腹腔镜Nissen胃底折叠术治疗胃食管反流病（图文演示）

LAPAROSCOPIC   SHORT   FLOPPY   NISSEN   FUNDOPLICATION   FOR   GASTROESOPHAGEAL   REFLUX   DISEASE
Authors
B Dallemagne
Abstract
The original fundoplication technique as described by Rudolf Nissen in 1955 consisted in wrapping the fundus of the stomach around the esophagus, while leaving the gastrosplenic vessels and the diaphragmatic hiatus intact. Additionally, the vagus nerves were little or not preserved.
The basic principles of a fundoplication are:
- tension-free repositioning of the gastroesophageal junction (along with 2 cm of lower esophagus in a subphrenic position);
- use the gastric fundus to create the fundoplication;
- make sure that the resistance generated by the anti-reflux mechanism matches the preoperative assessment of esophageal peristalsis.


中文版：腹腔镜Nissen胃底折叠术治疗胃食管反流病（中文图文）

1. Introduction
The original fundoplication technique as described by Rudolf Nissen in 19551 consisted in wrapping the fundus of the stomach around the esophagus, while leaving the gastrosplenic vessels and the diaphragmatic hiatus intact. Additionally, the vagus nerves were little or not preserved.
The modern tools of study when analyzing the physiology of the proximal digestive tract and the review of clinical results have led to numerous changes to the original concept.
The complete 360-degree wrap (“Nissen” fundoplications) is currently more used than the partial fundoplications (Toupet 270-degree fundoplication, 240-degree Guarner wrap, Dor or partial 180° and anterior fundoplication2,7, etc.).

The basic principles of a fundoplication are:
- tension-free repositioning of the gastroesophageal junction (along with 2 cm of lower esophagus in a subphrenic position);
- use the gastric fundus to create the fundoplication;
- make sure that the resistance generated by the anti-reflux mechanism matches the preoperative assessment of esophageal peristalsis.

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There are two different types of total fundoplication.

1. Nissen-Rossetti fundoplication:
The technique was described by Mario Rossetti, one of Nissen’s pupils8.
Technical features:
- mobilization of the cardioesophageal junction by division of the phrenoesophageal membrane;
- mobilization of the fundus by division of the gastrophrenic ligament;
- creation of a 360° fundoplication fashioned with the anterior wall of the fundus which is brought to the anterior aspect of the esophagus, without systematic division of the short gastric vessels.

2. Laparoscopic short floppy Nissen fundoplication:
The full concept of this fundoplication was introduced by Donahue and Bombeck in 19779, and accredited by DeMeester in 198610.
Technical features:
- mobilization of the cardioesophageal junction by division of the phrenoesophageal membrane;
- mobilization of the gastric fundus by division of gastrosplenic ligament, short gastric vessels and gastrophrenic ligament;
- short (<2 cm) 360-degree fundoplication fashioned with the posterior and anterior walls of the fundus which are brought to the anterior aspect of the esophagus.

One same denomination is used for two slightly different techniques, even though they obey to the same original concept.
The technique described in this chapter is the “short floppy Nissen”. It respects the basic principles of the Nissen fundoplication whilst insisting particularly on the necessity of both restoring a segment of intra-abdominal esophagus in a tension-free manner and carrying out an efficient and systematic repair of the crura11,12.

3. Anatomy

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1. Lesser omentum
2. Left liver lobe
3. Esophageal hiatus

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The lower esophagus may be divided into 3 portions from cephalad to caudal:
1. a sub-diaphragmatic portion often referred to as “ampullar region”, without there being a real ampulla anatomically speaking. It corresponds to a zone often exposed to negative intrathoracic pressure, anterior to a high pressure zone.
2. a high pressure zone: it corresponds to the diaphragmatic zone and to the lower esophageal sphincter (LES).
3. an intra-abdominal segment or “vestibule”. Its linking with the stomach creates the angle of His (esophagogastric angle).
The squamoglandular junction, Z line, can be found in 60% of cases 1 cm above the gastroesophageal junction.

