Laparoscopic Nissen Fundoplication Jessica J. Siu M1, University of Kentucky College of Medicine Minimally Invasive Surgery Elective 20 April 2011

Objectives Indications for Nissen Fundoplication Laparoscopic vs. Open Procedure Operating Room Set-up Equipment Patient Position Trocar Placement Procedural Steps Possible Complications Post-Operative Care

Case Study 25 year old Active Duty military male presents with consistent heart burn for 2+ years, with increasing frequency for the past 6 months. He complains of unintentional vomiting following meals and exercise. Diet and social history: 2 cups coffee per day, several beers during the weekend, prepared meals in the dining facility. Patient with a 10 pack year history. Current weight is within normal healthy limits. Patient scheduled to deploy in 6 months.

Case Study Patient diagnosed with Gastroesophageal Reflux Disease (GERD) GERD affects more than 10% of the adult population Symptoms of GERD Heartburn from reflux of gastric acid Regurgitation of gastric contents up into the mouth Severe epigastric pain with sudden onset

Case Study Conservation Treatment: Lifestyle modification Weight loss, effective only if patient is overweight Reduced high fat food intake Elevation of upper body for 30 minutes following meals Cessation of smoking Medications Antacids for improving heartburn symptoms Proton pump inhibitors (PPI) Conservative treatment may improve symptoms but may not treat underlying cause of GERD.

Indications GERD has a complex pathophysiology: Caused by an incompetent anti-reflux barrier, due to a displacement of the lower esophageal sphincter into the chest, disruption of hiatal crura, or impairment of esophageal peristalsis PPI’s fail to control GERD long term, especially in the presence of large hiatal hernias, poor esophageal peristalsis, regurgitation of large volumes, or dysphagia Nissen Fundoplication Surgical therapy: Addresses the functional nature of GERD Restores anti-reflux barrier, strengthens esophageal peristalsis, speeds gastric emptying, and improves gastric clearance Curative in 85-93% of patients Research of post-operative Nissen Fundoplication patients have supported good long term results, with low morbidity and mortality

Open Procedure versus Laparoscopic Incision of roughly 20-25 cm in the abdomen Hospital stay: Several days Recovery time: 4-6 weeks Indicated in patients who have had multiple abdominal surgery Laparoscopic: Minimally invasive technique producing five 0.5-1cm incisions Hospital stay: 1-2 days Recovery time: 2-3 weeks

Equipment Liver Retractor Grasping Forceps Suction Harmonic Scalpel Flexible Dissector Penrose Drain French Bougie Needle Holder Scissors

Operating Room Set-Up and Patient Position Patient’s position: Supine with legs apart 30° Reverse Trendelenburg General anesthesia Endotracheal intubation Surgeon in between patient’s legs Assistant to surgeon’s left Scrub nurse to surgeon’s right

Trocar Placement Midline—2/3 from xiphoid to umbilicus, 10mm Laparascope Immediately below Xiphoid Process, 5mm Grasping forceps Anterior Axillary Line just below Costal Margin Right, 10mm Liver retractor around middle of left lobe to retract ventrally Exposes anterior surface of the proximal stomach near the gastroesophageal junction Left, 5mm Grasping forceps, suction, scissors Midclavicular Line, Left Upper Quandrant, 5mm Dissecting and Suturing Devices

Procedure Steps Crural Dissection Circumferential Dissection of the Esophagus Fundic Mobilization Preparation of Crural Closure Crural Closure Fundoplication around the Lower Esophagus

Procedural Steps

1. Crural Dissection Expose right crus of diaphragm by opening the hepatogastric ligament (lesser omentum) over caudate lobe of liver Avoid the hepatic branch of the vagus nerve Avoid left hepatic artery Incision of phrenoesophageal membrane on medial side of right crus of diaphragm Use heat at first, then blunt dissection parallel to crus Blunt dissection helps avoid damage to the anterior vagus nerve located tight against the anterior wall of the esophagus Rostral Border: At observation of the mediastinal pleura, appears as a glistening yellow fat pad Caudal Border: Posterior part of the crus The dissection is continued transversally towards the anterior surface of the left crus and caudally towards the crural arch

2. Esophagus Dissection Dissection of the posterior esophagus helps open the retroesophageal window Identify the posterior vagus nerve and protect it

3. Fundic Mobilization “Routine division of the shorts” to decrease dysphagia Enter lesser sac one third of the way down the greater curve of the stomach Divide gastrosplenic ligament Isolate and divide short gastric vessels working towards the gastroesophageal junction Harmonic scalpel can take vessels up to 5mm in size Do not partially divide vessels Stay close to stomach, being careful of spleen Within lesser omental sac, Grab posterior of stomach to continue dividing short gastric vessels Divide gastrophrenic ligament Gastric fundus completely immobilized

