1. Pediatric Laproscopic Nissen Fundoplication
Lindsey Bendure
Minimally Invasive Surgery Lab

2. Nissen Fundoplication
The fundus of the stomach is wrapped around the esophagus so that the lower portion of the esophagus passes through a small tunnel of stomach muscle
This strengthens the lower esophageal sphincter which prevents acid from retreating into the esophagus (when the stomach contracts, it closes off the sphincter)

3. Indications and Pre-op Evaluation
Patients with GERD and any of the following may be considered for a fundoplication:
Erosive esophagitis, stricture and/or Barrett’s esophagus
Hiatal hernia
Dependence upon proton pump inhibitors for relief of symptoms in the absence of documented mucosal injury
Atypical or respiratory symptoms with a good response to medical treatment
Risk factors that predict a poor response to medical therapy
Nocturnal reflux on 24-hr esophageal study
Structurally deficient lower esophageal sphincter
Mixed reflux of gastric and duodenal juices

4. Gerd Treatment Options
Lifestyle changes
Eat smaller, more frequent meals
Limit intake of acid-stimulating foods/drinks
Don’t lie down for about 2 hours after eating (or hold baby upright)
Slightly elevate head when sleeping (or bed for infants)
Maintain a reasonable weight
Don’t smoke or drink alcohol
Wear loose fitting clothing

5. GERD Treatment Options
Proton pump inhibitors
H2 blockers
Antacids
Surgery

6. Nissen Fundoplication
Safe and effective
89.5% of patients are still symptom free after 10 years
Mortality rate <1%

7. Laproscopic vs Open Surgery
1-2 days in hospital post-op
2-3 weeks recovery
Increased risk for difficulty swallowing
Several days in hospital post-op
4-6 weeks recovery
Increased risk for infection and bleeding

8. Procedure Outline Retract the liver Crural dissection
Circumferential dissection of the esophagus
Crural closure
Fundic mobilization by division of short gastric vessels
Creation of a short, loose fundoplication by enveloping the anterior and posterior wall of the fundus around the lower esophagus

9. Liver Retraction
Insert liver retractor through the 10MM cannula on the patient’s right side
Position the liver retractor so that the left lobe of the liver is retracted ventrally
This exposes the anterior surface of the proximal stomach near the gastroesophageal junction

10. Crural Dissection Identify and preserve both vagus nerves
Open the omentum over the caudate lobe of the liver, just above the hepatit branch of the vagus nerve; this exposes the right crus of the diaphragm
Carry the incision to the patient’s left, over the anterior surface of the left crus
Dissect the right crus from its base, through the crural arch
Similarly, dissect the left crus from its base

11. Esophageal Dissection
Gently dissect between the crura at their bases, opening the retroesophageal window
Identify and preserve vagus nerve
Pass a 1 inch Penrose drain around the distal esophagus and use it as a handle for further dissection
Dissect the distal esophagus out of the chest until at least 4 cm of distal esophagus can be pulled below the diaphragm without tension

12. Crural Closure Use a Maryland and a needle driver
Close the crura together using non-absorbable sutures
Can use a bougie to measure it when completed

13. Mobilize Gastric Fundus
Enter the lesser sac, on third of the way down the greater curve of the stomach and isolate an divide short gastric vessels, working back towards the GEJ
Divide any filmy attachments between the posterior wall of the proximal stomach and the anterior surface of the pancreas
Bring the mobilized gastric fundus through the retroesophageal window and around the distal esophagus anteriorly to ensure adequate mobilization

14. Fundoplication
Complete the fundoplication around a 60 French esophageal dilator (inserted by anesthesiologist)
2 or 3 non-absorbable sutures are places with bites taking full thickness gastric fundus and partial thickness anterior esophageal wall
When completed, the wrap should be no greater than 2 cm in length
Sutures from the wrap to the diaphragm are optional

15. Operating Room Set-up: Patient
Endotracheal intubation
30degrees reverse Trendelenburg to spontaneously lower the abdominal organs
Supine position, arms at 90degrees and legs apart
Dual lumen gastric tube to decompress the stomach; moved up to the middle third of the esophagus once the stomach has been decompressed
Surgeon stands between the legs and uses both hands

17. Trocar Placement/Incisions
5 total incisions
Laproscope is inserted slightly superior and lateral to the umbilicus
4 other incisions made: 2 in upper left quadrant and 2 in upper right quadrant, bordering and inferior to the rib cage
Liver retractor goes into the incision farthest away from the surgeon on his left

19. Instruments Liver retractor with Babcock clamp Maryland dissector
Scissors
Cautery or Harmonic scalpel, depending on size of patient
Needle holders

20. Surgical Complications
Perforation of the stomach or esophagus (1% of patients)
Bleeding
Infection
About 5% of laproscopic cases result in a conversion to the open procedure

21. Post-Operative Complications
“Gas Bloat Syndrome” – accumulation of gas in the stomach or intestine due to inability to burp (2-5% of patients)
Inability to vomit
Chest pains

22. Post-Operative Care 1-3 day hospital stay Liquid diet for 1-2 weeks
Rest and relax
No heavy lifting
No strenuous activities
Expect weight loss