Laparoscopic Nissen Fundoplication

Patient Positioning

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During Laparoscopic Nissen Fundoplication, the patient is typically positioned as follows:

• Position: Modified lithotomy position. The patient lies on their back with their legs placed in stirrups or abducted on split leg holders.
• Table Tilt: The operating table is tilted into a steep reverse Trendelenburg position (head up, feet down). This uses gravity to help displace the abdominal organs (bowel) inferiorly, away from the surgical field in the upper abdomen (hiatus).
• Surgeon and Assistant Positioning:
  • The primary surgeon usually stands between the patient’s legs.
  • The first assistant is typically positioned on the patient’s left.
  • The camera operator (if separate) is often on the patient’s right.
• Monitors: Video monitors displaying the laparoscopic view are placed at the head of the bed for easy viewing by the surgical team.
• Some surgeons may use a beanbag to help secure the patient’s position.

Port Placement

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Laparoscopic surgery involves making several small incisions (ports) in the abdomen to insert a laparoscope (camera) and specialized surgical instruments. While specific placements can vary slightly based on surgeon preference and patient anatomy, a common configuration includes:

• Camera Port: Typically a 10 mm or 12 mm port, often placed near or slightly superior to the umbilicus (belly button). This can be adjusted based on the patient’s torso length. Some techniques describe it two fingerbreadths superior and left of the umbilicus.
• Working Ports (usually 5 mm or 8 mm, with one possibly larger for instrument/specimen passage):
  • Right Subcostal Port: Placed under the right rib cage, often in the anterior axillary line. This may be used for a liver retractor or working instruments.
  • Left Subcostal Port(s): One or two ports placed under the left rib cage. One might be in the anterior axillary line and another more laterally in the mid-axillary line. These are primary working ports for the surgeon.
  • Subxiphoid Port: A port placed just below the xiphoid process (the lower tip of the sternum). This is commonly used for a liver retractor to lift the left lobe of the liver and expose the esophageal hiatus.
  • Assistant Port: An additional port (e.g., 11 mm) may be placed on the left side between the camera and the lateral left subcostal port for assistant tasks like suction or retraction.

The goal of port placement is to provide optimal triangulation for instruments, good visualization, and ergonomic access for the surgeon while minimizing interference between instruments. The ports are generally placed under direct visualization after initial abdominal access and insufflation (filling the abdomen with carbon dioxide gas to create working space).

Intraoperative Steps

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The Laparoscopic Nissen Fundoplication procedure involves several key steps performed under general anesthesia:

1. Pneumoperitoneum Establishment: Carbon dioxide gas is insufflated into the abdominal cavity to create space for visualization and maneuvering instruments.
2. Port Insertion: Small incisions are made, and trocars (ports) are inserted as described above. The laparoscope and surgical instruments are introduced through these ports.
3. Liver Retraction: The left lobe of the liver is gently retracted upwards (anteriorly) to expose the esophageal hiatus and the gastroesophageal junction.
4. Hiatal Dissection:
   • The surgeon carefully dissects the tissues around the lower esophagus and the diaphragmatic crura (the muscle fibers of the diaphragm that surround the esophagus).
   • The phrenoesophageal ligament (a membrane attaching the esophagus to the diaphragm) is opened.
   • The esophagus is mobilized circumferentially for an adequate length (e.g., distal 6 cm) to allow it to sit tension-free within the abdomen.
   • Care is taken to identify and preserve the vagus nerves (anterior and posterior trunks), which run along the esophagus and control gastric function. The fat pad near the gastroesophageal junction may be resected.
5. Crural Repair (Hiatorrhaphy): If a hiatal hernia is present or the hiatus is enlarged, the diaphragmatic crura are approximated (sutured together) posterior to the esophagus to narrow the opening. Non-absorbable sutures are typically used.
6. Fundus Mobilization: The upper part of the stomach (fundus) is mobilized. This often involves dividing some of the short gastric vessels, which run between the stomach and the spleen, to ensure the fundus can be wrapped around the esophagus without tension. This is a critical step for creating a “floppy” Nissen fundoplication.
7. Creation of the Fundoplication (Wrap):
   • The mobilized gastric fundus is passed behind the esophagus.
   • It is then wrapped around the lower esophagus in a 360-degree fashion (the “Nissen” wrap). The wrap should be “floppy,” meaning it’s not too tight, to avoid postoperative dysphagia (difficulty swallowing). The length of the wrap is typically 1.5 to 2 cm.
   • A bougie (a sizing tube) may be placed in the esophagus by the anesthesiologist during the creation of the wrap to ensure it is not made too tight. Common sizes range from 32F to 56F.
   • The fundus is sutured to itself (and sometimes to the esophageal wall and/or diaphragm) using non-absorbable sutures to secure the wrap in place. Techniques like the “shoe-shine” maneuver can be used to ensure the fundus slides freely and is of appropriate length.
8. Final Inspection and Closure:
   • The surgical area is inspected for hemostasis (control of bleeding).
   • The instruments and laparoscope are removed.
   • The carbon dioxide gas is released from the abdomen.
   • The small port site incisions are closed with sutures or surgical staples and covered with dressings.
   • A nasogastric tube, if placed, may be removed at the end of the procedure or shortly thereafter, though some surgeons may leave it in for 1-3 days.

