Left side first: a different approach for teaching laparoscopic Nissen fundoplication

Abstract

Rudolf Nissen reported his initial experience with fundoplication for gastroesophageal reflux disease (GERD) in 1956. Dallemagne and associates and Geagea first introduced laparoscopic Nissen fundoplication in 1991. Since the advent of the minimally invasive treatment for GERD, more patients are being referred for definitive surgical treatment earlier in their disease, before its complications become debilitating. A relative constant among laparoscopic techniques has been the approach to the initial crural dissection. Most authors advocate initiating division of the hepatogastric ligament over the caudate lobe. This is then carried superiorly until the right diaphragmatic crus is encountered. The right crus is then dissected along its medial border, which reveals the esophagus. The dissection is then carried over the anterior aspect of the esophagus until the left crus is encountered. The left crus is then exposed in a fashion similar to the right. This dissection is carried down to the angle of His and then the esophagus is encircled. The difficult and dangerous portion of the dissection occurs when dissecting the crura and developing the retroesophageal window. Esophageal injuries have been reported to occur at this juncture. In a series of 17 patients with esophageal or gastric perforations during laparoscopic Nissen fundoplication, Schauer and colleagues reported that 10 of these injuries were due to improper retroesophageal dissection. As our experience in laparoscopic fundoplication increased, we began to approach the crural dissection from a different direction; namely, the left. A few factors have led us to develop this approach. First, we were concerned about possible esophageal injury while dissecting the crura and encircling the esophagus. Second, because we routinely divide the short gastric vessels to facilitate our wrap, we find it is easier to perform the occasionally difficult short gastric vessel division early in the case, when fatigue is not a factor. Third, the operation is more efficient because all the trocars can be used to retract the stomach and omentum for the division of the short gastric vessels. Fourth, the trocar location and operative strategy is ideal for instruction, allowing the instructor to use both hands to “set up” the case for the resident or fellow in training. Fifth, by dividing the short gastric vessels first, the surgeon is not tempted to try to “get away” with not dividing the short gastric vessels when the fundus is “almost” adequate for the wrap without short gastric division.