Nissen Fundoplication
Gastroesophageal reflux disease is commonly managed using the laparoscopic Nissen fundoplication technique in a large number of pediatric centers worldwide. The procedure is performed with ease using minimal access techniques; however attention has to be
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Nissen Fundoplication Shawn D. St Peter and George W. Holcomb III
27.1
Operation Room Setup
Surgical Team Position
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Chapter 27 Nissen Fundoplication
27.2
Patient Positioning
27.3
Frog-leg position at the end of the table with arms tucked for infants and small children. Older children require stirrups.
• •
27.4
Location of Access Points
Special Instruments
Endoscopic liver rectractor Patients over 5 years age require one of the following devices to divide short gastric vessels: – Ultracision® shears (Johnson & Johnson Medical Products, Ethicon Endo-Surgery, Cincinnati, OH, USA) or – LigaSure™ (Valleylab, Boulder, CO, USA) or – EnSeal® (SurgRx, Redwood City, CA, USA)
Port Placement Sites
Optic port (3.5 / 5 mm)*
X
X
X X
Work port (2 / 3.5 mm)* X
Work port (2 / 5 mm)* *Port size depends on the age of the patient
Shawn D. St Peter and George W. Holcomb III
27.5
Indications
27.6
Contraindications
Gastroesophageal reflux causing one or more of the following problems: 1. Failure to thrive. 2. Aspiration pneumonia. 3. Apparent life-threatening event. 4. Esophagitis, persistent vomiting or severe symptoms refractory to medical therapy.
Severe cardiac or pulmonary diseases and severe musculoskeletal malformations.
27.7
27.8
Preoperative Considerations
Technical Notes
1. Place a nasogastric tube and have bougie available for the anesthesiologist to place. 2. Place foot pedals for hemostatic devices at the end of the bed. 3. Choose the length of sutures to be prepared by the scrub nurse. 4. Prep to the nipples as the skin will be drawn inferiorly by insufflation. 5. Drape in a manner that will provide easy access to the mouth for the anesthesiologist. 6. Place the drape in reverse direction. So the head portion, which is shorter, is not in the way of the surgeon’s feet.
1. If a gastrostomy button is to be placed, identify the spot on the abdomen prior to insufflation and this will serve as the port used by the surgeon’s operating right hand. 2. Place a 2-0 nonabsorbable suture in the crus posteriorly, tie a knot, then secure it to the posterior esophagus. 3. Place four interrupted 3-0 nonabsorbable sutures between the crus and the esophagus circumferentially (7, 11, 2, and 5 o’clock). 4. Identify the portion of fundus to be brought around the esophagus, then push it back through to the left side while the bougie is inserted.
27.9
27.10 Laparoscopic Nissen Fundoplication
Procedure Variations
1. A 5-mm port for the surgeon’s right hand allows vessel sealing devices to be used. 2. The esophagophrenic attachments can be completely mobilized or left in place laterally and anteriorly. 3. Pledgets may be employed to buttress the fundoplasty sutures. 4. A liver retractor can be a locking grasping forcep secured onto the right crus of the diaphragm 5. A table-mounted device can be used to hold the liver retractor in place.
Please see Figs. 1–6.
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Chapter 27 Nissen Fundoplication
Figure 27.1
Dissection is commenced beyond the short gastric vessels toward the le
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