doi:10.1510/mmcts.2007.002931
Laparoscopic Nissen fundoplication Philippe Nafteux*, Willy Coosemans, Paul De Leyn, Dirk Van Raemdonck, Herbert Decaluwe´, Georges Decker, Toni Lerut Department of Thoracic Surgery, UZ Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium The dissection is started performing a crural dissection with visualization and preservation of both vagus nerves, followed by circumferential dissection of the esophagus at the gastroesophageal junction. Adequate intra-mediastinal mobilization of the esophagus is performed to obtain 3–4 cm of intra-abdominal esophagus without undue downward traction on the cardia or stomach. The gastric fundus is then mobilized through adequate short gastric vessel division. The left and right pillars of the right diaphragmatic crus are approximated using interrupted sutures. A short (-2 cm), floppy 3608 fundoplication anchored to the esophagus is created.
Keywords: Antireflux procedure; Fundoplication; Gastro-esophageal reflux (GER); Laparoscopic Nissen Introduction The Nissen fundoplication is the gold standard for the operative treatment of gastro-esophageal reflux disease (GERD). This well-established procedure has proved itself to be both durable and safe after followup periods of 20 years and beyond. Since its introduction by Rudolf Nissen in 1956, this procedure has undergone many modifications. The laparoscopic Nissen fundoplication was first reported by Dallemagne et al. in 1991.
Surgical technique Position After induction of general anesthesia and introduction of a bladder catheter, the patient is placed in supine position, legs in split position with both arms alongside the body, secured to the operating table (Photo 1). * Corresponding author: Tel.: q3216346822; fax: q3216346821. E-mail: [email protected] 䉷 2008 European Association for Cardio-thoracic Surgery
The surgeon stands between the patient’s legs with the first assistant to the patient’s left and the second assistant to the patient’s right. Two monitors stand at the level of the patient’s head, on the right and left side, respectively.
Ports placement Pneumoperitoneum up to 15 mmHg is achieved by inserting a Veress needle at the umbilicus. A five-ports (one 10 mm- and four 5-mm ports) technique is used (Photos 2 and 3). At first we place the camera port cautiously in a blind manner; all other ports are placed under direct vision from the camera.
Surgical procedure w1, 2x A 5-mm liver retractor is placed through the right hypochonder port so as to retract the liver anteriorly and medially to expose the hiatus. 1
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931
Photo 1. Classical installation of the patient in dorsal decubitus, legs in split position and both arms alongside the body. The table is then positioned in reverse-Trendelenburg position to improve exposure during the procedure.
Photo 3. In a classical way, the camera is placed in a paramedial position and is held by an assistant surgeon. The left hand of the main surgeon will work through the sub-xyphoı¨dal port, his right hand through the 10-mm port positioned in the left upper quadrant. The liver will be retracted through a 5-mm port placed in the right upper quadrant and the second port in the left upper quadrant (placed lower and more laterally) can be used by an assistant surgeon to present structures during dissection.
The lesser omentum left of the stomach is incised until visualization of the right crus is obtained. During the dissection of the pillars, great care is taken not to damage the hepatic branches of the vagus nerve (Video 1).
Photo 2. Ports placement: the camera port is placed in a slight paramedial position, about 1/3 of the distance between umbilicus and xyphoı¨d. All ports are 5 mm of diameter except the one placed in a subcostal position in the left upper quadrant (10 mm diameter).
2
The next part of the procedure consists in the dissection of the esophageal hiatus. The hiatus is formed by the division of the right crus in two anatomically distinct parts: the left part turning below the esophagus to form the left border of the esophageal hiatus (left pillar), the right part forming the right border of the hiatus (right pillar) (Video 2). Dissecting both pillars will prepare these muscular structures for an appropriate narrowing of the esopha-
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931
Video 1. The gastrohepatic ligament is incised, using the harmonic scalpel or scissors. This exposes the lesser sac distally and proximally from the hepatic branches of the vagal nerves which are left intact. In the depth the right crus now will appear.
