Laparoscopic Technique for Nissen fundoplication
Surgical Details of Nissen fundoplication Procedure
1. To start the Nissen fundoplication a 10 mm incision is made in the supraumbilical area.
2. Dissection is done through the subcutaneous tissue with a combination of blunt dissection and Bovie cautery.
3. The fascia is appreciated with retraction by Army-Navy retractors or S retractors.
4. Stay sutures of 2-0 Vicryl are placed on either side of the midline and the fascia is incised.
5. Forceps are used to grasp the peritoneum and a small incision is made to enter the abdomen.
6. Finger palpation of the inside of the abdomen is performed to insure there are no adhesions.
7. The Hasson cannula is placed into the abdomen with the stay sutures used to secure its position.
8. Pneumoperitoneum with carbon dioxide is effected to a pressure of 15 mmHg.
9. Under direct visualization after the videoscope is white-balanced, focused, and applied with antifog solution, a 10 mm port is placed bluntly in the left subcostal area.
10. Under direct visualization, three 5 mm ports are placed in the epigastric, right abdominal, and left abdominal areas.
11. A liver retractor (usually a fan-shaped retractor or loop-shaped retractor) in most Nissen fundoplication operations is introduced through the right abdominal port.
12. The left lobe of the liver is retracted superiorly and laterally and the external portion is attached to the holding bracket on the operating table siderail.
13. The greater curvature of the stomach is grasped with a endo Babcock retractor and the stomach is retracted anteriorly and to the right.
14. The assistant grasps the lateral gastrosplenic ligament and retracts this and the spleen to the left.
15. The gastrosplenic ligament is inspected and opened in an area away from the short gastric vessels.
16. The harmonic scalpel is used to divide the short gastrics approximately 1 cm from the edge of the stomach to avoid injury to the stomach wall.
17. To aid in visualization during Nissen fundoplication, the stomach is sequentially grasped beneath the just cut short gastrics.
18. Dissection of the short gastrics is performed until the left crus of the diaphragm is visualized.