4. Preparation of Crural Closure Place flexible dissector into retroesophageal window, flip stomach to grab penrose drain Penrose drain used to encircle and retract the distal esophagus Ensure adequate intraesophageal mobilization (2-3 cm) Grasping forceps in the opened position is roughly 2 cm In the process of opening peritoneum, the diaphragm moves up Insert french bougie in patient’s mouth and guide into stomach 52” for women, 54” for men Greatest area for perforation is gastroesophageal junction and at the curvature of stomach French bougie helps to determine tightness of hernia repair and fundoplication so patient does not get dysphagia post-surgery

5. Crural Closure Reconstruct esophageal hiatus by suturing the right and left crura behind the esophagus Remove french bougie during suturing Stitch in left crus, dip into right crus Repeat twice No biological mesh required for Nissen Fundoplication crural closure, although it is used for more severe hiatal hernias Readvance french bougie to check tightness of reconstruction

6. Fundoplication Bring the mobilized gastric fundus through the retroesophageal window and around distal esophagus anteriorly Find the cardiac angle where esophagus meets stomach Pull short gastric side of stomach out to the right to find the true fundus 4-5cm distal from gastroesophageal junction Using grasping forceps, grab the posterior of the stomach If the wrong area is wrapped, it may cause poor reflux control (by twisting stomach) and/or a two compartment stomach, causing dysphagia Can test correct area with “shoe-shine” maneuver

6. Fundoplication Three sutures are placed with bites taking full thickness gastric fundus and partial thickness anterior esophageal wall 1 cm bite of stomach, I muscular bite around “10-o-clock position” of esophagus, 1 cm bite on other side of stomach Take Penrose Drain out after the 1st stitch Bottom stitch with no esophagus, just stomach bites When completed, wrap should be no greater than 2cm in length Advance French Bougie and check the tightness of the wrap Be able to fit forceps in between the wrap while the French Bougie is still in

Possible Complications Main Complications: Bleeding Perforation of esophagus Perforation of stomach Splenic injury. Approximately 5% of patients require conversion to open surgery because of bleeding, perforation or other complications. About 95% of all cases can be performed laparoscopically, while 5% of laparoscopic cases can result in a conversion to the open procedure.

Post-Operative Care Most patients are able to return home the first or second day after laparoscopic surgery Return to full activity usually takes 1 to 2 weeks Acid reducing medication is recommended for 2 weeks following surgery Follow up appointment should be made with the surgeon 7 to 10 days after discharge Questions can be answered Progress can be assessed Patient can be examined

Post-Operative Care Operation creates a sphincter mechanism at the bottom of the esophagus to prevent reflux May cause resistance to the passage of food, causing more air to be swallowed Patients often experience periods of gas-bloat syndrome Episodes can last up to 2 to 3 hours Increase in swallowed air makes it difficult to belch or vomit Patients often experience abdominal distention, nausea and an increase in flatulence About 6 weeks after the laparoscopic repair, patients may experience dysphagia (difficulty swallowing) due a post-surgical swelling at the wrapped site Although dysphagia is almost always temporary, 2% of patients experience long term symptoms

Post-Operative Care Clear diet for three days following surgery, advance as tolerated Soft Diet after Nissen Fundoplication Surgery helps control diarrhea, excess gas, and dysphagia Eat small frequent meals (4-6 meals per day), taking small bites and chewing well before swallowing Avoid foods that may cause stomach gas and distention: corn, dried beans, peas, lentils, onions, broccoli, cauliflower and any food from the cabbage family Sweet foods should be eaten last to avoid quick digestion Foods that are soft and moist are easier to digest. Avoid coarse grains, dried fruits, nuts and seeds. Drink fluids between meals, and avoid drinking through a straw Milk products should be slowly added to diet as tolerated Avoid caffeine, carbonated drinks and alcohol Do not chew gum or tobacco, since it may increase the amount of air swallowed

References Dr. Roth’s Nissen Fundoplication Procedure (2010) Skandalakis JE, Skandalakis PN, Skandalakis LJ. Minimally Invasive Surgical Procedures and Anatomy. Year: Pages. Dallemagne B. Laparoscopic short floppy Nissen fundoplication for gastroesophageal reflux disease. Epublication: WeBSurg.com, Nov 2006;6(11). URL: http://www.websurg.com/ref/doi-ot02en331.htm Wykypiel H, Wetscher GJ, Klinger P, Glaser K (2004). The Nissen Fundoplication: Indication, Technical Aspects and Postoperative Outcome. Langenbecks Arch Surg 390:495-502