Video 2. The peritoneum overlying the right crus is incised and the dissection is extended anteriorly, posteriorly onto the V-shaped commissure of the right crus. Using a grasper or the harmonic scalpel for blunt dissection, the mediastinum is opened widely which helps in localizing the left pillar and esophagus.
Video 3. Attention is now directed towards the left pillar which is dissected along its medial and lateral aspect. The medial dissection will further widen the access to the mediastinum and the dissection laterally allows to create a window behind the esophagus.
geal hiatus and will open a window behind and lateral to the left of the esophagus (Video 3). A Penrose drain is placed around the abdominal esophagus and secured with an endoloop (Video 4). During the dissection of the inferior part of both pillars, great care is taken not to damage the posterior vagal nerve (Video 5). The next step is to complete the dissection of the esophagus within the esophageal hiatus and to further extend the peri-esophageal dissection into the medi-
Video 4. The Penrose drain is introduced in the window behind the esophagus and placed around the abdominal part of the esophagus; it is then secured using an endoloop. This maneuver allows the assistant to apply traction onto the esophagus and gastroesophageal junction which helps in opening dissection planes and in presenting structures.
Video 5. Visualization of the vagus nerve on the posterior aspect of the esophagus. Continuously keeping in mind the presence of both vagus nerves limits the possibility of harming them.
Video 6. The dome of the right crus is incised, using blunt and sharp dissection the esophagus is further dissected eventually becoming completely free in the esophageal hiatus. Using traction on the Penrose drain to the patient’s left for dissecting on the right side, to the right for the left side and downwards traction for dissecting the upper part of the hiatus is of great help during this part of the procedure.
astinum in order to mobilize enough length of it thereby avoiding upward retraction of the gastroesophageal junction and fundoplication (Videos 6 and 7). A tension-free abdominal esophageal segment to be surrounded by the fundoplication is essential as it will limit the risks of subsequent intrathoracic migration of the fundoplication or migration of the gastro-esophageal junction through the hiatus. At least 3–4 cm 3
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931
Video 7. The circular dissection around the esophagus is now extended upward into the mediastinum to liberate a segment of the esophagus of approximately 10 cm in length. The dissection consists essentially in dividing loose connective tissue and the lower arterial branches coming off the descending aorta. Care is taken not to open the mediastinal pleura. In some patients presenting with fibrotic sequelae of periesophagitis this dissection can become notoriously difficult.
Video 9. With the surgeon’s left-hand instrument grasping the stomach and the assistant retracting the greater omentum laterally to the left, the dissection along the greater curvature is commenced. The short gastric vessels are divided individually using the harmonic scalpel. To avoid undue torsion on the gastro-esophageal junction when constructing the fundoplication, it is of the utmost importance to mobilize the fundus completely away from the diaphragm i.e. until reaching the base of the left pillar posteriorly.
tension-free abdominal esophagus must be present within the abdomen at the end of the dissection. If not, this might be an indication to perform a CollisNissen gastroplasty. During the upper dissection of the hiatus, great care is taken not to damage the anterior vagus nerve (Video 8). Mobilization of the upper part of the fundus of the stomach is the next step; this is achieved by dividing the gastrophrenic adhesions and the medial short gastric vessels until the upper part of the fundus is completely liberated (Video 9).
Video 10. The pillars are approximated from the right of the esophagus with interrupted nonabsorbable sutures. Incorporating the peritoneal coverage of the pillars thereby avoiding a frayed musculature is important in order to achieve a strong and lasting repair.
The dissection and division of these vessels is greatly facilitated by using the harmonic scalpel. When dissection is finished, the reconstruction begins by approximating the two pillars in order to narrow the opening of the esophageal hiatus (Video 10). The narrowing of the esophageal hiatus should be calibrated to a size that allows supple passage of a 10 mm scope alongside the esophagus. One can also introduce a bougie inside the esophagus (size 52–56) to assist in calibrating the narrowing of the hiatus.
