NISSEN-FUNDOPLICATION
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This is a 360° fundoplication.
It consists in transposing the gastric fundus around the abdominal oesophagus by ligating and dividing the short gastric arteries.
The plastic hemi-valves are sutured anteriorly with extramucosal stitches which, in the original description of the operation, include the oesophageal wall, covering a length of 4-5 cm.
Over the years, various modifications have been applied to the original description so as to avoid the high percentage of side-effects caused by the original operation.
These modifications include anchoring the fundoplication to the right crus of the diaphragm, calibrating the plasty on an endo-oesophageal probe with the creation of a so-called floppy plasty, and the creation of a short plasty so that it cannot exert resistance on the relaxed sphincter that would hamper the contractile capacity of the oesophageal body.
Posterior hiatoplasty can be associated with the operation.
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The oesophagus has been completely freed from the crura of the diaphragm. The vagus nerves have been isolated and identified.
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The malleable hook has loaded the oesophagus from left to right, passing in front of the posterior vagus nerve.
This window, through which the stomach valve has to pass, can be suitably enlarged by inserting another hook from the right as well and opposing it to the first.
The gastric fundus has already been fully mobilised.
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While the hook holds the oesophagus upwards, the operator passes the forceps in his left hand behind the oesophagus to grasp the already mobilised gastric fundus (phreno-fundal reflection and, generally, 1-2 short vessels divided), which is brought in by another forceps operated by the assistant. |
The forceps has withdrawn the gastric fundus behind and to the right of the oesophagus. This passage must take place without exerting force and the fundus must stay in position.
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A probe is pushed into the stomach to calibrate the cuff. The authors say that the calibre ranges from 40 to 60 Fr.
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With the probe in position, correct gastro-gastric alignment is verified and, if required, mobilisation of the fundus is completed.
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The most cranial stitch in the plasty is placed first. The more stitches there are on the outside part of the cuff, the wider the fundoplication will be, the stomach wall in direct contact with the oesophagus remaining abundant. The left edge of the stomach valve is loaded by the stitch.
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The stitch, as envisaged in the original technique, is about to transfix the muscle wall of the oesophagus. Care must be taken not to damage the anterior vagus nerve.
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In particular, one notes the grip on the oesophageal muscle system. This is to prevent the oesophagus and the stomach from rising inside the gastric cuff.
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The plasty must be floppy and short. Generally speaking, three stitches one centimetre apart are sufficient.
Indeed, a rigid, unidirectional valve should not be made, but rather, a dynamic anti-reflux mechanism which hampers reflux as intra-gastric and intra-abdominal pressure increases but does not prevent vomiting and belching.
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Further calibration consists in passing a 10-mm exploratory probe inside the cuff with the endo-oesophageal tube still in place. The probe should be inserted without force being exerted.
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Some details and variations in the technique: incision of the peritoneal phreno-fundal reflection as far as penetration into the retroperitoneum in order to mobilise the gastric fundus. This stage is essential in the Rossetti technique, which envisages respect of the short vessels.
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Some details and variations in the technique: the so-called Rossetti stitch, which fixes the anterior wall of the stomach to the inferior edge of the left part of the anti-reflux cuff. This stitch, if the oesophagus is not transfixed with the cuff sutures, is indispensable for preventing the stomach from slipping into the fundoplication.
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Some details and variations in the technique: in the case of voluminous hernias, one frequently encounters, generally between the right crus and the oesophagus, hernial lipomas, even large ones, which should be resected before the plasty is created.
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Some details and variations in the technique: a short vessel has been isolated, grasped between clips and is about to be divided.
Freeing and dividing the short vessels is more convenient if one starts from the point chosen on the greater curvature and proceeds towards the fundus.
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Some details and variations in the technique: some authors suggest that the most cranial part of the right part of the anti-reflux valve should also be fixed to the diaphragm so as to avoid the entire cuff from slipping into the mediastinum.
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Laparoscopy.com would like to thank Prof. Enrico Croce for his CD-ROM contribution BIT SURGERY - Multimedia Surgical - Surgery of the Functional Diseases of Oesophagus. For further information regarding how to get the complete series of CD-ROM and Video about Multimedia Surgical, please contac STEFANO OLMI, MD or write to Prof. Enrico Croce. Scuola Speciale Ospedaliera A.C.O.I. Di Chirurgia Laparoscopica e Mini-Invasiva. 1st. Divisione di Chirurgia, Corso di Porta Nuova, 23 - 20121 - Milano, Italy.
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