65 year old man who underwent a laparoscopic Nissen fundoplication in August 2015. Preoperative manometry was normal and DeMeester score was 25. Two months later he began to experience difficulty of swallowing solid foods, then liquids. After 2 dilatations, dysphagia persisted.
Referred By: Jeffrey B. Matthews
Laparoscopic conversion from Nissen to 270 degrees fundoplication.
Persistent dysphagia after two endoscopic dilations.
There were no contraindications in this case.
The patient was placed on a beanbag with lower extremities on stirrups (surgeon stands in between). Orogastric tube was used to decompress the stomach.
Barium Swallow (BS) and esophago-gastro-duodenoscopy (EGD) were performed before the operation.
Steps of the operation.
1 - Free fundoplication from adhesions to the left lobe of the liver
2 - Free top portion of the fundoplication from its attachments to the left lobe of the liver
3 - Free lower portion of the fundoplication from its attachments to esophagus and stomach
4 - Create a tunnel between the esophagus and stomach, without perforating the esophagus or injuring the anterior vagus nerve, to accommodate the stapler
5 - Transection of the fundoplication
6 - Ensure all the short gastric are divided
7 - Shoeshine maneuver to confirm complete mobilization of the esophagus and no twisting of the fundoplication behind the esophagus
8 - Confirming that there is no herniation of the fundoplication into the chest and that the hiatus is closed properly
9 - Perform a 270 degree fundoplication with a right and left row of 3 interrupted non-absorbable sutures between the esophagus and the stomach