Video 11. The posterior wall of the fundus is passed from left to right with atraumatic graspers. The ‘shoe-shine’ maneuver involves sliding the gastric fundus back and forth behind the esophagus to confirm its correct position. Grasping the fundus too close to the gastro-esophageal junction will cause twisting of the esophagus resulting eventually in dysphagia. The aim is to create a loose ‘floppy’ fundoplication.
The fundus is then passed behind the esophagus (Video 11) to initiate the fundoplication.
Video 8. Visualization of the anterior vagus nerve.
4
One can introduce a bougie (56- to 60-French) into the esophagus to calibrate the fundoplication but most of the time performing a de visu floppy fundoplication will suffice to achieve a correct fundoplication.
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931 The fundoplication is performed by stitching both sides of the gastric fundus together in front of the esophagus (Video 12). Anchoring the fundoplication to the esophagus using an additional suture completes the intervention (Video 13). The procedure is finished by removing the Penrose drain and controlling the fundoplication and hiatal narrowing (Video 14). The ports are removed de visu and the pneumoperitoneum is removed. The fascia perforated by the
Video 12. Two separate nonabsorbable full-thickness 2/0 sutures are placed starting near the greater curvature on the left and onto the part of the fundus lying on the right side of the esophagus, creating a short fundoplication of about 2 cm.
10-mm port is closed using interrupted sutures, the skin is then closed. Dressings are applied.
Postoperative care Anti-emetics are administered to avoid forceful vomiting the first hours postoperatively as this may cause early disruption of the sutures and intrathoracic migration of the fundoplication. A nasogastric tube is routinely kept in place for 24 h after the surgery. At day one a contrast study is performed to check for leaks and the correct location of the fundoplication and the easy passage of the contrast material through the fundoplication. If satisfactory, fluids and soft diet are allowed. The patient is usually discharged at day two after the surgery. Although outpatient laparoscopic Nissen fundoplication has been performed, patient satisfaction in such a setting is rather low since the management of nausea or pain during the first 24 h after the surgery may be difficult without parenteral access. All patients are again seen at the outpatient clinic one month after the procedure. Further follow-up is arranged on individual basis.
Results
Video 13. Grasping the fat pad of the gastro-esophageal junction will help presenting the esophagus for the last step of the fundoplication i.e. anchoring it to the esophagus to avoid telescoping. To do so a third suture is used to anchor the fundoplication to the left anterolateral side of the distal esophagus (partial-thickness), proximal to the gastro-esophageal junction. Great care is taken not to include the anterior vagus nerve in this last stitch.
The overall short-term results in appropriately selected patients are excellent w3, 4x. Minor self-limiting symptoms may occur in the postoperative period. However, up to 50% of the patients will present transient dysphagia caused by postoperative edema secondary to surgical manipulation. This will improve typically within six weeks. Endoscopic dilation may be necessary in case of persistent dysphagia. Occasionally this may require redo surgery. Other common symptoms are bloating, early satiety, nausea and diarrhea. Those symptoms again tend to improve within weeks and respond usually to appropriate medication. Long-term results in correctly selected patients are excellent w5, 6x; more than 90% of patients report satisfaction with their laparoscopic Nissen fundoplication. A minority of patients report persistent dysphagia, bloating and/or recurrent reflux.
Video 14. The floppy aspect of the fundoplication is once more checked by passing a grasper alongside the esophagus. Absence of upward tension on the abdominal part of the esophagus is controlled. Finally the re-approximation of the pillars is verified.
