What Is a Laparoscopic Nissen Fundoplication?

Fundus fundoscopy includes Toupet, Dor, and Belsey. Nissen and Toupet techniques are commonly used at present.

Fundoplication

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Fundus fundoscopy includes Toupet, Dor, and Belsey. Nissen and Toupet techniques are commonly used at present.

Chinese name

Fundoplication

Technique

Nissen and Toupet

1. Cases of failed medical treatment;

2. People who have side effects of drug treatment or are unwilling to use it for a long time;

3. Cases of Barrett's esophagus with stenosis or severe reflux esophagitis

4.Gastroesophageal reflux disease causes severe respiratory diseases

5. Paraesophageal hernia or mixed esophageal hiatal hernia

The necessary preoperative evaluation must be performed before surgery. Patients are generally in good condition, without severe underlying disease or have been well controlled, without difficult to control coagulopathy, and those with good cardiopulmonary function can perform laparoscopic fundoplication. Stop aspirin and other non-steroidal anti-inflammatory drugs for one week before surgery.

1. Skin preparation before surgery: Generally, the hair in the surgical area is removed 1 day before the operation, and the range should not be less than 15-20 cm around the surgical incision. The patient bathes the day before surgery to keep the skin clean and reduce the chance of surgical infection. Special attention should be paid to the underarms, chest, hands, and groin when taking a bath, and not to catch a cold. Objective: To prevent postoperative wound infection.

2. Preparation of gastrointestinal tract: 12 hours before the operation of water, generally stop all imported food at 22:00 the night before the operation. Prevent suffocation or aspiration pneumonia caused by vomiting during anesthesia or surgery. Glycerin enema (Shutaiqing) was given before the operation to prevent the anal sphincter from loosening after anesthesia, and the stool was discharged to contaminate the surgical area, and to prevent constipation and abdominal distension.

3. Respiratory preparation: Smokers are required to ban smoking for 2 weeks before surgery to prevent postoperative pulmonary complications caused by excessive secretions in the respiratory tract, and try to learn abdominal breathing (deep inhalation, belching), effective sputum (from Deep cough outwards). Pay attention to keep warm and prevent respiratory infections. Infected patients are usually treated with acid suppression for more than a week before treatment. Intravenous antibiotics and aerosolized inhalation for more than three days to control respiratory inflammation. If necessary, use methylprednisolone to control asthma symptoms.

4. Prepare blood one day before surgery, and perform drug allergy test.

5. Maintain good mood and ensure a good night's sleep before surgery.

6. On the morning of the operation, measure vital signs, indwell the gastric tube and perform gastrointestinal decompression, suck the gastric liquid and gas, and indwell the urinary tube.

7. Self-care people can shave themselves and cut their hands and feet before surgery. Those who cannot take care of themselves should be handled by nurses. Do not apply nail polish. Remove glasses, hairpins, dentures on the day of the operation. Do not bring any jewelry into the operating room. Give your valuables to your family for safekeeping.

Endotracheal tube

Nissen fundoplication (transabdominal approach):

The patient is supine and the spine is elevated. Open the abdomen in the middle of the abdomen. After incision of the peritoneum, the degree of herniation of the sliding hiatal hernia was judged, and the direction of the lower esophagus was found according to the direction of the large gastric tube placed into the stomach before the operation. The left hepatic lobe is pulled inward by incision of the hepatic triangular ligament, and the peritoneum above the esophagogastric junction is cut transversely. Extend the incision, cut off the gastric sacral ligament and its combined part with the gastric spleen ligament on the left side, open the omentum sac on the right side, and then separate the upper part of the gastric liver ligament. The branches of the left gastric artery, short gastric artery, and iliac artery encountered should be ligated firmly to prevent bleeding. Push up the peritoneum, connective tissue, and esophageal membrane, and free the lower esophagus 4-6cm, taking care to avoid damage to the vagus nerve. Cover the esophagogastric cardia with an esophageal tape and pull down. Pull the posterior wall of the stomach bottom from left to right and pull it behind the lower esophagus. When it reaches the right side, the posterior wall only covers the esophagus and not the proximal stomach. The first needle suture passes through the anterior wall of the gastric fundus, the muscular and submucosal layers of the lower esophagus, and the posterior wall of the gastric fundus. Tighten this suture, if you can pass an index finger between the bottom of the stomach and the esophagus (with a large stomach tube inside), indicating that the tightness is appropriate, you can air the suture. Then place another one under it and two other sutures under it, but neither pass through the wall of the esophagus, then check the tightness of this package. Some surgeons recommend passing all gastric sutures through the wall of the esophagus to prevent the lower esophagus from sliding up and down in this gastric wrap. In order to stabilize the gastric fundus, 2 to 3 sutures are used to fix the lower seam to the anterior gastric wall. After closing the abdomen, before removing the tracheal intubation, remove the large gastric tube and replace it with a nasal tube for postoperative decompression.

