Task analysis of Laparoscopic Nissen Fundoplication
By Dr WAEL ABU SIAM
1. Place patient in dorsal lithotomy position
2. Reverse Trendelenburg to about 30 degree
3. Camera—insert port one third from the umbilicus to xiphoid just left of midline
4. Examine abdomen—search for abnormal pathology, injuries from port placement
5. Surgeon’s left hand—insert port at right subcostal margin, midaxillary line
6. Surgeon’s right hand—insert port at left subcostal, midaxillary line
7. Assistant retractor—insert port at left anterior axillary line, level of umbilicus
8. Liver retractor—insert port at subxiphoid or at right anterio axillary line at level of umbilicus
9. Visualize insertion of trocars
10. Retract left lobe of liver anteriorly and toward the patient’s right Assistant retract stomach towards left foot
11. Distract gastrohepatic ligament on tension
12. Incise gastrohepatic ligament(cautery or harmonic)
13. Identify right crus
14. Dissect right crus from esophagus
15. Assistant retract stomach caudally and posteriorly
16. Dissect anterior aspect of esophagus from crus
17. Identify/protect anterior vagus nerve
18. Assistant retract stomach caudally and to the right
19. Identify left crus
20. Dissect left crus from esophagus
21. Dissect posteriorly down left crus toward crural decussation
22. Dissect fundus from left crus
23. Assistant regrasp near gastroesophageal junction and retract anteriorly and to the left
24. Complete dissection of right crus down to inferior crural decussation Identify/protect posterior vagal nerve
25. Develop posterior esophageal window
26. Pass penrose drain through created window to use as retractor
27. Secure both penrose tails together with suture
28. Assistant retract esophagus with penrose anteriorly and to the left Complete posterior window and left and right crural
dissection
29. Dissect into mediastinum around esophagus to obtain a minimum of 2 cm intra-abdominal length
30. Develop 2nd window posterior to esophagus
31. Pass a 2nd penrose through this new window
32. Secure both tails of 2nd penrose together with suture and remove 1st penrose
33. Place multiple figure of 8 sutures to close crura
34. Place most inferior suture first and proceed anteriorly
35. Complete all sutures now or add last suture after creation of fundoplication
36. Suspend gastrosplenic omentum between assistant’s retractor and surgeon’s left hand
37. Pick a point 1/3 down the greater curve to incise gastrosplenic omentum
38. Sequentially ligate short gastric arteries moving towards gastroesophageal junction
39. Dissect any posterior fundic gastric attachments
40. Complete dissection of any remaining gastric attachments to crus or diaphragm
41. Retract greater curve of stomach anteriorly towards liver
42. Measure 6 cm along greater curvature from GE junction and 2 cm from the edge of the curvature down the posterior fundic
wall
43. Mark this location with a loosely tied 3-0 silk suture
44. Pass suture and posterior fundic wall of stomach through posterior esophageal window
45. Grasp anterior fundic wall of stomach and drag anteriorly towards patient’s right
46. Kissing/shoeshine maneuver to orient fundoplication into final position—fundic edges meet on right side without twisting and
with short gastric in natural position
47. Relax penrose retraction of GE junction
48. Pass 60 French bougie
49. Re confirm configuration of wrap
50. Insert first suture into abdominal cavity—a double armed, pledgeted suture
51. first suture (1st needle) through anterior fundus then esophagus at 11 o’clock then posterior fundus
52. Pass 2nd arm of 1st suture as above
53. Place 2nd pledget and tie
54. Pass 2nd suture through anterior fundus then posterior fundus cranial to 1st suture
55. Pass 3rd suture through anterior fundus then posterior fundus caudal to 1st suture
56. Remove bougie
57. Examine crural closure, insert final suture to a gap of approximately 5mm(one instrument pass)
58. Remove penrose retractor
59. Pass nasogastric tube
60. Remove ports under direct visualization and close ports sites