Laparoscopic anterior fundoplication

Keywords: laparoscopic anterior fundoplication, gastro-oesophageal reflux disease

BACKGROUND

Currently, there is increasing interest in the surgical management of gastro-oesophageal reflux disease (GORD). There are a number of reasons for this. Despite the fact that current medical management is very effective for the majority a small number of patients do not get complete relief of symptoms. Secondly, some patients, particularly those who are in their twenties or thirties, face the prospect of a lifetime of continuous proton pump inhibitor therapy with the possible risk of, as yet, unknown side effects. In addition, the laparoscopic approach with its benefits of reduced operative trauma and less time off work has become more commonplace. As a consequence, general practitioners and gastroenterologists are more ready to refer patients with disabling symptoms for surgical treatment. The gold standard anti-reflux operation is undoubtedly the Nissen type of total fundoplication and many studies have affirmed its effectiveness in controlling acid reflux. However, new symptoms after fundoplication such as gas bloat and dysphagia, which probably result from a hyper-competent lower oesophageal sphincter produced by the Nissen operation, are common.

Surgeons have investigated alternative procedures including anterior and posterior partial fundoplication. Anterior fundoplication was described by Dor in 1962 as an anti-reflux operation for patients who had a Heller’s myotomy for achalasia. In the 1970s, Watson developed an operation for GORD. The main elements of this operation consist of: (a) mobilisation of 5cms of intra-abdominal oesophagus; (b) insertion of posterior sutures to tighten the crural opening; (c) approximation of the posterior aspect of the oesophagus to the crural repair using the same sutures as for the crural repair, (d) construction of a 120º fundoplication anterior to the oesophagus. The results were published by Watson and his colleagues in 1991 (1); symptomatic improvement was achieved in 94% of patients, symptomatic cure in 82% and restoration of normal ph profile in 84% of cases. A further positive feature of this operation was the absence of gas bloat, inability to belch and vomit and the fact that only 2% of patients had troublesome dysphagia afterwards.

The Watson operation was first performed in our department in 1986; between 1986 and 1995 open Watson procedures were performed on 49 patients with GORD assessed clinically and by 24 hour ambulatory pH studies. A structured follow-up was performed by an independent observer at a median of 5 years after the operation. This included modified Visick grading in all patients and 24 hour ambulatory pH studies in those willing to undergo this assessment; 53% of all patients had postoperative pH studies . Visick 1 or 11 grading was achieved by 93% of patients whereas 82% of the series had a normal postoperative pH profile. (2)

The first randomised double-blind trial comparing laparo-scopic anterior partial fundoplication with Nissen fundoplication, has recently been reported by Watson and colleagues from Adelaide. (3) The operating time for both procedures was similar. Heartburn control at 6 months after the operation was equally effective for both operations but there was a significantly higher incidence of dysphagia for solid food at 6 months after Nissen fundoplication, compared with anterior fundoplication. Significantly more patients who had anterior fundoplication were satisfied with the postoperative result.

OPERATIVE TECHNIQUE

Although the laparoscopic technique which was initially used in our practice was essentially similar to the method described by Watson et al (1991) (1) for the open operation a number of small modifications have been made more recently, the main alteration being a change from 120° to 180° fundoplication.

Patient Position and Port Sites

The patient is placed on the operating table with the legs in stirrups, the knees slightly bent and the hips flexed approximately 10°. The operating table is tilted head up by approximately 20°. Since the patient will be on the operating table for 1-2 hours it is crucial to provide adequate protection against thrombo-embolic complications. We use a combination of once daily low molecular weight heparin, which is commenced pre-operatively, and intermittent pneumatic compression leggings are used during the operation. Prophylactic antibiotic therapy is not provided routinely. The surgeon stands between the patient’s legs. The first assistant, whose main task is to position the video camera, sits on the patient’s left side. The instrument trolley is also placed on the patient’s left allowing the scrub nurse to assist with placing the appropriate instruments in the operating ports. Television monitors are positioned on either side of the top end of the operating table at a suitable height. Positioning the operating ports is critical to ensuring good access (Figure 1).

