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Laparoscopic Antireflux Procedures

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Sages Guidelines
OR Set-up
Trocars
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Lap Nissen-360
Lap Toupet-270
w Esophageal Length.
Redo LapNissen
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Laparoscopic Antireflux Procedures
Technical Analysis
 
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Concept of High Resistance and Low Resistance Fundoplication: The Nissen Fundoplication has a clear mechanical effect on the LES. By lowering the position of the Gastro-esophageal junction and increasing the intra-abdominal length of the lower esophagus, it increases the LES resting pressure accordingly. Consequently, with a normal Nissen of 2.0 to 2.5 cm in length, adequate resting LES pressure will be restored in most patients. In patients with decreased primary esophageal motility (decreased propulsion across the LES), the LES resting pressure should be lower thus a "low resistance" Nissen Fundoplication (1 cm in length) or a Toupet Fundoplication  will be constructed. Such procedure can also be performed on patients with endstage gastro-esophageal reflux (stricture, Barrett's) who usually have associated decreased motility.

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bulletThe Need for Crural Closure: We routinely perform a crural closure . The closure is usually performed posterior to the esophagus. It is performed with a a #60 French Bougie in place. We leave a small triangular window of  0.5 cm between the last silk suture and the esophagus.
bulletThe Need for the Placement of a Pledgets: We strongly believe manipulation with grasping laparoscopic instruments of the lower esophagus should be avoided. Thus, we do not recommend placing pledgets and sutures into the lower esophagus.
bulletLaparoscopic Nissen Fundoplication in the Pediatric Patient Population: Although we perform fewer anti-reflux procedures in children, there are reports in the surgical literature, this procedure is safe in infants and children. We are now performing these procedures with 2mm laparoscopic instruments.
bulletLaparoscopic Nissen Fundoplication in Patients with Large Hiatal or Paraesophageal Hernias: The hernia sac should be dissected meticulously and the entire fundus mobilized. If the crural closure is under tension, a prosthetic Mesh can be used to close the diaphragmatic defect.
bulletReinforced Fundoplication: The concept of reinforcing the fundoplication is not recent. We first introduced  this technique in 1991 and have used routinely since 1998. We realized patients who underwent a laparoscopic reinforced Nissen fundoplication did better and had a negligible long term failure rate. This additional technical step has since become an essential part of our procedure.

 

 

Procedural Videos
> Lap Nissen: 360 Deg. Simple - Full

> Lap Nissen: 360  Deg. Complicated

> Lap Nissen: Using the EndoStich Instrument.

> Lap Nissen: Taking down the short gastric vessels with the UltraShears instruments

> Lap Nissen: Management of Iatrogenic Splenic Tear

> Lap Toupet: 270 Deg. Full

> Reinforced Lap Nissen: 360 Deg. Full

> Lap Nissen with closure of large Paraesophageal Hernia

> LapNissen with Esophageal Lengthening

> Lap Nissen: Revision of Failed Lap Nissen

> Lap Nissen: Revision of Open Nissen Fundoplication

> Lap Nissen with Hepatic Shoulder


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