Nissen fundoplication (transthoracic approach):

The patient was lying in the right side, and a posterolateral incision was made into the chest through the left sixth intercostal space under general anesthesia. Before surgery, a large gastric tube was inserted into the stomach through the nasal cavity to identify the lower esophagus and prevent the bottom of the stomach from being too tight. Surgical steps: After entering the chest, cut the left lower lung ligament, cut the mediastinal pleura on the left side of the esophagus, expose and use the esophageal band to pull up the lower esophagus. Pull the esophagus forward and upward to separate the pleura covering the hernia sac and the fissure. The palatine-esophageal membrane (ligament) located below the pleura connects the intra-abdominal fascia and intra-thoracic fascia. It is cut open from the front side to push open. The peritoneal reflex and retroperitoneal fat move the cardia away from its attached tissue, ligate and rise to the branch of the left gastric artery on the outside of the vagus nerve, pull the cardia into the thorax, and ligate the branch of the left gastric artery in the upper part of the hepatogastric ligament Separate the esophageal branch of the left gastric artery and preserve the hepatic branch of the vagus nerve. The short gastric artery was detached, ligated, and severed on the left, completely freeing the fundus. Put the ribs back into the abdominal cavity to expose the two lame feet that form the crack. Generally, three intermittent sutures are used to shrink the enlarged crack. These three sutures are left ligated later. In the case of short esophagus, it is difficult to place this package in the abdominal cavity and ligate three lame sutures. Check again the tightness of the gastric fundus wrap. Continuous sutures were used to close the mediastinal pleura, the pleural drainage tube was placed in the lower left thoracic cavity, and the chest was closed in layers. After the operation, replace the large stomach tube with a normal nasogastric humiliation tube.

Laparoscopic Nissen fundoplication:

The patient took a supine lower extremity abduction position with the head and feet low 30 & ordm; the surgeon stood between the patients' legs. Pneumoperitoneum was established with a pressure of 12-15mmHg. Generally need to pierce two 1.0cm and three 0.5cm holes in the upper abdomen to place a trocar of the corresponding size. The first 1.0cm hole is located at the junction of the middle and lower 1/3 of the umbilicus and the xiphoid process, and 30 & ordm; endoscope is placed; the second 1.0cm hole is located 2cm below the left clavicle midline costal margin, and is the main operation hole. And other main operating instruments; the first 0.5cm hole is located under the anterior line of the left axillary line and is used by assistants such as non-injury grasping forceps; the second 0.5cm hole is located under the costal line of the right clavicle. , Put the grasping forceps or separating forceps; the third 0.5cm hole is located under the xiphoid process, put Babcock forceps (babcock) forceps to grasp the fascia above the esophageal hiatus to open the liver and expose the hiatus. Have

Intraoperative complications: 1. Bleeding: liver hook injury, electrocoagulation to stop bleeding; short gastric blood vessels bleeding, ultrasound knife or titanium clip to stop bleeding; splenic pedicle bleeding; abdominal aortic bleeding; splenic capsule tearing bleeding; 2. Gastric perforation: isolated short gastric blood vessels are too close to the stomach wall; 3. vagus nerve damage; 4. subcutaneous emphysema; 5. pneumothorax.

Postoperative complications: 1. Difficulty swallowing; 2. Swelling of the upper abdomen; 3. Displacement of folding; 4. Formation of postoperative hiatal hernia; 5. Diarrhea.

1. After the patient returns to the ward, the patient will be treated according to the first-level nursing care after general anesthesia. Add an extra bed, remove the pillow to the supine position, and tilt the head to one side. It is easy to expel vomit and throat secretions in the mouth to prevent accidental attraction The patient is choking or aspiration pneumonia.

2. Continuous oxygen inhalation to relieve shoulder and back pain caused by direct stimulation of the phrenic nerve caused by residual carbon dioxide after pneumoperitoneum during the operation. Monitoring vital signs, such as a slight increase in body temperature within 2-3 days after surgery, generally less than 38 degrees, is clinically referred to as heat absorption or surgical heat, without special treatment. If the temperature rise is greater than 38 degrees or the fever persists, and the fever is within 5 days after the operation, the cause must be actively sought and treated actively.

3. Observe whether the intravenous infusion is smooth, whether the drip rate is appropriate, and potassium-containing drugs should not be too fast.

4. Connect a variety of drainage tubes, such as gastric tube and urinary tube, to ensure effective drainage and prevent distortion, folding, compression, and lumen obstruction. Observe whether the dressing of the surgical department has fallen off. If it comes off, contact the medical staff in time.

5. Bedside activities can be performed after removing various ducts after surgery, which is conducive to promoting gastrointestinal function recovery, preventing pulmonary complications and deep vein thrombosis.

6. Due to edema in the surgical site for a short period of time, there will be difficulty in swallowing and eating sensation, which are normal reactions.

7If any of the following symptoms occur after surgery, please inform your treating physician in time: nausea, vomiting, blood in the stool, abdominal pain, severe difficulty swallowing, chest tightness, shortness of breath, cough, sputum, fever, palpitations, asthma attacks, etc.

7. Chronic cough and chronic asthma patients have chronic inflammation of the respiratory tract due to long-term reflux. It may take a long time to adjust before they can gradually improve. Some complications such as emphysema, pulmonary heart disease, and pulmonary fibrosis are irreversible diseases. Some patients still require long-term treatment of the respiratory tract.

8. One year after treatment, there may be re-examination. The review content includes 24-hour esophageal PH monitoring, esophageal pressure monitoring, gastroscopy, etc., and re-examination items are decided according to specific circumstances.

1. The suture in the folded part is loose. If the patient has obvious bloating, severe cough in the early stage, the technique with the operator (suture and knotting technique) may be the reason;

2. The treatment of palatal hiatus is not exact. If the patient has obvious bloating, severe cough in the early stage, the technique with the operator (suture and knotting technique) is the main reason for late recurrence.

3. The folding site is incorrect (the folding site should be at the junction of the gastroesophagus), which may be related to the inexperience of the surgeon;

4. Although the fold is correct, the fold is moved above the palatine hiatus to form a new hiatal hernia, which is one of the main reasons for late recurrence.

5. Imperfect pre-operative assessment and insufficient understanding of esophageal body pressure. There will be deviations in the selection type.