The cause of failed reflux control is mostly due to (1) total disruption of the wrap, (2) a slipped Nissen fundoplication (with a part of the stomach above and below the fundoplication), (3) herniation of the wrap into the chest w7x. Surgical failure may require reoperation. When re-intervention is required a laparoscopic approach is technically feasible in the hands of experienced surgeons. The overall results of redo surgery 5
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931 however being somewhat inferior as compared to those obtained after primary surgery w8x. w5x
References w1x Wykypiel H, Wetscher GJ, Klingler P, Glaser K. The Nissen fundoplication: indication, technical aspects and postoperative outcome. Langenbecks Arch Surg 2005;390:495–502. w2x Ferguson MK. Pitfalls and complications of antireflux surgery. Nissen and Collis-Nissen techniques. Chest Surg Clin N Am 1997;7:489–509. w3x Peters JH, DeMeester TR. Indications, benefits and outcome of laparoscopic Nissen fundoplication. Dig Dis 1996;14:169–179. w4x Peters JH, DeMeester TR, Crookes P, Oberg S, de Vos Shoop M, Hagen JA, Bremner CG. The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective
6
w6x
w7x
w8x
evaluation of 100 patients with ‘typical’ symptoms. Ann Surg 1998;228:40–50. Cowgill SM, Gillman R, Kraemer E, Al-Saadi S, Villadolid D, Rosemurgy A. Ten-year follow-up after laparoscopic Nissen fundoplication for gastroesophageal disease. Am Surg 2007;73:748–752. Erenoglu C, Miller A, Schirmer B. Laparoscopic Toupet versus Nissen fundoplication for the treatment of gastroesophageal reflux disease. Int Surg 2003;88:219–225. Graziano K, Teitelbaum DH, McLean K, Hirschl RB, Coran AG, Geiger JD. Recurrence after laparoscopic and open Nissen fundoplication: a comparison of the mechanisms of failure. Surg Endosc 2003;17:704–707. Oelschlager BK, Lal DR, Jensen E, Cahill M, Quiroga E, Pellegrini CA. Medium- and long-term outcome of laparoscopic redo fundoplication. Surg Endosc 2006;20:1817–1823.
Laparoscopic Nissen fundoplication Philippe Nafteux*, Willy Coosemans, Paul De Leyn, Dirk Van Raemdonck, Herbert Decaluwe´, Georges Decker, Toni Lerut Department of Thoracic Surgery, UZ Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium The dissection is started performing a crural dissection with visualization and preservation of both vagus nerves, followed by circumferential dissection of the esophagus at the gastroesophageal junction. Adequate intra-mediastinal mobilization of the esophagus is performed to obtain 3–4 cm of intra-abdominal esophagus without undue downward traction on the cardia or stomach. The gastric fundus is then mobilized through adequate short gastric vessel division. The left and right pillars of the right diaphragmatic crus are approximated using interrupted sutures. A short (-2 cm), floppy 3608 fundoplication anchored to the esophagus is created.
Keywords: Antireflux procedure; Fundoplication; Gastro-esophageal reflux (GER); Laparoscopic Nissen Introduction The Nissen fundoplication is the gold standard for the operative treatment of gastro-esophageal reflux disease (GERD). This well-established procedure has proved itself to be both durable and safe after followup periods of 20 years and beyond. Since its introduction by Rudolf Nissen in 1956, this procedure has undergone many modifications. The laparoscopic Nissen fundoplication was first reported by Dallemagne et al. in 1991.
Surgical technique Position After induction of general anesthesia and introduction of a bladder catheter, the patient is placed in supine position, legs in split position with both arms alongside the body, secured to the operating table (Photo 1). * Corresponding author: Tel.: q3216346822; fax: q3216346821. E-mail: [email protected] 䉷 2008 European Association for Cardio-thoracic Surgery
The surgeon stands between the patient’s legs with the first assistant to the patient’s left and the second assistant to the patient’s right. Two monitors stand at the level of the patient’s head, on the right and left side, respectively.
Ports placement Pneumoperitoneum up to 15 mmHg is achieved by inserting a Veress needle at the umbilicus. A five-ports (one 10 mm- and four 5-mm ports) technique is used (Photos 2 and 3). At first we place the camera port cautiously in a blind manner; all other ports are placed under direct vision from the camera.
