(1)
Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh, EH9 1LF, UK
17.1 General Information
The laparoscopic approach to fundoplication may offer advantages over the open approach. It offers good access to the hiatus, oesophagus and stomach, while minimising the surgical wound. There is less postoperative need for use of high dependency units, less respiratory depression due to pain, less postoperative adhesions, better cosmesis and at least equal efficacy. There is less morbidity and equal efficacy with the laparoscopic approach.
17.2 Working Instruments
5 mm Hasson port
30° telescope (length proportionate to patient size)
3 or 5 mm instruments depending on patient size
needle holders
hook diathermy
scissors
Maryland and/or Yohan forceps
Natheson’s liver retractor (size depending on patient weight) with table attachment
Ultrasonic scalpel or ligasure (optional for dissection and dealing with short gastric vessels)
17.3 Positioning, Port Siting and Ergonomic Considerations
The patient is positioned at the end of the table in frog legged position (the operating surgeon will be between the legs during the procedure). Patients with severe contractures secondary to neuro-muscular disorders may have to be placed with legs together, which are then placed on one side of the patient. Primary port is placed in the umbilical fold (the upper or lower fold may be chosen depending on patient size and body habitus to maximise ergonomics). Two further working ports are placed in the left and right upper abdomen under vision. The port in the right side of the patient may need to be slightly long to be beyond the falciform ligament, thereby avoiding catching it on introducing instruments. Slight head up positioning may be useful in allowing the intestines to fall away from the operating field.
A Natheson’s retractor is placed through an epigastric incision under vision. The size is chosen appropriate to patient size. It is positioned to allow the left lobe of the liver to be lifted out of the operative field of the oesophagus.
17.4 Relevant Anatomy
- 1.
View of the oesophageal hiatus
Fig. 17.1
This view shows the initial view seen in-situ. The zona pellucida of the lesser omentum overlying the caudate lobe of the liver is seen. The left lobe of the liver is seen (beneath the Natheson’s liver retractor), ending in the left triangular ligament. The oesophagus and stomach is seen with the gastro-epiloic vessels along the lesser curvature
- 2.
View of the anatomy of the hiatus
Fig. 17.2
The zona pellucuda has been opened and the right (and left) crus of the diaphragm is seen, creating the oesophageal hiatus. The posterior vagus can be seen on the oesophagus
- 3.
Another view of anatomy of the hiatus
Fig. 17.3
In this figure the left crus is more visible. The posterior vagus is again seen applied to the back of the oesophagus and an oesophageal vessel is also seen going through the hiatus
17.5 Surgical Technique
- 4.
Exposure of the oesophagus
Fig. 17.4
An initial incision is made in the zona pellucida of the lesser omentum overlying the caudate lobe of the liver. Hook diathermy dissection is useful, and care is taken when approaching a small vessel bundle in the otherwise relatively avascular structure. The dissection is continued caudally to expose the oesophagus
- 5.
Exposure of the oesophagus GOJ and crus
