PREOPERATIVE DIAGNOSES:
1. Chronic gastroesophageal reflux disease.
2. Sliding axial hiatal hernia.
POSTOPERATIVE DIAGNOSES:
1. Chronic gastroesophageal reflux disease.
2. Sliding axial hiatal hernia.
OPERATION PERFORMED: Laparoscopic Nissen fundoplication.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 30 mL.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This patient presents with a history of gastroesophageal reflux disease, which has been poorly controlled with maximal medical management. Preoperative evaluation with upper GI series and upper endoscopy revealed a sliding axial hiatal hernia without evidence of Barrett’s esophagus. The patient’s 24 hour pH study was positive for pathological acid reflux. The patient will now undergo planned laparoscopic Nissen fundoplication for chronic gastroesophageal reflux disease and sliding axial hiatal hernia.
DESCRIPTION OF OPERATION: The patient was transported to the operating room and placed supine on the operating table. Following induction of satisfactory general endotracheal anesthesia, the patient was placed in the dorsal lithotomy position using Allen stirrups and appropriate padding of all pressure points. The abdomen was then prepped and draped in the customary fashion using Betadine solution and sterile towels and sheets.
A skin incision was made approximately 8 cm inferior to the xiphoid process superior to the umbilicus and to the left of the midline. The dissection was carried down to the level of the anterior fascia and the abdominal cavity entered under direct vision using an Optiview trocar. Carbon dioxide gas was instilled and satisfactory pneumoperitoneum was achieved without evidence of respiratory compromise. The 30 degree laparoscope with video camera was threaded through this trocar site and the upper abdomen explored.
Examination of the right upper quadrant revealed no evidence of inflammatory changes in the region of the gallbladder fossa. The liver was grossly normal without nodularity over its surface and there was no evidence of splenomegaly. The anterior serosal surface of the distal fundus and antrum of the stomach were unremarkable. Having completed the exploration, a 10 mm trocar was placed along the left costal margin at the midclavicular line and a 5 mm trocar placed on the left costal margin at the anterior axillary line. Two additional 5 mm trocars were placed in the subxiphoid position as well as in the right upper quadrant lateral to the rectus musculature. The 5 mm liver retractor was introduced in the right upper quadrant trocar site and used to elevate the left lobe of the liver. This allowed for complete exposure of the esophageal hiatus. A sliding axial hiatal hernia was present and was easily reduced from the mediastinum.
The gastrohepatic ligament was opened over the caudad lobe of the liver using the Harmonic shears and the hepatic branch of the vagus nerve was identified and carefully preserved. The peritoneal incisions were extended over the left and right crus and the mediastinum entered. The esophagus was circumferentially mobilized and all vessels encountered controlled with the Harmonic shears. The anterior and posterior vagal nerve trunks were identified and the posterior nerve trunk left in place along the posterior wall of the esophagus. The posterior aspect of the gastroesophageal junction was fully mobilized as well, and a pediatric Penrose drain passed around the esophagus at this level. This was secured in place with a 0 PDS Endoloop. Using the drain for retraction, the esophageal mobilization was completed to allow for approximately 3-4 cm of the esophagus to lie comfortably within the abdominal cavity without tension.
Next, the lesser sac was entered along the greater curvature of the stomach inferior to the inferior pole of the spleen. The short gastric vessels were divided with the Harmonic shears to the level of the left crus and care was taken to ensure that the entire posterior aspect of the upper fundus of the stomach was completely mobilized. The diaphragmatic defect was then closed posteriorly using horizontal mattress sutures of 0 Ethibond and felt pledgets. The closure was sized to allow for passage of a #60 Maloney dilator through the esophageal hiatus. The dilator was withdrawn back into the thoracic esophagus and the posterior aspect of the upper fundus of the stomach was passed posteriorly to the esophagus.
The esophagus appeared to lie comfortably within the bed of the fundus and there was no evidence of tension. The dilator was advanced back into the lumen of the stomach under direct vision and the fundoplication completed using interrupted 2-0 Ethibond sutures. The suture line was oriented at the 10 to 11 o’clock position and the superior and inferior sutures were anchored to the wall of the esophagus. The medial stitch was placed between the walls of the fundus of the stomach. The dilator was then withdrawn and the wrap secured to the diaphragm at the 10 o’clock and 2 o’clock positions using 2-0 Ethibond suture. At the completion of the fundoplication, it measured approximately 2 cm in length, appeared to have the proper geometry, and there was no evidence of tension.
The area of dissection was thoroughly irrigated with Kantrex solution and checked for hemostasis. Any remaining fluid was evacuated and the suction irrigator used to remove as much carbon dioxide gas as possible. The trocars were removed and the incisions irrigated with Kantrex solution. The fascia opening at the 10 mm trocar sites were closed with 0 Vicryl suture and 0.5% Marcaine instilled into the incisions. The skin was closed with 4-0 Vicryl subcuticular suture and Benzoin and Steri-Strips as well as Tegaderm dressing placed across the incisions. The patient was then awakened and transported back to the recovery room in satisfactory condition with sponge and needle counts reported as correct at the end of the procedure.
