain at the GE junction, the mediastinal dissection of the esophagus is completed and the esophagus is free from the pleura, the aorta and the crural muscles.

At this point, one obtains an elongation of the intra-abdominal segment of the esophagus and a re- duction of the hiatal hernia if one exists (Fig. 6).

This intramediastinal dissection must be extended to permit 2 to 3 cm of the lower esophagus to

stay without traction in the abdomen, below the diaphragm. This a crucial part of the operation. If this length is not obtained, an extended mediastinal dissection should be carried out. If this is not sufﬁcient, one should consider the possibility of a shortened esophagus and apply adequate techniques.

The following step consists of the mobilization of the gastric fundus. This requires division of the gastrosplenic ligament and the most cephalic short gastric vessels. This dissection starts on the stomach at the end of the gastro-splenic ligament, where a small fat pad is founded (Fig. 7). The rear cavity is opened and all the posterior attachements of the

Fig. 4. Division of the phrenoesophageal membrane and identi- ﬁcation of the right crus

Fig. 5. Creation of the retroesophageal window

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176 Chapter 16 Laparoscopic Nissen-Rossetti fundoplication Controversies still exist about the need for gastric mobilization to construct a real ﬂoppy fundoplication. Number of surgeons applies the Nissen Rossetti fundoplication, the anterior wall technique that does not need short gastric vessels division.

From the original description by Marco Rossetti, here are the main steps of the operation [2] (Fig. 11).

Patient’s positioning and trocars placement are iden- tical to the ﬂoppy Nissen technique.

Esophageal dissection and mobilization is performed in the same manner. The gastrophrenic ligament is divided and a large retroesophageal channel is created. In the original technique, crural repair was performed only in wide hiatus. In the conventional open technique, division of the short gastric vessels was usually not necessary, but was always performed in the presence of ﬁbrosis, adiposity, short fundic convexity and shortened esophagus.

The wrap is different: it is constructed using the anterior wall of the gastric fundus. A wide, tension free, fold of the anterior gastric fundic wall is passed behind the esophagus, grabbed on the right side of the esophagus and sutured with the anterior wall of the stomach on the left side of the esophagus, without fixation on the esophagus itself. Two additional sutures between the base of the fundic fold and the anterior wall of the stomach help to avoid eversion and “tele- scoping’’ of the junction.

upper gastric fundus are divided, including the fundic posterior vessel that has its origin from the splenic artery on the superior border of the pancreas. This dissection ends up when the left crus is reached after division of the gastro-phrenic ligament (Fig. 8).

The next step involves repair of the hiatal oriﬁce:

interrupted sutures, using non-absorbable materiel are placed on the diaphragmatic crura to close the oriﬁce. Calibration can be obtained with a 60 frenches bougie, or by modeling the crural repair on the diameter of the esophagus, without traction on the GE junction. At the end of the repair, the esophagus must be lying without compression in the repaired oriﬁce (Fig. 9).

The last part of the operation consists of the passage and ﬁxation of the antireﬂux valve. An atraumatic forceps is passed behind the esophagus, from right to left. It is used to grab the posterior wall of the gastric fundus to the left of the esophagus and to pull it behind, forming the wrap. At this point, a large bare bougie (50–60 frenches) can be passed down the cardia. It is used to calibrate the fundoplication.

Three interrupted stitches form and secure the wrap. A 1.5–2 cms wrap is constructed. This wrap is ﬁxed on the anterior and left border of the esophagus by two sutures, one at the upper part and one at the lower part of the wrap (Fig. 10).

The peritoneum is rinsed with warm normal saline. No drains are placed. The trocars are removed and the wounds are stapled closed.

