Robot-Assisted Trans-Abdominal Nissen Fundoplication

Objective

This video demonstrates a robot-assisted Nissen fundoplication through a trans-abdominal approach. 

History

A 41-year-old male presented with a 20-year history of gastroesophageal reflux disease and associated reflux laryngitis. His symptoms were only partially controlled with proton pump inhibitors. A barium esophagram revealed reflux, but no mass lesions. Esophagogastroscopy revealed changes consistent with reflux. Esophageal biopsies did not reveal any metaplasia or dysplasia. 

Operative Technique

After endotracheal intubation, an esophagogastroscopy was performed with a standard flexible endoscope. Care was taken not to insufflate air, as this makes laparoscopy very difficult. A Foley catheter was placed.

Positioning

The patient was placed in the supine position with the arms tucked at the side. The operating table was turned 90 degrees, as the robot comes in from the head end of the patient. Care was taken to make sure that long corrugated ventilator tubes were available to help the anesthesia team with ventilator management.

Port Placement

A three-arm robot and six-port technique was used.  A 12 mm camera port was placed at the umbilicus. Two additional 8 mm ports were placed on either side of the camera port, a handbreadth away in the epigastrium, to accommodate the working arms of the robot. A 5 mm port for the liver retractor was placed as lateral as possible in the right subcostal area. An additional 5 mm port was placed in the left subcostal area to help with retraction. A 12 mm utility port was placed in the left lower quadrant for passing sutures and needles into the field.

Procedure

The clear space of the gastrohepatic ligament was divided to expose the right crus of the diaphragm. The hiatus was dissected with the help of ultrasonic shears (Harmonic). A complete 360 degree mobilization of the esophagus was performed. Posteriorly, both the left and the right crura were identified. Anteriorly, the esophagus was dissected high up into the mediastinum. Posteriorly the mediastinum was separated from the aorta. Laterally, care was taken not to enter the pleural spaces or injure the vagus nerves.

The gastrocolic omentum was separated from the greater curvature of the stomach and the short gastric vessels were divided. A Penrose drain was passed around the esophagus in a “lasso technique” to help assist in dissection. Mobilization of the esophagus was continued until adequate intra-abdominal length was achieved. The posterior crura were approximated with interrupted Ethibond sutures. The fundus of the stomach was passed behind the esophagus, and a “shoe shine” maneuver was performed. A fundoplication was performed over a standard flexible esophagoscope and an NG tube, by taking several interrupted stitches comprising stomach-esophagus-stomach. Once the 360 degree wrap was created, the lasso was removed. The fundus of the stomach was tacked onto the right crus of the diaphragm. The abdomen was deflated and the 12 mm port sites were closed with 0 Vicryl.

Post-Operative Care

A CXR was obtained to assess the position of the nasogastric tube and the presence of a pneumothorax. An esophagram was performed on the first post-operative day. The NG tube was removed after the study, and a clear liquid diet was initiated. The patient was discharged home on the first post-operative day. Over the next couple of weeks, the patient’s diet was slowly advanced to soft foods.

Conclusion

Robot assisted trans-abdominal Nissen fundoplication is a feasible operation. It offers several advantages in terms of ease of performing the dissection and easy knot tying.