Surgical procedure w1, 2x A 5-mm liver retractor is placed through the right hypochonder port so as to retract the liver anteriorly and medially to expose the hiatus. 1
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931
Photo 1. Classical installation of the patient in dorsal decubitus, legs in split position and both arms alongside the body. The table is then positioned in reverse-Trendelenburg position to improve exposure during the procedure.
Photo 3. In a classical way, the camera is placed in a paramedial position and is held by an assistant surgeon. The left hand of the main surgeon will work through the sub-xyphoı¨dal port, his right hand through the 10-mm port positioned in the left upper quadrant. The liver will be retracted through a 5-mm port placed in the right upper quadrant and the second port in the left upper quadrant (placed lower and more laterally) can be used by an assistant surgeon to present structures during dissection.
The lesser omentum left of the stomach is incised until visualization of the right crus is obtained. During the dissection of the pillars, great care is taken not to damage the hepatic branches of the vagus nerve (Video 1).
Photo 2. Ports placement: the camera port is placed in a slight paramedial position, about 1/3 of the distance between umbilicus and xyphoı¨d. All ports are 5 mm of diameter except the one placed in a subcostal position in the left upper quadrant (10 mm diameter).
2
The next part of the procedure consists in the dissection of the esophageal hiatus. The hiatus is formed by the division of the right crus in two anatomically distinct parts: the left part turning below the esophagus to form the left border of the esophageal hiatus (left pillar), the right part forming the right border of the hiatus (right pillar) (Video 2). Dissecting both pillars will prepare these muscular structures for an appropriate narrowing of the esopha-
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931
Video 1. The gastrohepatic ligament is incised, using the harmonic scalpel or scissors. This exposes the lesser sac distally and proximally from the hepatic branches of the vagal nerves which are left intact. In the depth the right crus now will appear.
Video 2. The peritoneum overlying the right crus is incised and the dissection is extended anteriorly, posteriorly onto the V-shaped commissure of the right crus. Using a grasper or the harmonic scalpel for blunt dissection, the mediastinum is opened widely which helps in localizing the left pillar and esophagus.
Video 3. Attention is now directed towards the left pillar which is dissected along its medial and lateral aspect. The medial dissection will further widen the access to the mediastinum and the dissection laterally allows to create a window behind the esophagus.
geal hiatus and will open a window behind and lateral to the left of the esophagus (Video 3). A Penrose drain is placed around the abdominal esophagus and secured with an endoloop (Video 4). During the dissection of the inferior part of both pillars, great care is taken not to damage the posterior vagal nerve (Video 5). The next step is to complete the dissection of the esophagus within the esophageal hiatus and to further extend the peri-esophageal dissection into the medi-
Video 4. The Penrose drain is introduced in the window behind the esophagus and placed around the abdominal part of the esophagus; it is then secured using an endoloop. This maneuver allows the assistant to apply traction onto the esophagus and gastroesophageal junction which helps in opening dissection planes and in presenting structures.
Video 5. Visualization of the vagus nerve on the posterior aspect of the esophagus. Continuously keeping in mind the presence of both vagus nerves limits the possibility of harming them.
Video 6. The dome of the right crus is incised, using blunt and sharp dissection the esophagus is further dissected eventually becoming completely free in the esophageal hiatus. Using traction on the Penrose drain to the patient’s left for dissecting on the right side, to the right for the left side and downwards traction for dissecting the upper part of the hiatus is of great help during this part of the procedure.
astinum in order to mobilize enough length of it thereby avoiding upward retraction of the gastroesophageal junction and fundoplication (Videos 6 and 7). A tension-free abdominal esophageal segment to be surrounded by the fundoplication is essential as it will limit the risks of subsequent intrathoracic migration of the fundoplication or migration of the gastro-esophageal junction through the hiatus. At least 3–4 cm 3
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931
Video 7. The circular dissection around the esophagus is now extended upward into the mediastinum to liberate a segment of the esophagus of approximately 10 cm in length. The dissection consists essentially in dividing loose connective tissue and the lower arterial branches coming off the descending aorta. Care is taken not to open the mediastinal pleura. In some patients presenting with fibrotic sequelae of periesophagitis this dissection can become notoriously difficult.