Figure 1 Port sites for laparoscopic fundoplication. (1) 10 mm cannula for camera; (2) 5 mm cannula; (3) 10 mm cannula with 5 - 10mm diaphragm; (4) 5 mm cannula; (5) site for insertion of Nathanson liver retractor

The 10mm camera port (1) is placed in the mid-line approximately 5cm above the umbilicus; this position will vary depending on the build of the patient. After inserting the camera, a 5mm port (2) is inserted in the right upper quadrant 8-10 cms from the mid-line. A port (3), with a variable 5-10 mm diaphragm, is placed in the left upper quadrant - a mirror image of the one on the patient’s right. This allows both 5 mm and 10 mm instruments to be used through the same cannula without changing ports. A further 5 mm port (4) is positioned in the left anterior axillary line immediately below the costal margin. This port is mainly used for a forceps which will hold the tape encircling the oesophagus. Liver retraction used to be one of the more problematic aspects of laparoscopic fundoplication. In our experience these difficulties have been largely overcome by the use of the Nathanson liver retractor.

Video WM56modem WMBroadband

This is inserted through a 5 mm incision in the midline (5), extending from skin to the peritoneal cavity, 1 cm below the ziphisternum made with a no. 11 scalpel blade after infiltration of the area with 0.25% bupivicaine and 1/2000,000 adrenaline. The retractor is placed under the inferior surface of the left lobe and the lobe is lifted to create space between the anterior aspect of the stomach and the liver. It is held in place with an adjustable clamp attached to the operating table - a Bookler clamp is suitable.

Tissue Dissection and Mobilisation

The dissection begins using diathermy scissors to divide the avascular portion of the lesser omentum above the hepatic branch of the vagus (Figure 2). Video WM56modem WMBroadband

Figure 2 The lesser omentum is opened above and below the hepatic branch of the vagus. The hepatic branch of vagus is preserved if possible. The Nathanson retractor holds the left lobe of the liver forward

An opening is also created in the lesser omentum below the hepatic branch of vagus to allow better access to the hiatus. The hepatic branch of the vagus nerve may need to be sacrificed if it interferes excessively with exposure of the hiatus. The right crus is dissected using diathermy scissors to identify the plane between the crus and surrounding loose areolar tissue (Figure 3),

Figure 3 The right crus is dissected by incising the loose areolar tissue with diathermy scissors. The epimysium of the crus is preserved if possible

taking care to leave the epimysium of the right crus intact. Video WM56modem WMBroadband    If the epimysium is destroyed the crus will tend to shred more easily when sutures are inserted. When the superficial aspect of the right crus is dissected clean a plane is sought between the deeper aspect of the right crus and the right side of the oesophagus. Gentle distraction forces are applied after placing one closed grasping forceps on the right crus and another on the oesophagus. This exposes the loose areolar tissue around the oesophagus and makes any blood vessels readily visible. These can be dealt with either by using the diathermy hook or diathermy scissors. It is important to keep well away from the oesophageal wall and vagal fibres when dissecting this area.

A grasping forceps is used to elevate the phreno-oesophageal membrane which is dissected off the anterior aspect of the oesophagus. The space between the hiatus and the anterior aspect of oesophagus is developed using diathermy scissors to divide blood vessels crossing this space (Figure 4). Video WM56modem WMBroadband

Figure 4 When dissection of the right crus is completed the phreno-oesophageal membrane is elevated using grasping forceps and diathermy scissors are used to develop the plane between the anterior aspect of the oesophagus and the hiatus

The posterior aspect of the left crus is identified as it meets the right crus and dissection of its surface commences. Dissection of the posterior aspect of the left crus is facilitated by lifting the intra-abdominal oesophagus forwards with a blunt instrument (Figure 5).

Figure 5 Dissection of the left crus commences posteriorly at the point where it joins the right crus. Dissection continues forwards while the oesophagus is elevated using a closed grasping forceps

The upper 2 cm of the greater curve of the stomach is dissected free. This allows a clear view of the anterior aspect of the left crus. It is usually possible to complete the dissection of the left crus at this stage; the grasping forceps inserted through port 2 is passed behind the oesophagus and appears on the left side of the oesophagus above the spleen. A tape is fed into the jaws of the grasping forceps and then pulled round behind the oesophagus (Figure 6). Video WM56modem WMBroadband

Figure 6 The oesophagus is lifted forwards using a grasping forceps placed in port 3. A short length of tape is inserted into the peritoneal cavity and placed into the jaws of a grasping instrument passed behind the oesophagus from port 2

A further grasping forceps is inserted through port 4 and this instrument is used to hold the tape so that the oesophagus can be manipulated, thus facilitating good access. At this stage it is useful to measure the length of intra-abdominal oesophagus. We aim to have approximately 5 cm of the intra- abdominal oesophagus. If further mobilisation is required this can be achieved readily by dissecting round the oesophagus in the posterior mediastinum, at the same time carefully preserving the nerve supply to the oesophagus. It is possible to dissect alongside the oesophagus in the posterior mediastinum for 5 to 6 cm without undue difficulty.

