The Laparoscopic Nissen Fundoplication Mark S. Allen  Operative Techniques in Cardiac and Thoracic Surgery  Volume 2, Issue 1, Pages 44-51 (February 1997) DOI: 10.1016/S1085-5637(07)70087-6 Copyright © 1997 Elsevier Inc. Terms and Conditions

1 The patient is positioned supine on the operating room table with the legs suspended, so that the surgeon can stand between the patient's legs and operate with both hands while watching the television monitor. The first assistant is on the left side of the patient and manipulates the retractors (Endoretract, United States Surgical, Norfolk, NJ). The second assistant is on the right side and controls the camera. The operation is begun by decompressing the stomach with a nasogastric tube. After pneumoperitoneum is established, five ports are placed, the first just superior to the umbilicus for the camera. A port is placed in the right lower quadrant for a fan retractor to retract the liver. An iron intern is used to hold the retractor so inadvertent movement does not damage the liver. The third and fourth ports are placed to the right of the xiphoid and in the left upper quadrant and are used by the surgeon's left and right hands. The fifth port is placed in the left lateral midabdomen and used by the assistant for retraction. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

2 The first assistant grasps the body of the stomach with an endo-Babcoek clamp and retracts it to the left side. This exposes the gastrohepatic ligament and the peritoneum over the right crus. The endoretract is fixed in position pulling the stomach laterally providing traction and countertraction. The surgeon grasps the peritoneum over the right crus and with the scissors in the right hand opens the peritoneum to expose the right crus and the right portion of the distal esophagus. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

3 This dissection is continued to expose the entire right crus and right portion of the esophagus. The first assistant grasps the stomach and retracts laterally while the left hand of the surgeon grasps the right crus and retracts to the right. Both the right and left vagus nerves are identified and carefully preserved. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

4 Attention is then turned to the left crus, and an extensive dissection is performed along the left crus and the left side of the esophagus. The first assistant grasps the fundus of the stomach and retracts inferiorly and medially while the left hand of the surgeon grasps the left crux with an endo-babcock and retracts superiorly and laterally. The scissors are in the right hand of the surgeon and are used to dissect. Complete dissection of this area is critical to ensure excellent exposure when encircling the esophagus and also when dividing the short gastric vessels. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

5 After the intra-abdominal esophagus has been dissected free, an angled grasper is passed posterior to the esophagus and anterior to the right vagus nerve. An umbilical tape is placed around the esophagus and held in place with urgical clips for future retraction. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

6 Once the esophageal dissection is complete, the fundus of the stomach is retracted to the right, and the short gastric vessels between the fundus of the stomach and the spleen are ligated and divided. These can also be divided by using the harmonic scalpel. Adequate division of the short gastric vessels is necessary to allow a tension-free fundoplication. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

7 Once the dissection is completed, sutures of 0 silk are placed in the left and right crura to narrow the diaphragmatic hiatus. The first suture is placed inferiorly and additional sutures are placed more anteriorly as necessary. Exposure is obtained by the first assistant grasping the stomach and the umbilical tape around the esophagus and retracting laterally and inferiorly. Additionally, the surgeon can grasp the crux with an endo-babcock in the left hand and suture in the right hand. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

8 A number 58 Maloney dilator is then carefully passed into the stomach, and the sutures are tied down, tightening the crura around the esophagus. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

9 Using the curved grasper or a Babcock clamp, the fundus of the stomach is brought behind the esophagus, but anterior to the right vagus nerve. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

10 Using two graspers, enough of the fundus is brought from behind the esophagus for an adequate fundoplication. When the fundus is no longer being held in this position, it should not fall back to the left side. If it does, this indicates an inadequate dissection along the greater curvature, and this area should be dissected further so that there is no tension on the wrap. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

11 The wrap is then sutured into place using 0 silk sutures. The suture is begun by a seromuscular bite of the stomach as shown. The suture in the esophagus should include the longitudinal, circular, and submucosal tissue of the esophagus. It should not be placed intraluminally. The third portion of the stitch grasps the part of the stomach that has been brought around for a fundoplication. The wrap should be on the lower esophagus, not on the stomach. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions

12 The dilator is readvanccd into the esophagus, and the suture is tied down. A second suture is then placed approximately 1.0 to 1.5 cm away from the previous suture and includes the same three tissues as the first. This suture is tied down, and the fundoplication is complete. The liver retractor is removed. Each port site is examined as the cannulas are removed, and the incisions are closed in layers. Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 44-51DOI: (10.1016/S1085-5637(07)70087-6) Copyright © 1997 Elsevier Inc. Terms and Conditions