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The phrenoesophageal membrane is composed by the transversalis fascia on the inferior surface of the diaphragm and by elements of the endothoracic fascia. This important structure links the lower esophagus to the diaphragm allowing vertical movements during breathing. It inserts itself circumferentially on the muscle structure of the esophagus and around the junction of esophageal and gastric mucosa.

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The short gastric vessels originate from the splenic artery. They run along the posterior surface of the stomach, in the gastrosplenic ligament and end on the fundus of the stomach.
1. Gastrosplenic ligament
2. Splenic artery
3. Left kidney
4. Toldt’s fascia
5. Diaphragmatic crura

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The esophageal hiatus is the opening through which the esophagus and the vagus nerves enter the abdominal cavity. It is usually formed by the right diaphragmatic crus with a small contribution of the left crus. The right crus originates from the anterior (longitudinal) vertebral ligament that covers the lumbar vertebras. It then constitutes two muscular strips that cross each other, build the edges of the hiatus and merge anterior to the esophagus.

4. Classification of hiatal hernias

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1. Thoracic esophagus
2. Thoracic cavity
3. Right crus
4. Left crus
5. Abdominal esophagus
6. Gastric fundus
A hiatal hernia is a defect in the anatomy of the gastroesophageal junction: structures normally confined within the abdomen move through the hiatal orifice.

A hiatal hernia is often associated with gastroesophageal reflux disease (GERD). However, it can be present without GERD. Certain voluminous hernias can lead to specific symptoms (see chapter about Technique for laparoscopic treatment of giant hiatal hernias).

&#8226; Types of hiatal hernias

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In type I, or sliding HHs, the hiatal opening is enlarged and the phrenoesophageal membrane is circumferentially mobile, allowing part of the cardia to herniate itself above the diaphragm.
The phrenoesophageal membrane remains intact.

Most of type I hiatal hernias are symptom-free. The usual clinical consequence is the occurrence of GERD whose probability increases according to the size of the hernia.

The migration of the abdominal esophagus results in:
- the disappearance of the esophagogastric valve (EGV) due to the widening of the esophagogastric angle (angle of His);
- a weakening in the lower esophageal sphincter effect (LESE) due to the loss of normal anatomical relationships and lowered extrinsic (intra-abdominal) pressures

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Type II, or paraesophageal hernias, represent 5 to 15% of hiatal hernias.
Some of those may be associated with GERD, but above all they can lead to mechanical and ischemic complications.
They occur through a defect in the phrenoesophageal ligament. The gastroesophageal junction nevertheless remains in the abdominal cavity. The gastric fundus migrates towards the mediastinum.

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Type III hiatal hernias combine elements of type I sliding hernias with elements of type II hiatal hernias (i.e. defect of the phrenoesophageal membrane).
In some cases, the whole stomach lies in a supradiaphragmatic position and can rotate, turning into what is usually called the “upside-down stomach”.

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Type IV hiatal hernias are characterized by a very large defect in the gastroesophageal membrane through which the stomach, but also other viscera may migrate to the mediastinum.

5. Antireflux barrier
&#8226; Antireflux barrier

The anti-reflux barrier corresponds to a high pressure zone that protects the esophagus against reflux of gastric substances that are highly corrosive and likely to cause damage.
The tone of the anti-reflux barrier results from of three elements: the lower esophageal sphincter, the diaphragm and its crura, and the muscular architecture of the gastric cardia (its most distal element). In addition, the tangential joining of the esophagus to the stomach constitutes an anatomical intragastric flap13,14.

