Dr. François N. Schutte

Laparoscopic Nissen Fundoplication

In a time of rapid growth and advances in modern technology, a need for the adoption of new surgical and anaesthetic approaches to the Laparoscopic Nissen Fundoplication has become apparent. This procedure has evolved to one that is simplistic in its approach, using an opiate-free anaesthetic aimed at reducing post-operative diaphragmatic stressors, with an easy OR set up and a more efficient OR change-over time. It can be performed with just one surgical assistant / camera operator and is cost-effective whilst providing reproducible results, without sacrificing the three crucial steps when performing a laparoscopic anti-reflux procedure, and, most importantly, achieving the goals of surgery.

With Olympus

Laparoscopic Nissen fundoplication: get it right everytime

Clinical Case Recurrence rates following successful surgery varies from different centres but can account for as high as 30% of all Nissen Fundoplications over time. Despite the fact that nowhere in surgery the pre-operative patient is more thoroughly evaluated and surgeons strictly adhere to the indications for surgery, as well as following all mandatory surgical steps, an increase in re-do hiatus hernia repairs has been documented in almost every major high volume centre where surgery of the upper G.I.T. has been performed. A successful approach to anti-reflux surgery requires that the surgeon must have a clear understanding of the pathophysiology of gastro-esophageal reflux disease and of the complex, contributing anatomical factors, anomalies and their mechanical sequels. A critical analysis of the reasons for recurrence of hernias demonstrates the fact that the majority of failures can be attributed to crural disruption. This prompted me to compile a video in which I will highlight the reasons why anti-reflux surgery fails, and how failures can be avoided. Meticulous surgical technique is the surest way to prevent recurrence and this will be highlighted in the compilation video that follows a presentation on the pathophysiology, anatomy, anomalies, patient selection, choice of suture material and mandatory surgical steps. The video will begin with the O R setup, and emphasis will be placed on the importance of the positioning of the patient on the O R table, the direction of the trochar placements, and the positioning of the surgical team and the scrub assistant. The surgery will be completed with the assistance of only one surgical assistant -camera operator, focusing on the relevant anatomy and anatomical variations and will illustrate how to effectively perform a Nissen Fundoplication, using a chronologically ordered approach, minimising unnecessary movements. All mandatory technical steps, including the three crucial steps, will be demonstrated, namely: The return of the intra-abdominal esophagus, and ensuring that it remains intra-abdominally. The reconstruction of the crural support The reproduction of a competent L.E.S, proximal to the gastro-esophageal junction. This Fundoplication, or new sphincter must provide a competent barrier to gastro-esophageal reflux whilst allowing effective esophageal clearance and remain intact and in place below the diaphragm. Although only Type I and type III hernias are seen in this video it is important to understand that the techniques and principles are relevant to all four types of hernias. The take-away messages are: The surgeon must realise that: An in depth knowledge of the pathophysiology, anatomy and anomalies is imperative. They must be well trained in laparoscopic surgical techniques. They must adhere strictly to all indications for surgery and follow all surgical principles. Not all patients who qualify for surgery should be offered a surgical repair. Re-do surgery should preferably be performed in high volume upper G.I.T. surgical units. Despite the surgeon’s best efforts and compliance to all surgical principles – UNFORTUNATELY RECURRENCES DO OCCUR!

Simplified Roux-en-Y Gastric Bypass (RYGBP)

