Reoperative Laparoscopic Anti-Reflux Surgery

Contributors: Marco P. Fisichella

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.

DOI#: http://dx.doi.org/10.17797/egw2097cpq

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.
Set up. 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

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