Task Analysis of Laparoscopic Nissen Floppy Fundoplication

DR SANDEEP VARMA                                   

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases in which the gastric contents flow into the esophagus through the incompetent lower esophageal sphincter (LES) and can cause troublesome symptoms and complications. Symptoms include the taste of acid in the back of the mouth, heartburn, bad breath, chest pain, vomiting, breathing problems, and wearing away of the teeth. Complications include esophagitis, esophageal strictures, and Barrett's esophagus.

Currently, the therapy approaches of GERD include lifestyle modifications, proton pump inhibitor-based pharmacologic therapy and surgical intervention.

There are two major anti-reflux procedures: 360° total (Nissen) fundoplication and 270° partial (Toupet) fundoplication. Currently, laparoscopic Nissen fundoplication (LNF) is the most common surgical procedure for the management of GERD offering promising long-term outcomes and has been recommended as a choice of surgical therapy by the European Study Group for Anti reflux Surgery and the Society of American Gastrointestinal Endoscopic Surgeons.

Risk factors include

• Obesity, 
• Pregnancy, 
• Smoking, 
• Hiatus hernia, and 
• Medications (antihistamines, calcium channel blockers, antidepressants, etc) 
Indications of surgery
1. Chronic uncomplicated GERD with the partial or total response to PPI   therapy but requiring long term maintenance therapy.
2. Poor response of confirmed GERD to PPI therapy or refractoriness.
3. PPI intolerance and hypersensitivity.
4. Peptic esophageal stricture with the need for repeated dilatation.
5. Barret’s esophagus.
6. Respiratory complications of GERD like laryngitis, pneumonia.

Goals in Fundoplication surgery 

The standard surgical treatment for severe GERD is the Nissen fundoplication. In this procedure, the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia.  It is recommended only for those who are refractory to medical treatment and not to those who are resistant to medical therapy.

Pre-operative assessment:

1. Detailed history
2. Endoscopy
3. Barium Swallow
4. Esophageal manometry
5. Ph monitoring
6. Bile reflux monitoring.

Final goal 

1. Symptomatic relief from GERD
2. No dysphagia symptoms postoperatively
3. Reduced intra operative complications
4. Reduced post operative hospital stay
 

TASK ANALYSIS:

1. Procedural steps
2. Executional steps

Procedural steps:

1. General anesthesia followed by patient positioning.
2. Cleaning and sterile draping.
3. Co2 Insufflation with veress needle at 5cm superior to the umbilicus.
4. Insertion of ports.
5. Liver retraction by Nathenson’s retractor and identification of pars flacida. 
6.  Exposing the right and left crura of the diaphragm.
7.  Mobilization of esophagus up to 5cm intra abdominally.
8.  Approximating the gap between both crura through sutures.
9.  Mobilization and preparation of stomach for wrapping by dividing short gastric vessels.
10. Plication of the fundus of the stomach around the mobilized esophagus.
11. Inspection of tightness of fundoplication.
12. Irrigation and suction.
13. Hemostasis achieved.
14. Removal of ports under vision.
15. Skin closure.

Executional steps:

Anesthesia: General anesthesia

Patient Position:

1. The patient is placed in the supine position with legs in the lithotomic position.
2. Operating table height must be 0.49 x surgeon height
3. The operation table is tilted approximately 15° head up.
4. The surgeon stands in between the patient’s leg.
5. The first assistant with the telescope and video camera stands on the left of the patient.
6. Scrub nurse along with instrument trolley stands on the left of the patient next to the first assistant.
7. A video monitor is positioned at the head end on either side of patient shoulder.
8. The monitor should be placed at a distance of 5 times multiplied by the diagonal measurement of the monitor screen and should be at a height of approximately 10° lower from the surgeon's eye
9. The surgeon, target organ (gastro-oesophageal junction), and monitor are to be present in a co-axial alignment.

Port position:

1.  All ports are made according to “ baseball diamond concept”
2.  10 mm optical port should be placed 5 cm above the umbilicus
3.  5 mm port on right hypochondria 7.5 cm away from the optical port
4.  Another 5mm port is made on left hypochondria 7.5 cm away from optical port.
5.  One more 5mm port is made in left mid-clavicle line just below the left costal margin.
6.  The 5th port of 5mm caliber for Nathensson’s retractor is made in the epigastric region.