Video 9. With the surgeon’s left-hand instrument grasping the stomach and the assistant retracting the greater omentum laterally to the left, the dissection along the greater curvature is commenced. The short gastric vessels are divided individually using the harmonic scalpel. To avoid undue torsion on the gastro-esophageal junction when constructing the fundoplication, it is of the utmost importance to mobilize the fundus completely away from the diaphragm i.e. until reaching the base of the left pillar posteriorly.
tension-free abdominal esophagus must be present within the abdomen at the end of the dissection. If not, this might be an indication to perform a CollisNissen gastroplasty. During the upper dissection of the hiatus, great care is taken not to damage the anterior vagus nerve (Video 8). Mobilization of the upper part of the fundus of the stomach is the next step; this is achieved by dividing the gastrophrenic adhesions and the medial short gastric vessels until the upper part of the fundus is completely liberated (Video 9).
Video 10. The pillars are approximated from the right of the esophagus with interrupted nonabsorbable sutures. Incorporating the peritoneal coverage of the pillars thereby avoiding a frayed musculature is important in order to achieve a strong and lasting repair.
The dissection and division of these vessels is greatly facilitated by using the harmonic scalpel. When dissection is finished, the reconstruction begins by approximating the two pillars in order to narrow the opening of the esophageal hiatus (Video 10). The narrowing of the esophageal hiatus should be calibrated to a size that allows supple passage of a 10 mm scope alongside the esophagus. One can also introduce a bougie inside the esophagus (size 52–56) to assist in calibrating the narrowing of the hiatus.
Video 11. The posterior wall of the fundus is passed from left to right with atraumatic graspers. The ‘shoe-shine’ maneuver involves sliding the gastric fundus back and forth behind the esophagus to confirm its correct position. Grasping the fundus too close to the gastro-esophageal junction will cause twisting of the esophagus resulting eventually in dysphagia. The aim is to create a loose ‘floppy’ fundoplication.
The fundus is then passed behind the esophagus (Video 11) to initiate the fundoplication.
Video 8. Visualization of the anterior vagus nerve.
4
One can introduce a bougie (56- to 60-French) into the esophagus to calibrate the fundoplication but most of the time performing a de visu floppy fundoplication will suffice to achieve a correct fundoplication.
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931 The fundoplication is performed by stitching both sides of the gastric fundus together in front of the esophagus (Video 12). Anchoring the fundoplication to the esophagus using an additional suture completes the intervention (Video 13). The procedure is finished by removing the Penrose drain and controlling the fundoplication and hiatal narrowing (Video 14). The ports are removed de visu and the pneumoperitoneum is removed. The fascia perforated by the
Video 12. Two separate nonabsorbable full-thickness 2/0 sutures are placed starting near the greater curvature on the left and onto the part of the fundus lying on the right side of the esophagus, creating a short fundoplication of about 2 cm.
10-mm port is closed using interrupted sutures, the skin is then closed. Dressings are applied.
Postoperative care Anti-emetics are administered to avoid forceful vomiting the first hours postoperatively as this may cause early disruption of the sutures and intrathoracic migration of the fundoplication. A nasogastric tube is routinely kept in place for 24 h after the surgery. At day one a contrast study is performed to check for leaks and the correct location of the fundoplication and the easy passage of the contrast material through the fundoplication. If satisfactory, fluids and soft diet are allowed. The patient is usually discharged at day two after the surgery. Although outpatient laparoscopic Nissen fundoplication has been performed, patient satisfaction in such a setting is rather low since the management of nausea or pain during the first 24 h after the surgery may be difficult without parenteral access. All patients are again seen at the outpatient clinic one month after the procedure. Further follow-up is arranged on individual basis.