Fig. 6. Reduction of the gastroesophageal junction below the diaphragm

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Fig. 7. Mobilization of the gastric fundus

Fig. 9. Repair of the hiatal oriﬁce: the esophagus is lying down on the repair without stricture

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Fig. 10. Fundoplication with the posterior wall of the fundus on the right side of the esophagus and the anterior wall on the left side of the esophagus

From this original description, there have been a lot of adaptations. The most widely accepted is the need for crural repair in all patients. There is a general trend towards ﬁxation of the valve on the anterior wall of the esophagus.

Some authors have described a “minimal dissection’’ technique, where no dissection of the lower esophagus is performed, some times no division of the phreno-esophageal membrane and the anterior gastric fundus is passed trough a small retroesophageal channel to create the valve. There is no systematic crural repair [6], [7].

Postoperative care

No naso gastric tube is left at the end of the operation.

The patient is allowed to drink on the ﬁrst evening.

An intravenous line is left in place until the morning of the ﬁrst postoperative day at the latest.

A Gastrografin swallow is performed on the first postoperative day to verify the position and proper functioning of the antireflux valve. The patient is discharged on the second postoperative day. Dietary instructions are given to avoid the risk of food im- pacting in the distal esophagus during the early postoperative period.

Controversies

Floppy Nissen vs Nissen-Rossetti fundoplication

Demeesteer et al demonstrated in 1986 that fundic mobilisation and short valve, build on a large bare esophageal bougie, led to decreased incidence of side effects (dysphagia, bloating) compared to long valve and valve without gastric mobilization [5]. That concept became the “gold standard’’ of open fundoplication for years.

In the laparoscopic area, some authors reproduced this technique and reported excellent results [8]–[11].

Other authors defend the concept of the anterior wall technique (Nissen-Rossetti technique) without systematic division of the short gastric vessels. Ran- domized trials fail to demonstrate any difference between the two techniques [7], [12], [13], [14].

What can be the advantages and disadvantages of both techniques?

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Difference between the short floppy Nissen and the anterior wall Nissen-Rossetti technique are not limited to the short gastric vessels division. The shape of the antireflux valve is also different. One is constructed with both the anterior and posterior wall of the gastric fundus. By definition, the other one is constructed with the anterior wall of the gastric fun- dus (Fig. 12).

Technically, we feel that the ﬂoppy Nissen fundoplication it is the most reproducible operation.

Mobilization of the gastric fundus allows the surgeon to see the upper fundus in toto, and to use systematically the same landmarks to create the fundoplication. With a good fundic mobilization, the risk is to create a too ﬂoppy valve, if this idea might exist. This looseness of the valve allows also a very precise positioning of the fundoplicature on the GE junction. No traction means no tension on the sutures (risk of disrupted valve), no twist on the GE junction (risk of dysphagia).

But the fundic mobilization is not an easy step of this operation even if it has been facilitated by the new technologies (ultrasonic scissors, ligating sy- stems...). The risk of splenic injury is present. If one mobilizes, it has to be in the good extent and not limited to the vessels of the gastro-splenic ligament.

Some have advocate that gastric mobilization increas- es the risk of intrathoracic migration of the fundoplicature or paraesophageal acute gastric intrathoracic migration. Surgical teams who did not mobilize the

stomach have reported the largest incidence of this type of complication.

The anterior wall technique appears as a more easy operation. It is not. It imposes a very precise choice of the right part of the anterior wall of the gastric fundus that has to be used for fundoplication.

Bad landmarks will lead to complications such as the typical laparoscopic complication, the bilobed stomach. The stomach is divided in two pouches because the valve has been created with the body of the stomach instead of the fundus. Reoperation is unavoidable (Fig. 13).

Other complications include a too tight valve, a twisted fundoplication, and a gastric valve.

The defenders of this type of fundoplication argue that they can adapt their technique depending on the anatomy of the gastric fundus, that sometimes implies division of the short gastric vessels. It is not a true reproducible operation and should be reserved to well trained and experienced eso-gastric surgeons.

Crural repair

There are no randomized control trials evaluating the role of routine crural repair. Nonrandomized studies have shown an intolerable rate of intrathoracic migration and paraesophageal herniation in patients not undergoing crural repair [15]–[18]. Most surgeons use the standard posterior hiatoplasty.