Quadro manometric settings are assessed.

1) Preset pressure is maintained at 15 mm of Hg.
2) Cautery check with monopolar and animal return plate, harmonic device connections are confirmed. 
3) The light source and coaxial alignment with the surgeon are checked.
4) Co2 cylinder checked for availability of sufficient Co2 for insufflation.
5) Working status of all the lap instruments along with insulation check is properly made.

Operative steps:

Access and Insufflation

1. Check veress needle for patency and spring action 
2. A small stab incision using number 11 blade at 5cm superiorly to the umbilicus is made
3. Lift the lower abdominal wall between your palm and four fingers 
4. Measure the thickness of the abdominal wall 
5. Hold the veress needle like a dart exposing only 4cm + the measured abdominal wall thickness, and direct it at 45 degrees to the animal abdominal axis yet 90 degrees to the abdominal wall aiming towards the anus 
6. You must feel two give away clicks 
7. Make sure you are inside the abdominal cavity using the following tests:
i) Irrigation and suction test: free flow of 5cc saline with no resistance, then on suction, only air must come back 
ii) Hanging drop test: put one drop of saline at the opening of the veress needle then lift the abdominal wall, the drop must go through the needle 
iii) Connect to the insufflator : intra-abdominal pressure must be zero
8. Start insufflation with Co2 gas at flow rate of 1L/min and keep an eye on the Quadromanometric readings on the insufflator to make sure that the rise in the intraabdominal pressure is proportional to the total amount of gas pumped 
i) When reaching 12 mmHg pressure  enlarge your incision to 1.1 cm, then insert a size 10mm port at 90 degrees using screw movement to the right and left 
9. Remove  the trocar and connect the gas tube to the port
10. Connect the 30° telescope to the camera head and make sure that white balance setting is achieved 
11. Insert the telescope into the abdominal cavity above the umbilicus,  inspect all four quadrants  and the abdominal cavity for any other  pathology 
Liver retraction: Through the epigastric 5mm port a Nathensson’s self-retaining retractor is introduced and the liver is lifted and retracted exposing the gastro-esophageal junction and pars flacida ligament.

Dissection:

Identification of Pars flacida: 

After the liver is retracted using Nathensen’s self-retaining retractor, pars flacida is identified as it is the thinnest layer of peritoneum devoid of any fat, 
Dissection is started by dividing this layer and exposing the caudate lobe of the liver. 
Just medial to caudate lobe lies the inferior vena cava, so care should be taken not to dissect in this area and to avoid overshooting of the instruments. 

Identification and dissection of both right and left crus of diaphragm:

The stomach is retracted Antero laterally using an atraumatic grasper by the assistant so that right crus of the diaphragm is exposed. 
Dissection is carried on carefully to delineate the right crus, using diathermy/ harmonic scalpel and dissecting forceps.
The loose areolar tissue between the right crus and the esophagus is dissected carefully, taking note of not injuring the posterior vagal trunk and avoiding perforation of the esophagus.
After dissecting right crus, the stomach is retracted anteromedially to expose the left crus of the diaphragm. Careful dissection using diathermy/harmonic and scissors will delineate the left crus.   

Mobilization of the esophagus:

Anterior mobilization of the esophagus is done and care must be taken to avoid undue cutting of anterior vagus which runs on the anterior wall of the esophagus, slightly embedded in it.
Posterior mobilization of the esophagus is done to form a window for the stomach to insert a sling and the posterior vagus nerve is visualized which lies just on the posterior wall of the esophagus.

Insertion of a sling:

A sling is passed through a separate puncture wound from the abdominal wall without inserting a separate port.
A grasping forceps is inserted through one of the port to hold the sling so that the esophagus can be manipulated.
The gastro-esophageal junction is retracted by the help of the sling in anteromedial pull.
The surroundings of the oesophagus in the posterior mediastinum are dissected for 5- 6 cm.

