Laparoscopic treatment of GERD in an obese patient

Authors

Abstract

We present a laparoscopic Nissen technique for the surgical management of a hiatal hernia. In order to better understand the technique, a stepwise approach is performed and tips and tricks on how to avoid major problems are presented.

Classification

basic techniques

Keywords

laparoscopy, treatment, GERD, fatty patient, gastroesophageal reflux disease

Media type

Duration

15'19''

Publication

2008-10

Popular

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Audio

Subtitles

E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2419.htm

Laparoscopic treatment of GERD in an obese patient

1. Introduction 00'11''

One of the major difficulties in the laparoscopic treatment of gastroesophageal reflux disease is to operate relatively fatty patients, since all the gastrosplenic and gastrohepatic ligaments are thick, fatty and obstruct the view of the anatomy. This video shows a few technical tips to avoid most major problems.

2. Incision of the phrenoesophageal membrane 00'32''

The basic technique is well outlined with the incision of the phreno-esophageal membrane and identification of the esophagus. It appears that the fat of the gastrosplenic ligament may hinder access to the base of the left crus. However, we know that this technical step is essential as it prepares the retro-esophageal passage. In some cases, it is useful to resect the fat covering the right diaphragmatic crus in order to obtain a good view and identify the major anatomical landmarks.

3. Hiatal dissection 01'11''

This first landmark is the right crus. Here we enter the mediastinum by following the relief of the right crus. Dissection using traction and counter-traction is helpful. The fatty tissue masks the anatomy and it is therefore important to use a stepwise approach and follow the muscular relief of the hiatal orifice. We dissect gradually from the right crus to the left crus, the dissection must be very meticulous as we must identify the position of the anterior vagus, which in certain cases twists around the left crus. Dissecting downwards along the left crus is essential in order to prepare the posterior dissection of the esophagus and at this level, the fat can become a hindrance at times when we work deep down. This procedure is performed with a 0 degree optic. In some cases, we can use angulated optics with 30 or 45 degrees. We must be careful when penetrating into the mediastinum as we can also identify the right pleura here, which is being retracted. Once again, the fat can mask the anatomy of the cardioesophageal junction. As a result, all the operative steps must be extremely careful and measured.

4. Posterior esophageal dissection 02'56''

During the posterior dissection of the esophagus, it is essential to apply a good traction on the cardio-esophageal junction in order to open the posterior triangle, this is probably the secret of this dissection. Without any traction, it is almost impossible to find the retro-esophageal passage easily. In order to avoid traction on the structures, and especially on the fat that may bleed easily, the loop placed around the cardio-esophageal junction is very useful as in this way traction is applied in a totally atraumatic fashion.

5. Intramediastinal esophageal dissection 03'34''

Such tractions are important to facilitate the mobilization of the intramediastinal esophagus. We can see that the fat here again masks the anatomical structures. Therefore, the dissection must be atraumatic. First, we must isolate the structures. They are identified and only then can they be divided using the ultrasonic dissector. First we identify the posterior vagus, then the anterior vagus. Such identification is necessary before division or cauterization. The intra-esophageal mobilization must be sufficient to obtain about 2 to 3cm of esophagus in a subdiaphragmatic position and intra-abdominally. Usually, the intramediastinal mobilization must be performed almost up to the pulmonary veins. It is then carried out to the right, anterior and left to the esophagus. At this level, we can find structures that may fix the esophagus intramediastinally. Therefore it is important to identify the position of the anterior vagus, either visually or by palpation. Once this esophagus is mobilized, the subdiaphragmatic portion should be assessed and to do so, traction on the pericardial loop must be released and we can see that we can obtain 2.5 to 3cm of esophagus intra-abdominally. Dissection is extended to stabilize this intra-abdominal esophageal and contrarily to what is usually done, that is preserving the hepatic branches of the vagus nerve, we decide here to divide them in order to obtain a safe access to this pre-aortic retro-esophageal area.

6. Crura repair 05'40''

Repair of the crura is undertaken by dissecting the crura. This dissection attempts to preserve the peritoneal layer covering the crura, which is important as it helps to stabilize the suture of the crura. The retro-esophageal window is also extended as it will accommodate the wrap of the fundoplication. This posterior dissection aims not only to obtain a sufficient portion of esophagus, but also to prepare a retro-esophageal window that will accommodate the wrap of the fundoplication without too much pressure on the posterior aspect of the esophagus.

