Laparoscopic Nissen Fundoplication

Question 1

Laparoscopic Nissen Fundoplication

Answer 1

• Surgical procedure to correct hiatal hernia

Question 2

Surgical Anatomy & Pathology (lower esophagus)

Answer 2

. Abdominal esophagus extends from the esophageal hiatus to the opening of the cardia of the stomach
. Abdominal esophagus lies in the esophageal groove on the posterior surface of the left lobe of the liver
. At the point where it joins the stomach is a layer of circular muscle fibers called the lower esophageal sphincter (LES), which contracts to close the opening to the stomach and prevent food & gastric juices from reentering the esophagus
. Hiatal Hernia occurs when the esophageal hiatus is weak, which allows the abdominal esophagus and superior portion of the stomach to protrude into the thoracic cavity

Question 3

Preoperative Diagnostic Tests (DX) & Procedures

Answer 3

Diagnostics (DX):
. History
. Fluoroscopy during barium swallow (is diagnostic radiology exam using an X-ray to examine the upper gastrointestinal (GI) tract, specifically the esophagus, throat and back of the mouth. A barium swallow can help diagnose structural or functional issues of the upper GI tract.)
. Diagnostic endoscopy
. Manometry

Surgical:
. Correction of anatomical defect (what sx is this?)
. Reconstruction of valve mechanism in lower esophagus (what sx is this?)
. Therapeutic endoscopy (what sx is this?)

Laparoscopic Nissen Fundoplication - Surgical procedure to correct hiatal hernia

Question 4

Equipment & Instruments Unique to Procedure:

Answer 4

. Harmonic Scalpel
. Laparoscopic equipment
. Insufflator
. Laparoscopy instrumentation:
. 0 & 30 degree laparoscopes
. Liver retractor (fan retractor) (?)
. Coagulation hook (?)
. Grasping forceps
. Laparoscopic ligating clip applier with various sizes of clips
. Trocars: 10mm x3; 5mm x2
. Minor instrument set
. Laparotomy instrument set with additional long instrumentation (available for conversion from laparoscopic to open procedure)

Question 5

Supplies Unique to Procedure:

Answer 5

. Maloney dilators
. #11 & #15 knife blades
. Laparoscopy supplies (Major Box)

Question 6

Preoperative Preparation:

Answer 6

. Position: Supine position with thighs slightly abducted & flexed; surgeon may prefer legs placed in low stirrup position; 20 degree reverse Trendelenburg
. Anesthesia: General
. Skin Prep: Nipple line to mid-thighs & laterally as far as possible
. Draping: Apply leggings if stirrups are used; square off with four towels-edge of upper towels - edge of upper towel placed mid-chest; lateral towels placed using anterior superior iliac spines as guide; edge of lower towel placed just above line of symphysis pubis; abdominal laparoscopic drape

Question 7

Practice Considerations

Answer 7

. X-rays & barium studies in OR
. Check all equipment prior to patient’s arrival in the OR
. Surgeon usually stands between the patient’s legs, surgical assistant on the patient’s left, and the surgical technologist on patient’s right
. Be prepared for conversion from laparoscopic to open procedure if complications arise

Question 8

1 Procedure

Answer 8

Five trocars are typically used in the following locations:
. Above umbilicus in midline
. Right subcostal
. Left subcostal
. Between the umbilical & left subcostal
. Under the xiphoid process

A 30 degree angled laparoscope is used in the periumbilical port

Consideration: Probable order of tracer use is 10 mm, 5 mm, 5 mm, 10 mm, 10 mm.

Question 9

2 Procedure

Question 10

3 Procedure

Question 11

4 Procedure

Question 12

5 Procedure

Question 13

6 Procedure

Question 14

7 Procedure

Question 15

8 Procedure

Question 16

9 Procedure

Question 17

10 Procedure

Question 18

11 Procedure

Question 19

12 Procedure

Question 20

Postoperative Considerations:

Answer 20

Immediate Postoperative Care:
. Transport to PACU

Prognosis:
. No complications: Return to normal activities within 2-4 weeks
. Complications: Esophageal or gastric perforation; pleural perforation; conversion to laparotomy; dysphagia; necrosis of wrap or failure of the wrap; pulmonary infection; incisional hernia; SSI; hemorrhage; failure to gain relief from preoperative complaint.

Wound Classification:
. Class 1: Clean