Transcript Pediatric Laproscopic Nissen Fundoplication

Pediatric Laproscopic Nissen
Fundoplication
Lindsey Bendure
Minimally Invasive Surgery Lab
Nissen Fundoplication
The fundus of the stomach is wrapped
around the esophagus so that the lower
portion of the esophagus passes through a
small tunnel of stomach muscle
This strengthens the lower esophageal
sphincter which prevents acid from
retreating into the esophagus (when the
stomach contracts, it closes off the
sphincter)
Indications and Pre-op Evaluation
• Patients with GERD and any of the following may be considered
for a fundoplication:
• Erosive esophagitis, stricture and/or Barrett’s esophagus
• Hiatal hernia
• Dependence upon proton pump inhibitors for relief of
symptoms in the absence of documented mucosal injury
• Atypical or respiratory symptoms with a good response to
medical treatment
• Risk factors that predict a poor response to medical therapy
• Nocturnal reflux on 24-hr esophageal study
• Structurally deficient lower esophageal sphincter
• Mixed reflux of gastric and duodenal juices
Gerd Treatment Options
• Lifestyle changes
• Eat smaller, more frequent meals
• Limit intake of acid-stimulating
foods/drinks
• Don’t lie down for about 2 hours after
eating (or hold baby upright)
• Slightly elevate head when sleeping (or
bed for infants)
• Maintain a reasonable weight
• Don’t smoke or drink alcohol
• Wear loose fitting clothing
GERD Treatment Options
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Proton pump inhibitors
H2 blockers
Antacids
Surgery
Nissen Fundoplication
• Safe and effective
• 89.5% of patients are still symptom free
after 10 years
• Mortality rate <1%
Laproscopic vs Open Surgery
• 1-2 days in hospital
post-op
• 2-3 weeks recovery
• Increased risk for
difficulty swallowing
• Several days in
hospital post-op
• 4-6 weeks recovery
• Increased risk for
infection and bleeding
Procedure Outline
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Retract the liver
Crural dissection
Circumferential dissection of the
esophagus
Crural closure
Fundic mobilization by division of short
gastric vessels
Creation of a short, loose fundoplication
by enveloping the anterior and posterior
wall of the fundus around the lower
esophagus
Liver Retraction
• Insert liver retractor through the 10MM
cannula on the patient’s right side
• Position the liver retractor so that the left
lobe of the liver is retracted ventrally
• This exposes the anterior surface of the
proximal stomach near the
gastroesophageal junction
Crural Dissection
• Identify and preserve both vagus nerves
• Open the omentum over the caudate lobe
of the liver, just above the hepatit branch
of the vagus nerve; this exposes the right
crus of the diaphragm
• Carry the incision to the patient’s left, over
the anterior surface of the left crus
• Dissect the right crus from its base,
through the crural arch
• Similarly, dissect the left crus from its base
Esophageal Dissection
• Gently dissect between the crura at their
bases, opening the retroesophageal
window
• Identify and preserve vagus nerve
• Pass a 1 inch Penrose drain around the
distal esophagus and use it as a handle for
further dissection
• Dissect the distal esophagus out of the
chest until at least 4 cm of distal
esophagus can be pulled below the
diaphragm without tension
Crural Closure
• Use a Maryland and a needle driver
• Close the crura together using nonabsorbable sutures
• Can use a bougie to measure it when
completed
Mobilize Gastric Fundus
• Enter the lesser sac, on third of the way
down the greater curve of the stomach and
isolate an divide short gastric vessels,
working back towards the GEJ
• Divide any filmy attachments between the
posterior wall of the proximal stomach and
the anterior surface of the pancreas
• Bring the mobilized gastric fundus through
the retroesophageal window and around
the distal esophagus anteriorly to ensure
adequate mobilization
Fundoplication
• Complete the fundoplication around a 60
French esophageal dilator (inserted by
anesthesiologist)
• 2 or 3 non-absorbable sutures are places
with bites taking full thickness gastric
fundus and partial thickness anterior
esophageal wall
• When completed, the wrap should be no
greater than 2 cm in length
• Sutures from the wrap to the diaphragm
are optional
Operating Room Set-up:
Patient
• Endotracheal intubation
• 30degrees reverse Trendelenburg to
spontaneously lower the abdominal
organs
• Supine position, arms at 90degrees and
legs apart
• Dual lumen gastric tube to decompress the
stomach; moved up to the middle third of
the esophagus once the stomach has
been decompressed
• Surgeon stands between the legs and
uses both hands
Trocar Placement/Incisions
• 5 total incisions
• Laproscope is inserted slightly superior
and lateral to the umbilicus
• 4 other incisions made: 2 in upper left
quadrant and 2 in upper right quadrant,
bordering and inferior to the rib cage
• Liver retractor goes into the incision
farthest away from the surgeon on his left
Instruments
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Liver retractor with Babcock clamp
Maryland dissector
Scissors
Cautery or Harmonic scalpel, depending
on size of patient
• Needle holders
Surgical Complications
• Perforation of the stomach or esophagus
(1% of patients)
• Bleeding
• Infection
• About 5% of laproscopic cases result in a
conversion to the open procedure
Post-Operative Complications
• “Gas Bloat Syndrome” – accumulation of
gas in the stomach or intestine due to
inability to burp (2-5% of patients)
• Inability to vomit
• Chest pains
Post-Operative Care
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1-3 day hospital stay
Liquid diet for 1-2 weeks
Rest and relax
No heavy lifting
No strenuous activities
Expect weight loss