&#8226; Lower esophageal sphincter
&#8226; Description

The lower esophageal sphincter corresponds to a muscular zone of the lower esophagus that extends 1 to 1.5 cm above and 2 cm below the junction between the gastric and esophageal mucosa (Z line). At that level, the architectural disposition of the muscular fibers of the cardia contributes in huge part to its basal tone.
1. Z line

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The lower esophageal sphincter (LES) presents a basal tone that is determined by complex mechanisms: a neurologic control in which both the central nervous system and the peripheral and enteric nervous system intervene.
The LES tone is reinforced by contact with the right diaphragmatic crus (extrinsic component of the high pressure zone).
The simultaneous contraction of the cardia’s semi-circular muscle fibers and of the stomach’s oblique muscle fibers will determine the sphincteric mechanism (Korn O, Stein HJ, Richter TH, Liebermann-Meffert D. Gastroesophageal sphincter: a model. Dis Esophagus 1997;10:105-9).
Accentuation of the angle of His will also amplify the intragastric valve.

6. Operating room set-up

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- general anesthesia;
- endotracheal intubation;
- 30° reverse Trendelenburg;
- supine position, arms at a 90° angle and legs apart;
- dual lumen gastric tube;
- urinary catheter (not mandatory).
The reverse Trendelenburg position results in spontaneous lowering of the abdominal organs.
Anesthetic paralysis of the patient must be adequate to increase the space within the abdominal cavity and limit diaphragmatic movements.
The maximum operating pressure of the pneumoperitoneum will be 12 mm Hg.
Gastric clearance:
A dual lumen gastric tube is placed to decompress the stomach.
It is moved up to the middle third of the esophagus once the stomach has been decompressed before starting the esophageal dissection.

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To enable a steep reverse Trendelenburg position (30°), which is sometimes compulsory, especially for obese patients, the patient is strapped to the table with thick adhesive strips.

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1. The surgeon stands between the legs of the patient.
2. The assistant stands on the patient’s left.
3. The scrub nurse stands on the patient’s right.

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The monitor is used by the surgeon and the assistant.
1. The laparoscopic and video units are placed on the patient’s right, behind his shoulder.
2. Operating table
3. Anesthetic unit

7. Trocar placement

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1. Xiphoid process
2. Costal margin
3. Midline
4. Midclavicular line
5. Anterior axillary line

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The pneumoperitoneum is established in normal fashion, with the usual precautions, at a maximal intraperitoneal pressure of 15 mm Hg.

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Trocar A, size 10 mm (laparoscope), on the midline, 2/3 from the xiphoid to the umbilicus
Trocar B, size 5 mm (grasping forceps), on the epigastrium just below the xiphoid
Trocar C, size 5 mm (liver retractor), on the anterior axillary line just below the right costal margin
Trocar D, size 5 mm (atraumatic grasper), on the anterior axillary line just below the left costal margin
Trocar E, size 5 mm (dissecting and suturing devices), on the midclavicular line in the left upper quadrant

8. Instrumentation

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Trocar A: 0° laparoscope
Trocar B: Grasping forceps
Trocar C: Liver retractor
Trocar D: Atraumatic grasper, scissors, suction-irrigation device
Trocar E: Ultrasonic scissors, scissors, clip applier, suction-irrigation device, needle holder

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A: Most procedures are completed using a 0° laparoscope.
A 30-degree laparoscope may be recommended, especially in stout patients as it will provide an easier access to the cardioesophageal junction.

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B: Grasping forceps
E: 5 mm ultrasonic scissors, 5 mm scissors, suction-irrigation device, needle holder

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C: Liver retractor (atraumatic; it will be fixed onto an articulated arm, on the right of the operating table), expandable liver retractor
D: Atraumatic grasper

9. Exposure

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The liver retractor, held by a mechanical arm fixed to the right of the operating table, is used to lift the left liver lobe. The mechanical arm is then locked into position to maintain the retractor in the chosen position.
The assistant holds the laparoscope and retracts the cardia with an atraumatic grasper (through trocar D) using caudal and leftwards traction.

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If present, the contents of the hiatal hernia is reduced and maintained in the abdomen with the assistant’s atraumatic grasper (through trocar D) placed on the fat pad anterior to the gastroesophageal junction.