Step 2: Preoperative Considerations
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EGD, esophageal motility, and 48-hour Bravo pH
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In special circumstances may order impedance
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Rarely need upper GI unless concern for paraesophageal hernia
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Exclude other causes of symptoms—peptic ulcer disease, achalasia, esophageal dysmotility, and malignancy
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For morbidly obese patients (BMI >40 kg/m 2 ), consider bariatric surgery
Step 3: Operative Steps
1.
Port Placement and Room Setup ( Figure 6-1AB )
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The room is set up as demonstrated in Figure 6-1 . A split leg table approach is preferable. The surgeon stands between the patient’s legs. The first assistant stands to the surgeon’s right, and the scrub nurse or second assistant stands to the surgeon’s left. Dual monitors are placed above the arms. An endoscopy cart is available at the patient’s head as well.
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Ports are placed similar to a paraesophageal hernia repair. The initial cutdown port is typically placed one third the distance to the xyphoid process from the umbilicus.
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It is not as critical in a standard Nissen fundoplication to place the ports as high, as an excessive mediastinal dissection is typically not required.
2.
Dissection at Base of Right Crus ( Figure 6-2 )
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After division of the gastrohepatic omentum, the right crus is identified.
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It is preferable to begin the hiatal mobilization at the base of the right crus, as this limits the potential for inadvertent esophageal injuries.
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The first assistant grasps the gastroesophageal fat pad and retracts cephalad and to the patient’s left. The surgeon grasps the base of the crus as far posteriorly as possible and gently sweeps the phrenoesophageal attachments away. This exposes the decussation of the crural fibers.
3.
Dissection of the Right Crus
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After identifying the base of the right crus, the surgeon gently grasps the right crus and sweeps everything medially. In essence this is a crural dissection, and no attempt is made to perform an esophageal dissection at this point. This is an important distinction because early dissection of the esophagus before anatomic structures are clearly identified can result in esophageal injuries.
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The right crus is dissected over the top of the crus until the left vagus is identified, traversing along the anterior esophagus.
4.
Division of Short Gastric Vessels
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It is preferable to divide the short gastric vessels prior to exposing the left crus.
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Exposure of the short gastric vessels proceeds in a systematic fashion.
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The surgeon grasps the stomach with the left working port, and the first assistant grasps the gastrosplenic omentum. A common mistake at this point is that the surgeon does not retract the stomach to the patient’s right and instead pulls down to the feet. In doing so, the surgeon does not elevate the stomach off the retroperitoneum and makes getting into the appropriate plane more difficult. This is another point at which care must be used to avoid injuring the transverse colon as it can be quite close to the greater curvature of the stomach.
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The dissection plane is approximately 5 to 7 mm off the edge of the stomach. Getting too close to the stomach can result in thermal injuries, and drifting too far away can result in excessive fatty tissue on the stomach or injury to the splenic hilum.
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After entering the lesser sac, the retraction changes. ( Figure 6-3 ) The surgeon places the left hand on the posterior wall of the stomach within the lesser sac and retracts inferiorly and to the left. The first assistant places one side of the grasper in the lesser sac straddling the gastrosplenic omentum. This provides visualization of both the anterior and posterior walls of the stomach prior to division and avoids inadvertent thermal injuries.