Controversies still exist on the use of prosthetic

Fig. 11. Nissen-Rossetti operation: the anterior wall technique (Reprint from Gastro esophageal reﬂux disease: back to surgery?

Büchler, Farthmann (eds) Karger 1997)

Fig. 12. Anterior fundoplication (warp) and ﬂoppy fundoplication

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180 Chapter 16

and pay careful attention to the details of crural repair.

There are two basic ways to reduce tension on the repair of a hiatal hernia. One is to mobilize the esophagus and the other is to add esophageal length with a Collis gastroplasty.

Mobilization should be the primary method used to achieve increased esophageal length [26]. This is a particular problem with laparoscopic antireflux surgery because several conditions conspire to mask the presence of a short esophagus with this approach. First, the laparoscopic pneumoperitoneum artificially elevates the diaphragm and gives the visual impression during the procedure that there is more abdominal length of esophagus than is actually the case. Second, the esophagus is usually pulled downward during the procedure, and because an assistant does the retraction the surgeon has little sense of the amount of force being used to pull the esophagus down into the abdomen. Both of these conditions are peculiar to the laparoscopic approach and contribute to unrecognized tension after an antireflux operation.

Although there are no absolute indicators, several abnormalities are frequently associated with a short esophagus and can be used clinically to identify patients at risk. These include an esophageal stricture, long-segment Barrett’s esophagus, a paraesophageal or a large (5 cm or greater) sliding hiatal hernia that fails to reduce in the upright position, and a failed previous fundoplication [21].

reinforcement for larger hiatal oriﬁce [19]. Expe- rience from repair of type-II-III hiatal hernia is in- creasing and some randomized trials demonstrate the usefulness of this concept. Long-term results are mandatory, with a special attention on the incidence of visceral injury related to the prosthesis.

Esophageal dissection-shortened esophagus Acquired shortening of the esophagus, while still an area of controversy, is recognized by many surgeons to occur as a complication of longstanding and se- vere gastroesophageal reﬂux disease in some patients [20]–[23]. Other authors consider that the short esophagus phenomenon is overemphasized, over reported, and over treated [24], [25].

However, most surgeons agree that a critical component of the surgical management of reﬂux disease is successful reduction of the gastroesophageal junction below the diaphragm with a minimum of tension: a minimum of 2 cm of intraabdominal esophagus is necessary. Although this is easily accomplished in most patients, in those with a shortened esophagus it can be problematic.

The fact that the most common forms of failure after laparoscopic fundoplication are recurrent hiatal hernia, intrathoracic migration and slipped fundoplication suggests that some esophageal shortening may be present more commonly than appreciated, and that surgeons should routinely assess esophageal length

Fig. 13. Typical laparoscopic error: the bilobed stomach. The fundoplication is build with the body of the stomach instead of the gastric fundus

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Conclusions

On a long-term evaluation, we feel that laparoscopic Nissen fundoplication is able to reproduce the results of open fundoplication as demonstrated in some studies. Our recent study of 100 patients at 10 years after laparoscopic fundoplication demonstrates a 90% rate of reﬂux control, which is comparable to the open long term results (paper submitted to publication).

Some randomized short term trials have demonstrate that after open operations, there are statistically more complains about scars. The other parameters seem to be equivalent: control of symptoms, side effects. But, we must keep in mind that these results are obtained, in the laparoscopic group, with a reduced mortality and morbidity rate, shorter hospital stay and sick leave and a lower incidence of incisional complications. There is also, a substantial reduction in the rate of incidental splenectomies, as they are reported in the open series (0–8%).

In summary, if long-term series conﬁrm the results obtained in dedicated centres, laparoscopic Nissen fundoplication should become the “gold standard’’ of treatment for gastro -oesophageal reﬂux disease in appropriately investigated and selected patients.

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