Results
Video 13. Grasping the fat pad of the gastro-esophageal junction will help presenting the esophagus for the last step of the fundoplication i.e. anchoring it to the esophagus to avoid telescoping. To do so a third suture is used to anchor the fundoplication to the left anterolateral side of the distal esophagus (partial-thickness), proximal to the gastro-esophageal junction. Great care is taken not to include the anterior vagus nerve in this last stitch.
The overall short-term results in appropriately selected patients are excellent w3, 4x. Minor self-limiting symptoms may occur in the postoperative period. However, up to 50% of the patients will present transient dysphagia caused by postoperative edema secondary to surgical manipulation. This will improve typically within six weeks. Endoscopic dilation may be necessary in case of persistent dysphagia. Occasionally this may require redo surgery. Other common symptoms are bloating, early satiety, nausea and diarrhea. Those symptoms again tend to improve within weeks and respond usually to appropriate medication. Long-term results in correctly selected patients are excellent w5, 6x; more than 90% of patients report satisfaction with their laparoscopic Nissen fundoplication. A minority of patients report persistent dysphagia, bloating and/or recurrent reflux.
Video 14. The floppy aspect of the fundoplication is once more checked by passing a grasper alongside the esophagus. Absence of upward tension on the abdominal part of the esophagus is controlled. Finally the re-approximation of the pillars is verified.
The cause of failed reflux control is mostly due to (1) total disruption of the wrap, (2) a slipped Nissen fundoplication (with a part of the stomach above and below the fundoplication), (3) herniation of the wrap into the chest w7x. Surgical failure may require reoperation. When re-intervention is required a laparoscopic approach is technically feasible in the hands of experienced surgeons. The overall results of redo surgery 5
P. Nafteux et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2007.002931 however being somewhat inferior as compared to those obtained after primary surgery w8x. w5x
References w1x Wykypiel H, Wetscher GJ, Klingler P, Glaser K. The Nissen fundoplication: indication, technical aspects and postoperative outcome. Langenbecks Arch Surg 2005;390:495–502. w2x Ferguson MK. Pitfalls and complications of antireflux surgery. Nissen and Collis-Nissen techniques. Chest Surg Clin N Am 1997;7:489–509. w3x Peters JH, DeMeester TR. Indications, benefits and outcome of laparoscopic Nissen fundoplication. Dig Dis 1996;14:169–179. w4x Peters JH, DeMeester TR, Crookes P, Oberg S, de Vos Shoop M, Hagen JA, Bremner CG. The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective
6
w6x
w7x
w8x
evaluation of 100 patients with ‘typical’ symptoms. Ann Surg 1998;228:40–50. Cowgill SM, Gillman R, Kraemer E, Al-Saadi S, Villadolid D, Rosemurgy A. Ten-year follow-up after laparoscopic Nissen fundoplication for gastroesophageal disease. Am Surg 2007;73:748–752. Erenoglu C, Miller A, Schirmer B. Laparoscopic Toupet versus Nissen fundoplication for the treatment of gastroesophageal reflux disease. Int Surg 2003;88:219–225. Graziano K, Teitelbaum DH, McLean K, Hirschl RB, Coran AG, Geiger JD. Recurrence after laparoscopic and open Nissen fundoplication: a comparison of the mechanisms of failure. Surg Endosc 2003;17:704–707. Oelschlager BK, Lal DR, Jensen E, Cahill M, Quiroga E, Pellegrini CA. Medium- and long-term outcome of laparoscopic redo fundoplication. Surg Endosc 2006;20:1817–1823.
![[Laparoscopic anterior hemi-fundoplication versus Nissen fundoplication. Long-term results].](/assets/img/hold.png)
