Sample Report: Laparoscopic Nissen Fundoplication

PREOPERATIVE DIAGNOSIS: Refractory gastroesophageal reflux disease.

POSTOPERATIVE DIAGNOSIS: Refractory gastroesophageal reflux disease.

PROCEDURE PERFORMED: Laparoscopic Nissen fundoplication.


DESCRIPTION OF PROCEDURE: With the patient in the supine position with his legs in the stirrups, initially an abdominal puncture was made for a Veress needle. After inflating the abdomen, a 10-mm port was placed approximately 5 cm above the umbilicus. Under direct vision, additional ports were placed in the right and left subcostal areas in the upper midline to facilitate dissection.

The liver was distracted superiorly using liver retractor, and this exposed the esophageal hiatus. There was a moderate-sized paraesophageal hernia, which was reduced. The crura were then dissected until the esophagus was freed from the crura circumferentially. Care was taken to preserve the vagus nerve trunk.

Once the crural area was well dissected, attention was turned to the fundus, which was mobilized by taking down the short gastric using a Harmonic scalpel. One of the short gastrics had some brisk bleeding which was controlled readily, again, with the Harmonic scalpel. Approximately 75 cc of blood was lost during the course of controlling that small short gastric bleeder. Once the fundus was completely freed, the crural repair was accomplished with interrupted sutures of 0 Ethibond placed with an EndoStitch device. The wrap was then passed posterior to the esophagus and held in place while a 50-French bougie was passed. With the bougie in place, the fundoplication was accomplished using interrupted sutures of 2-0 Ethibond, taking care to get the sutures through the medial and lateral portions of the fundus for the plication as well as the anterior surface of the esophagus. The most superior sutures were placed between the esophageal crura and the apex of the wrap.

Being satisfied with the wrap, the area of dissection was irrigated. Hemostasis was assured, and the ports were then removed under direct vision. The port sites were closed with 0 Vicryl interrupted for the fascia and 3-0 Vicryl subcuticular, with benzoin and Steri-Strips for the skin. The patient tolerated the procedure well.