Variations exist, such as the “right posterior approach,” which emphasizes early dissection of the lesser curve and posterior visualization of the stomach. Some surgeons also perform an anterior fundophrenopexy (suturing the fundus to the anterior hiatus) to prevent herniation.

Possible Complications and Management

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While Laparoscopic Nissen Fundoplication is generally safe and effective, potential complications can occur. These can be categorized as general surgical risks or specific to the procedure:

General Complications of Any Operation:

• Bleeding: Can occur intraoperatively or postoperatively. Minor bleeding usually stops on its own; significant bleeding may require blood transfusion or reoperation.
• Infection: Surgical site infection (wound infection) or intra-abdominal infection (peritonitis). Managed with antibiotics and possibly drainage.
• Blood Clots: Deep vein thrombosis (DVT) in the legs or pulmonary embolism (PE) if a clot travels to the lungs. Preventative measures include early mobilization, sequential compression devices, and sometimes anticoagulant medication.
• Hernia: Incisional hernia at a port site. May require surgical repair later.
• Allergic Reaction: To anesthesia, equipment, materials, or medications.
• Chest Infection (Pneumonia): Especially if lung function is compromised. Prevented by deep breathing exercises and early mobilization.

Keyhole Surgery (Laparoscopic) Complications:

• Damage to Intra-abdominal Structures: Injury to the bowel, liver, spleen, stomach, esophagus, or blood vessels during port insertion or dissection. Management depends on the specific injury and may require repair during the same surgery or a separate procedure.
• Surgical Emphysema: Trapped carbon dioxide in the skin or tissues, causing a crackling sensation. Usually resolves on its own.
• Gas Embolism: A rare but serious complication where CO2 enters a blood vessel.

Nissen Fundoplication Specific Complications:

• Dysphagia (Difficulty Swallowing):
  • Early/Temporary: Common immediately after surgery due to swelling. Usually resolves within a few weeks to months with a modified diet (liquids, then soft foods).
  • Persistent/Severe: May occur if the wrap is too tight, has slipped, or if there’s stenosis. Management may include dietary modifications, endoscopic dilation (stretching the wrap), or, rarely, surgical revision. Preoperative esophageal manometry helps identify patients at higher risk.
• Gas Bloat Syndrome: Difficulty belching or vomiting, leading to abdominal distension, discomfort, and increased flatus. Can occur in a significant percentage of patients. Often improves over time; dietary changes may help. Partial fundoplications may have a lower incidence.
• Pneumothorax (Collapsed Lung): Air escapes into the space around the lung, often due to proximity of the pleura during hiatal dissection. May require a chest tube if significant.
• Perforation of Esophagus or Stomach: A hole made during dissection or suturing. Requires immediate surgical repair.
• Wrap Slippage or Migration (Transdiaphragmatic Herniation): The fundoplication can slip down the stomach or herniate into the chest. This can cause recurrent reflux, pain, or acute obstructive symptoms. Incidence varies (reported 7-20% in some literature) and can require reoperation. Strategies to prevent this include adequate esophageal mobilization, crural repair, and proper wrap fixation.
• Wrap Ischemia: Reduced blood supply to the wrapped portion of the stomach, potentially leading to necrosis and perforation. A rare but serious complication, more likely in patients with underlying arteriopathy. May necessitate partial gastrectomy.
• Damage to Spleen or Liver: Can occur during dissection or retraction. May require repair or, rarely, splenectomy.
• Vagal Nerve Injury: Can lead to delayed gastric emptying, diarrhea, or other gastrointestinal motility issues. Careful dissection is crucial to avoid this.
• Recurrent Reflux Symptoms: Can occur in a percentage of patients over time due to wrap failure, loosening, or new hiatal hernia. Management may involve restarting medication, further investigation, or revisional surgery.
• Diarrhea: Can occur postoperatively, sometimes related to vagal nerve effects or altered digestion.
• Weight Loss: Can occur initially due to dysphagia or smaller meal capacity.
• Abdominal Discomfort or Pain: Can be related to the healing process or specific complications.
• Adhesions (Tissues Joining Abnormally): Can form after any abdominal surgery and may rarely cause later issues like bowel obstruction.

Management of Complications:

• Conservative Management: For mild symptoms like temporary dysphagia or gas bloat, dietary modifications and reassurance are often sufficient.
• Medical Management: Medications like antiemetics for nausea, analgesics for pain, or PPIs if reflux recurs.
• Endoscopic Procedures: Dilation for persistent dysphagia due to a tight wrap.
• Reoperation (Surgical Revision): May be necessary for significant complications like wrap migration, persistent severe dysphagia unresponsive to dilation, wrap ischemia, or perforation. Revisional surgery is often more complex than the initial operation.

Close postoperative follow-up is important to monitor for and manage any complications that may arise. Patients are usually discharged 1-3 days after laparoscopic surgery and can return to normal activities within a few weeks, depending on their recovery and type of work. Most patients experience significant improvement or resolution of their GERD symptoms.