12-Step Robotic Nissen Fundoplication
Nissen fundoplication is frequently performed by thoracic surgeons. This video shares the authors’ twelve-step operative technique for a robotic Nissen fundoplication. The patient is a sixty-three-year-old man with a history of longstanding gastroesophageal reflux disease refractory to medical treatment. He presented reporting chest and epigastric pain, regurgitation, and dysphagia despite maximal intervention of 40 mg Nexium daily.
The patient’s workup included a barium esophagram, which showed normal esophageal motility and no evidence of hiatal hernia. His EGD and gastric emptying studies were normal. Esophageal manometry demonstrated normal motility but also showed premature contractions of the esophagus and distal esophageal spasm. He underwent a twenty-four-hour pH study while on PPIs, which demonstrated a DeMeester score of 34 (normal <14.7) and markedly prolonged acid exposure at the GE junction. The patient was taken to the OR for a robotic Nissen fundoplication.
First, four 8 mm ports were placed 15 cm inferior to the xiphoid process. The left-most port, for arm four, was placed just superior to the colon. Arm two was placed slightly to the left and superior to the umbilicus. Arm three was placed between ports two and four. Arm one was 10 cm to the right of arm two. The assistant port was a 12 mm Airseal port in the right lower quadrant. A 5 mm subxiphoid port was also placed for a Nathanson retractor.
Step 1: Dissection of Pars Flaccida
The operation began with dissection of the pars flaccida until the right crus was visualized. Cadiere forceps were in arms one and four, and a vessel sealer was in arm three.
Step 2: Dissection of Right Crus
The right crus was dissected using a vessel sealer and Cadiere forceps. The Cadiere in arm four retracted the fat to the screen right, while the left hand retracted the crus to screen left and the vessel sealer dissected in between. The white line near where the vessel sealer dissecting indicated the peritoneum, and this belonged on the right crus. Keeping the peritoneum overlying the crus intact allowed for easier suture placement later in the operation.
Step 3: Greater Curvature and Short Gastrics
Next, the Cadiere in the left hand grabbed the stomach and retracted to the left, while the Cadiere in the right hand retracted the fat to the right. The lesser sac was then entered. This usually begins superior to where the right gastroepiploic artery is. Retracting the stomach posterior to the short gastric line facilitated exposure of the short gastrics that needed to be divided. As the dissection proceeded to the fundus, there were sizeable vessels close to the spleen, and this was a source of bleeding during the operation. Complete mobilization of the fundus and all the posterior attachments of the stomach facilitated fundoplication at the end of the operation and decreased tension on the wrap.
Step 4: Completion of Crural Dissection
Attention then returned to the crura, and the crural dissection was completed. The right crus was cleared off until the left crus was visualized. In this view, the stomach and fundus were retracted to the right, and the left crus was pushed to the left. This maneuver helped mobilize the left crus and the diaphragm, which is particularly important if a hiatal hernia is present with a sizeable crural defect.
Step 5: Identification of Vagus Nerves
The right and left vagus nerves were then identified coursing laterally over the esophagus and preserved.
Step 6: Dissection of Fat Pad and GE junction
Next, the fat pad overlying the distal esophagus was dissected and the gastroesophageal junction was identified. When dissecting the fat pad, the dissection was on the esophagus and on the stomach. This prevented injury to the vagus nerve. One of the advantages of mobilizing the gastric fat pad is that the GE junction is identified, and this allows placement of the fundoplication immediately above the GE junction, directly on the esophagus.
Step 7: Measurement of Intra-Abdominal Esophagus
The intra-abdominal esophagus was then measured in a tension-free position. There should be more than 3 cm of intra-abdominal esophagus. If there isn’t, which is often the case with hiatal hernias, intrathoracic esophageal mobilization should be performed.
Step 8: Esophageal Mobilization
A 15 cm x 1 cm Penrose drain was inserted and placed around the esophagus for retraction. The esophagus was then mobilized in order to achieve the 3 cm of intra-abdominal esophagus.
Step 9: Placement of 54 Fr Bougie
A 54 Fr bougie was then placed by the surgeon. This was performed with an aggressive jaw thrust maneuver by anesthesia.
Step 10: Cruroplasty
A cruroplasty was then performed using a single interrupted 0 Ethibond suture. In patients with larger crural defects, additional sutures may be required. As noted earlier, maintaining the peritoneum on the crus decreased the likelihood that the crus would fray when the stitch was tightened. A slip knot was used, which is particularly important for patients who have a sizeable crural defect. Once the cruroplasty was complete, the fundus was identified and pulled posteriorly behind the esophagus in order to prepare for the fundoplication.
Step 11: Shoeshine Maneuver
A shoeshine maneuver was then performed, ensuring an adequate amount of fundus was present for the Nissen wrap.
Step 12: Nissen Fundoplication
A Nissen fundoplication was then performed using 0 Ethibond suture and slip knots. The first stitch was stomach to stomach, and all subsequent stitches were stomach to esophagus to stomach. The Nissen fundoplication measured a standard 2 cm. It was performed with the bougie in place to prevent it from being too tight. An upper endoscopy was performed at the conclusion of the case, showing normal esophageal mucosa with the endoscope easily passing through the GE junction into the stomach with no step off.
The patient’s diet was slowly advanced postoperatively and he was discharged on postoperative day three on a clear liquid diet and his oral pain regimen. The patient was seen in the thoracic surgery clinic for a postoperative exam and was advanced to a full liquid diet with plans to progress to a mechanical soft diet in one week. One month following surgery, he was seen tolerating a full diet well with only minor reflux symptoms. A follow up esophagram two months after surgery demonstrated no evidence of reflux or hiatal hernia.