Crural Approximation and Fundoplication

The reconstructive part of the operation follows. The first stage is to approximate the crura behind the oesophagus using two or three sutures of 2/0 braided polyamide on a 30 mm needle. The suture is introduced into the abdomen by grasping the thread with the needle holder close to the needle and passing it through port 3. A further needle holder is inserted into port 2 and the position of the needle on the needle holder in the surgeon’s right hand is adjusted appropriately. The most posterior suture is placed first. The suture is tied using a slip reef knot. This involves constructing a standard reef knot intracorporeally. The reef knot is converted to a slip knot by grasping the piece of thread which has the needle still attached, using one needle holder, while the thread on the opposite side of the knot is held with the other needle holder.

The two needle holders are gently distracted until the knot ‘clicks’. The knot will then slip easily towards the crural repair. Once the correct tension is obtained, both ends of the suture are pulled to recreate the standard reef knot. One or two further throws are applied to complete the knot and the suture is cut. A further one or two sutures are inserted in the same way, at about 1cm intervals and tied in the same way (Figure 7). Video WM56modem WMBroadband

Figure 7 Three sutures of 2/0 braided polyamide are used to approximate the crura behind the oesophagus

It is important not to make the crural opening too tight since this will produce dysphagia.

The next step is to commence the construction of the fundoplication. Before inserting any sutures an appropriate portion of the anterior aspect of the fundus is chosen which will easily reach the right crus without tension. The first suture involves taking a 1cm bite of the seromuscular layer of gastric fundus. This area of fundus is sutured to the anterior aspect of the left crus (Figure 8). Video WM56modem WMBroadband

Figure 8 The fundoplication commences with a suture placed in the superior anterior aspect of the fundus and the left crus

Since the fundus lies some way from the left crus the slip reef knot is particularly valuable for this suture. Having tied this suture a further suture is placed between the fundus and the left anterior aspect of the hiatus. On this occasion, when inserting the needle through the hiatus, the needle holder is held in the surgeon’s left hand (Figure 9).

Figure 9 A suture is placed between fundus and the left anterior aspect of the hiatal opening

A suture is placed between the fundus of the stomach and the right anterior aspect of the hiatus (Figure 10).

Figure 10 Insertion of a suture between fundus of stomach, right side of oesophagus and right crus

A further three sutures are then positioned at approximately 1 cm intervals, picking up fundus of stomach, a substantial bite of the muscular layer of the right posterior oesophagus and the right crus. The most distal two sutures are inserted at the level of the hiatal repair (Figure 11).

Figure 11 A further two sutures are placed between gastric fundus, right side of oesophagus and right crus 1cm apart and tied, thus completing the fundoplication

The tape used for oesophageal retraction is removed and the procedure is complete. The liver retractor is removed. The 10 mm port sites are closed in two layers whereas the 5 mm sites are approximated with steristrips only.

POSTOPERATIVE CARE

Oral fluids are allowed on the evening of the operation. An intravenous infusion is left in situ overnight. The following day the patient resumes a normal diet. Analgesic requirements vary from patient to patient but most require no more than two or three doses of opiate after the operation. Patients are usually discharged two days after the procedure. They are warned that dysphagia for solids may become a problem in the succeeding two to three weeks due to oesophageal oedema but in most cases this will settle spontaneously.

ACKNOWLEDGEMENTS

I would like to thank Mrs Susan Mitchell, Department of Medical Illustration, Raigmore Hospital for her excellent illustrations and Professor Zygmunt Krukowski, Department of Surgery, University of Aberdeen for his helpful advice regarding the illustrative material.

REFERENCES

1. Watson A, Jenkinson LR, Ball CS, Barlow AP, Norris TL. A more physiological alternative to total fundoplication for the surgical correction of gastro-oesophageal reflux. Br J Surg 1991: 78; 1088-94
2. Campbell KL, Munro A. Efficacy and incidence of post fundoplication symptoms at a median of 5 years following open Watson fundoplication. Br J Surg 1998: 85; Supplement 1; 8
3. Watson DI, Jamieson GG, Pike GK, Davies N, Richardson M, Devitt PG. Prospective randomised double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication. Br J Surg 1999: 86; 123-30