Case The patient is a 54-year-old lady who has been obese since childhood. She has a BMI of 54 Kg/m2. She has consulted with obesity specialists and dietitians and has tried various forms of therapy to lose weight, to no avail. Her medical record is: Impaired glucose tolerance, severe OSA, HBP, dyslipidemia, Gastroesophageal reflux disease and Barrett’s esophagitis, NASH, lower back pain due to spinal stenosis, for which she may need surgery. Her mobility is very limited, and she’s dependent on crutches. Osteoarthritis involving both knees. Treatment The patient is in the supine position with the leading surgeon to the left, the patient and the camera and the assistant surgeon to the right. Five trocars were used, four of which were 12-mm ports. The reason for this is that the stapling device will be used through all four of the 12-mm ports. A 3D camera with a flexible tip was used. Its port is a 10-mm trocar. The first port is placed in a vision just beneath Palmer’s point on the left, 20 cm from the xiphisternum, in the mid-clavicular line. The second port is placed high up, just below the xiphisternum, directing downwards, towards the patient’s left-hand side, in order to facilitate the construction of the enteroenterostomy later on. This port will be used mainly for the retraction of the liver on a pneumatic stabilising arm. The third trocar is then placed in the mid-clavicular line, 20 cm from the xiphisternum, on the patient’s right-hand side. The fifth port is then placed on the left lateral position below the ribcage. The operation starts with the surgeon’s left hand grasping the fundus of the stomach. By gently pulling it downwards, the fibrous adhesions between the fundus, the diaphragm, and the left crus are exposed. By using the electric cautery, these adhesions are freed until the left crus is identified. This is to facilitate the stapling of the fundus. Care must be taken not to work too closely to the esophagus. Once this has been performed, the assistant surgeon uses a babcock through the right lateral port, and grasps the stomach between the second and third vascular arcade, which can be seen clearly. He then lifts and elevates the stomach, so that the surgeon can gain entry to the retrogastric space by using a cautery device. Once a small opening has been created, the assistant then grasps the exposed part of the stomach, so that he everts the stomach to expose the posterior wall. With blunt dissection, and by gently spreading with the soft bowel grasper, the retrogastric space is entered. The assistant surgeon places the articulated 45 mm yellow TriStaplerTM that will be used throughout the procedure. Make sure that the posterior blade enters the retrogastric space with ease, ensuring no surrounding tissues are present. The stapler is then rotated to the right, ensuring a nice, horizontal staple line and to avoid tapering the pouch. The staple line is inspected by lifting it with the suction tip. The anesthetist is then asked to advance the gastroscope with the surgeon’s help and guidance until a line can be seen at the staple line. The surgeon then uses a 60-mm stapler through the left clavicular port and gently maneuvers it towards the EG junction. Care must be taken that the posterior blade slides in easily. Stapling too close to the esophagus can result in an hourglass-shaped pouch, and also be associated with a high incidence of leakage. A small piece of untransected fundus still remains. A suction or any suitable instrument is used in the surgeon’s right hand to gain access to the retrogastric space and to create a tunnel.  The stapler is then introduced through the left lateral port. With the pouch now completed, attention is focused on the small bowel. The surgeon lifts the transverse colon and omentum, identifies the ligament of Treitz, then rotates the small bowel, so that the biliary loop is towards the patient’s left-hand side, and the future alimentary loop is on the patient’s right-hand side. A sufficient length of small bowel is moved into the upper epigastrium. Now that we are handling the small bowel, the bowel is grasped completely by the soft bowel grasper to minimise potential damage to the bowel wall. The length of this loop is typically between 30 and 40 cm. The surgical nurse introduces the babcock through the more lateral left port  and grabs the biliary loop. An enterotomy is created closer to the mesenteric side of the alimentary loop. Care must be taken to make sure that the mucosa is open, and the soft bowel grasper is used to maintain the exposure of the enterotomy. The surgical assistant the pulls the stomach downwards with the babcock while the surgeon creates the gastrostomy. In this case, it is done anterior to the distal staple line, but it can be easily done posteriorly as well. Care must be taken to adequately visualise the mucosal layer of the stomach ensuring that it’s open effectively to avoid creating a false tract. Next, the surgeon introduces a 45-mm stapler through the midclavicular point with his right hand. The blades are open, the enterotomy entered, and the blades are then closed. The babcock holding the biliary loop is then removed, and the surgeon gently moves the bowel upwards towards the gastric pouch. The reason for the close blades is to minimise small bowel injury. After the blades are closed and fired, the staple line is carefully inspected. The assistant surgeon lifts the pouch so that the posterior staple line can also be visualised. The enterotomy is closed with a V-lock 2.0. The assistant lifts the gastric pouch to expose the posterior staple line, and the first suture is placed 1 cm under the staple line. The enterotomy is closed in a two-line fashion using standard techniques. The internal layer is completed with a suture 1 cm above the staple line. The needle holder is opened and pushed down onto the bowel, ensuring the correct tension is applied. The alimentary loop is then moved to the patient’s right-hand side. The biliary and alimentary loops are lying in a nice crescent shape, and no twisting or acute angles are created. The endoscope is passed through the anastomosis and down the alimentary loop to ensure that the anastomosis is nice and wide open. The endoscope is then retracted and passed down the biliary loop and left inside to avoid the creation of an O loop. The patient is now rolled over to her right-hand side  the bowel falls away and will not interfere when creating the enteroenterostomy. Once a desired length of the alimentary loop is reached, in this case 220 cm, the assistant surgeon uses a babcock through the right lateral port and grasps the alimentary loop. This grasper  crosses right over the small bowel and grasps the mesenterium to avoid injuries of the small bowel. The assistant surgeon then moves the proximal part of the alimentary loop next to the biliary loop, which is clearly identified by the light of the endoscope inside. The surgeon then creates two enterotomies with the hook cautery, this time at the anti-mesenteric border of both bowel loops. The surgeon now uses his right hand through the left lateral port and introduces the mechanical suture, directing it upwards through both loops of small bowel. The babcock holding the alimentary loop is now removed and the surgeon pulls the small bowel over the blade, and inspects that everything is nicely in position before closing and firing. A 90-mm enteroenterostomy is now created, and the stapler is opened and retracted. The surgeon grasps the enterotomy from staple line to staple line, lifts it up, and the iDriveⓇ loaded with the 60-mm vascular medium yellow stapler is introduced by the assistant surgeon through the right lateral port. The enterotomy is stapled closed. The opening at the mesenterium of the biliary loop is created by hook cautery. Traction of the small bowel is accomplished by the surgeon's right hand. The 60-mm stapler is introduced by the surgeon's left hand through the left midclavicular port. Once the posterior blade is visible and the staple line is close enough to the stomach remnant the mechanical suture is fired. The Roux-en-Y gastric bypass is now completed, and all that remains now is to close the mesenteric gap. This is performed by a 2.0 prolene. A knot is tied and the suture is cut al 15mm. With the surgeon now unscrubbed to perform the gastroscopic evaluation of the gastroenterostomy, at the same time, the assistant surgeon inspects the anastomosis from outside. The purpose of the gastroscopic evaluation is to detect any staple line bleeding and to ensure that there is no leakage.