Laparoscopic Nissen Fundoplication

Laparoscopic Nissen Fundoplication is a surgical procedure used to treat gastroesophageal reflux disease (GERD) and hiatal hernias. The surgery involves creating a "valve" at the bottom of the esophagus to prevent stomach acid from flowing back into the esophagus, reducing symptoms such as heartburn, regurgitation, and difficulty swallowing. The surgery is performed using small incisions and a laparoscope, a small camera that allows the surgeon to see inside the body without making large incisions.

Position

Lithotomy with the head tilted up.

Step 1: Trocar insertion

During a Laparoscopic Nissen Fundoplication, trocars will be used to make incisions. The #3 knife handle with an 11 blade loaded onto it is usually used to create these incisions. The number of trocars needed and their size will depend on the surgeon's preference. The doctor will usually stand in between the patient's legs, with the surgical technologist positioned on the left.

Step 2: Initial Exploration

Once the trocars are in place, the surgeon will insert some laparoscopic graspers to explore the area. The person holding the camera will usually be on the right side. A fan retractor will be used to retract the liver, allowing the surgical team to have a clear view of the area.

Step 3: Retracting the Esophageal Hiatus

The next step is to view the esophageal hiatus, and a babcock will be placed on the fat pad and retracted with tension. This allows the surgeon to have better access to the area. A cautery hook and a grasper will be used on the ligament while avoiding the nerves and hepatic artery, creating a "window" that will allow for better access and visibility.

Step 4: Dissecting Around the Esophagus

After creating the "window," the surgical team will perform a blunt dissection around the esophagus with their graspers, ensuring that all major body landmarks have been found and dissected. This step is crucial in ensuring the safety of the patient during the surgery.

Step 5: Closing the Hiatus

Once all the necessary landmarks have been dissected, the hiatus can be closed, usually with proline suture. A bougie may be placed in the esophagus to ensure that the closure is in the right place. A harmonic may be used on vessels to minimize bleeding during the closure.

Step 6: Ligating Gastric Vessels and Closure

The stomach will then be freed by ligating the gastric vessels, allowing for better movement during the surgery. Hemostasis will be achieved before closure begins. After ensuring that the area is free from bleeding, the surgical team will begin the closure of the incision sites.

The Surgery Sparknotes

1. Insert trocars with #3 knife handle and 11 blade.
2. Use laparoscopic graspers to explore.
3. Retract liver with fan retractor.
4. View esophageal hiatus and retract with babcock.
5. Use cautery hook and grasper to create a "window".
6. Do blunt dissection around esophagus.
7. Close hiatus with proline suture.
8. Place bougie in esophagus and use harmonic on vessels.
9. Ligate gastric vessels and achieve hemostasis.
10. Closure of incision sites.