7. Mobilization of the fundus 06'23''

An essential aspect of the procedure is the mobilization of the gastric fundus. Here we can see that there is a pericardial lipoma that we must resect. We must do it since this lipoma may be included in the fundoplication at the time of its creation and that that may cause compression problems at the level of the esophagus, dysphagia, but it can also predispose to herniation of the stomach through the fundoplication; therefore it is preferable to resect it. The gastric fundus is mobilized with an access to the lesser sac. Once again, in fatty patients, such a dissection may be slightly difficult. The assistant applies lateral traction, the surgeon a medial traction and once the lesser sac is identified, the different structures of the gastrosplenic ligament are progressively divided along with the short gastrics. In this context, the short gastrics are difficult to reach and a few tricks may help in doing so. At this level, there are no major problems. We can easily visualize the different elements of the gastrosplenic ligament; however, the posterior attachments will be a hindrance. It is therefore important to largely open the posterior surface of the stomach using both a grasper, held by the assistant situated to the patient’s left, and a surgical gauze. This will help to retract or at least to stabilize the fatty tissues of the gastrosplenic ligament and allow gradual access to the posterior attachments of the gastric fundus. These posterior attachments must be freed in order to create the most flexible fundoplication. At times, a few bleeders may occur in these very thick ligaments. Usually, a meticulous control may help identify the origin of the segment. It is unnecessary to irrigate or aspirate profusely as it may contribute to obscuring the operative view; usually a gauze in the abdomen is sufficient to control the bleeding and cauterize it. Here we can see that this gauze is always applied to highlight the position of the posterior attachments. These are truly the short gastrosplenic vessels and their division helps to progressively mobilize the apex of the fundus. As a reminder, it is this part of the stomach that may be used to create the fundoplication. Usually, this dissection ends as in all individuals by the division of the gastrophrenic ligament that we can identify in this image. It is also important to divide it to obtain a good fundic mobility. At this stage of the procedure, the stomach is ready for the anti-reflux wrap. For an easier access, we prefer to start with the crural repair before creating the crural fundoplication.

8. Crural repair 10'06''

Visualization of the retro-esophageal region is easier if the wrap does not obscure or impair the vision of the 2 diaphragmatic crura, especially in fatty patients. The crus of the diaphragm is preserved while trying to keep the peritoneal cover which will reinforce the sutures. In this fatty patient with fragile diaphragmatic crura, we will perform a fairly extensible closure as 2 figure of eight stitches and a single stitch will be applied, along with a calibration done according to the size of the esophagus. We use a non-absorbable, size 0, suture material. In fattier patients, sometimes extracorporeal knots are used by the surgeon. It generally depends on the surgeon’s habits. We can see that this crural repair is extensive, which helps to reduce the spaces where the gastrosplenic ligament or the stomach may herniate. By releasing the traction on the esophageal junction, we can see that the esophagus finds its natural position at the level of the diaphragmatic repair.

9. Fundoplication wrap 12'08''

The fundoplication wrap is created. We identify the anterior and posterior surface of the gastric fundus. The fundus is passed posterior to the esophagus and the posterior surface is brought in such a way that it positions itself to the right of the esophagus. We check that there are no twists at the level of the stump, and as soon as the esophagus’s flexibility has been tested, the stump is sutured with 3 interrupted non-absorbable sutures. The first stitch does not fix the esophagus. This is a technique that helps to appreciate its flexibility. We can imagine that at this stage, a 50 French bougie would easily pass through this stump. This aspect is made possible following the mobilization of the gastric fundus. In this patient with a fatty esophagus and hard to identify structures, we prefer to suture the cardio-esophageal junction in a more resistant area, which is as a matter of fact the level of insertion of the phreno-esophageal membrane. At this level generally, there is a more resistant tissue than in the esophageal wall. As we know is the case in fatty patients, all the attachments of these mobile elements must be done to the strongest structures. Here we can see the fixation of the wrap at the level of the phreno-esophageal membrane and that it has been sutured to an extremely resistant tissue. The other advantage of this lateral stitch is to protect against a stomach herniation through the stump of the fundoplication; indeed it closes the space to the left border of the esophagus. In this patient, an additional left lateral stitch will be fixed to the superior part of the fundoplication, once again to ensure a sufficient re-approximation of the stump with the cardio-esophageal junction. At the end of the procedure, the loop and all the surgical gauzes and are withdrawn from the peritoneal cavity. It is evident that when gauzes are used, it is important to control the operative field at the end of the procedure.

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