Mobilization of the stomach:

The fundus part of the stomach is mobilized nicely along with the gastroesophageal junction by anteromedial traction
Sling for retraction of the esophagus is released at this point of time
The short gastric vessels are separated with the help of a bipolar or harmonic scalpel which aids in further mobilization of the fundus of the stomach through the earlier formed posterior window. 
Care must be taken not to injure the spleen which is adjacent to the stomach.
A grasper is advanced through the posterior window and the Posterior wall of the fundus is held and pulled through the window from right side to the left.
Perform a Shoeshine maneuver to form a FLOPPY NISSEN. 
Floppy Nissen has fewer chances of dysphagia which is the effect of tight wrap of the fundus.
After doing a floppy wrap of fundus around the mobilized esophagus  a buttock sign with the posterior wall of the fundus is ascertained to confirm the adequacy of the wrap

Crural approximation:

With the lower end of the mobilized esophagus, g- junction and the fundus of the stomach retracted anterolaterally, both the crura are identified and approximated for suturing.
The right and left crura are approximated with two or three surgeons knots or Tumble Square Knot with Ethibond which is a nonabsorbable suture. 
Care must be taken not to tightly approximate the crura and at least 5 mm gap must be left between the esophagus and the knots to avoid dysphagia.

Fundoplication:

Sling for retraction of the esophagus is released at this point of time

By serial movements of pulling posterior wall forward and pushing the anterior wall back, a sufficient amount of wrap is made around the esophagus, this can be ascertained by seeing the ‘buttock sign’.
The wrap made by both posterior and anterior wall of fundus should not be too tight, A Floppy Nissen’s is made by doing the ‘shoe shine’ maneuver.

Fixation of the wrap by intra-corporeal sutures:

Suture material used is nonabsorbable suture- Dacron, silk, polypropylene, etc
Approximately 5cm of the mobilized esophagus should be prepared for the fundal wrap.
First suture is taken with the full thickness of the anterior wall of the fundus and full thickness of the posterior wall of the fundus is taken
Intra corporeal surgeons knot are used for placating the stomach on to the esophagus, through ‘tumble square knots’ can also be used.
Two suture is taken above the first knot at a distance of 1cm between each knot, involving the full thickness of the anterior wall of the fundus, partial muscular layer of the esophagus and full-thickness posterior wall of the fundus .
In the above suture wall of the esophagus is sandwiched between walls of the fundus, 
Taking full thickness of esophagus in above sutures should be avoided as it may cause a complication of perforation of the esophagus
Two sutures are taken below the first knot at a distance of 1cm between each knot in a similar manner.

Completing the surgery:

The needle used for suturing is taken out
Hemostasis is achieved
Nathensen’s retractor is taken off and the liver is brought down in its anatomical position
All the cannula are withdrawn under vision, pneumoperitoneum is undone completely and both the 10 mm port site is closed using vicryl no 1 with the help of suture passer instrument.
Closure of 10 mm ports is to be done under the telescopic vision to avoid inadvertent injury to intra abdominal structures.

Complications:

The complication of pneumoperitoneum.

have significant effects on the patient, especially if they are elderly or have associated morbidity, it may cause some complications such as

1. Severe hypercarbia.
2. Cardio-pulmonary compromise.
3. Air embolism or gas migration (subcutaneous emphysema, pneumo-mediastinum, and pneumothorax.) 

The Complications of Operative procedure 

1. Hollow or solid viscus perforation, abdominal wall or major vessel injury, 
2. Incisional hernia 
3. Hemorrhage, 
4. Vascular injury, 
5. Retroperitoneal hematoma. 

Postoperative complications 

1. gas bloat syndrome, 
2. Dysphagia, 
3. Dumping syndrome, 
4. Vagus nerve injury, 
5. Achalasia.

Nissen (floppy) fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%. 
Studies have shown that after 10 years, 89.5% of patients are still symptom-free.

References:
1. Dr R K MISHRA, World Laparoscopy Hospital, Gurgaon.
2. B. DALLEMAGNE Les Cliniques Saint Joseph, Liege, Belgium