Antireflux Surgery: Total Fundoplication

Trocar Placement

We use five 10 mm ports for the procedure. The first port is placed in the mid-line about 14 cm below the xiphoid process; it can be also placed slightly (2–3 cm) to the left of the midline to be in line with the hiatus. This port is used for insertion of the scope. The second port is placed in the left midclavicular line at the same level of port 1, and it is used for the insertion of a Babcock clamp for traction, a grasper to hold the Penrose drain while surrounding the esophagus, or for devices used to divide the short gastric vessels. The third port is placed in the right midclavicular line at the same level of the other two ports, and it is used for the liver retractor. The fourth and fifth ports are placed under the right and left costal margins so that their axes and the camera form an angle of about 120°. These ports are used for the insertion of dissecting and suturing instruments (Fig. 15.2).

../images/473262_1_En_15_Chapter/473262_1_En_15_Fig2_HTML.png — Fig. 15.2

Position of trocars for laparoscopic fundoplication

Key Note

Trocars should not be placed too low. If this occurs, it might be difficult to take down the more proximal short gastric vessels or reach the gastroesophageal junction with the Babcock.

Division of Gastrohepatic Ligament and Identification of Right Crus of the Diaphragm and Posterior Vagus Nerve

The left lateral segment of the liver should be retracted to obtain an appropriate exposure of the gastroesophageal junction. The gastrohepatic ligament is then divided. The dissection begins above the caudate lobe of the liver and continues proximally until the right crus is identified. The crus is then separated from the right side of the esophagus by blunt dissection and the posterior vagus nerve is identified. The right crus is dissected inferiorly toward the junction with the left crus (Fig. 15.3).

../images/473262_1_En_15_Chapter/473262_1_En_15_Fig3_HTML.png — Fig. 15.3

Division of gastrohepatic ligament

Key Note

If an accessory left hepatic artery originating from the left gastric artery is encountered, it can usually be safely divided. The electrocautery should be used with caution next to the right pillar of the crus because the lateral spread of the monopolar current may injury the posterior vagus nerve.

Division of Peritoneum and Phrenoesophageal Membrane Above the Esophagus and Identification of the Left Crus of the Diaphragm and Anterior Vagus Nerve

The peritoneum and the phrenoesophageal membrane above the esophagus are transected with the electrocautery, and the anterior vagus nerve is identified. The left pillar of the crus is separated from the esophagus and dissected bluntly downward toward the junction with the right crus (Fig. 15.4).

../images/473262_1_En_15_Chapter/473262_1_En_15_Fig4_HTML.png — Fig. 15.4

Division of phrenoesophageal membrane

Key Note

In order to avoid injury of the anterior vagus nerve or the esophageal wall during this step of the procedure, the nerve should be always left attached to the esophageal wall and the phrenoesophageal membrane should be lifted from the esophageal wall by blunt dissection before it is divided.

Division of Short Gastric Vessels

The short gastric vessels are divided all the way to the left pillar of the crus, starting from a point midway along the greater curvature of the stomach. The division of the short gastric vessels will ensure a tension-free wrap (Fig. 15.5).