Comprehensive Study Notes on Laparoscopic Nissen Fundoplication and Surgical Principles
Abdominal Anatomy and Omentum
Definition and Anatomy of the Omentum:
The omentum is a broad, continuous sheet of tissue and adipose (fat) tissue that drapes over the entire abdominal cavity and its underlying organs.
During open or laparoscopic abdominal surgery, the omentum is encountered immediately upon entering the peritoneal cavity and must be reflected or moved aside to access deep abdominal structures.
Pathophysiological Significance in Malignancy:
Because the omentum covers all abdominal organs, it serves as an ideal surface and pathway for primary or metastatic cancerous cells to migrate and spread throughout the abdominal cavity.
In cases of widespread peritoneal carcinomatosis, opening the patient's abdomen reveals an omentum studded with numerous small tumors, creating an appearance reminiscent of a broken string of pearls.
Pathophysiology of Hiatal Hernia and Indications for Nissen Fundoplication
Anatomical Relationships of the Gastroesophageal Junction:
The esophagus descends through the chest cavity, passes through the esophageal hiatus of the diaphragm, and connects to the stomach.
The lower esophageal sphincter (LES) is a functional muscular ring located at the junction of the esophagus and stomach, responsible for preventing gastric acid and contents from refluxing into the esophagus.
Etiology of Lower Esophageal Sphincter Weakening:
Increased intra-abdominal pressure—such as from severe, prolonged, or recurrent vomiting and emesis—gradually stretches and weakens the LES.
Vibrations and pressure alterations in this area are also associated with physiological phenomena such as hiccups.
Hiatal Hernia Mechanism:
When the LES becomes structurally weakened, it can no longer keep the proximal stomach positioned beneath the diaphragm.
Over time, the superior portion of the stomach, known as the fundus, herniates upward through the weakened esophageal hiatus into the thoracic cavity.
Surgical Rationale for Nissen Fundoplication:
Nissen fundoplication is the primary surgical procedure indicated to repair a hiatal hernia.
During the procedure, the herniated stomach is reduced laparoscopically back into its anatomical position in the abdominal cavity.
Because the weakened LES itself cannot be directly tightened or repaired, the procedure increases the physical bulk of the upper stomach by wrapping a portion of the fundus around the lower esophagus.
This gastric wrap prevents the stomach from physically herniating back up through the diaphragmatic hiatus.
Surgical Equipment, Instruments, and Preoperative Setup
Standard Laparoscopic Equipment and Insufflation:
The procedure requires basic laparoscopic towers, high-definition video monitors, light sources, and an insufflation system to create a pneumoperitoneum.
Ultrasonic Instrumentation:
A harmonic scalpel is utilized, which relies on ultrasonic vibration to cut and coagulate tissue simultaneously.
For laparoscopic fundoplication, an extended, long-shafted harmonic scalpel is required to reach the gastroesophageal junction, as opposed to short, open-surgery harmonic scalpels.
Maloney / Bougie Dilators:
Description: Long, heavy rubber dilating rods passed transorally into the patient's esophagus during the fundic wrapping phase.
Surgical Function: Serves as a flexible internal stent inside the esophagus to ensure the gastric wrap is not constructed too tightly, which would cause esophageal stricture or narrowing.
Sterility and Protocol:
Because the oral cavity is considered non-sterile, scrubbed surgical team members (such as surgical technologists) do not handle or pass bougie dilators.
The dilators are maintained in the unsterile anesthesia area, where anesthesia personnel pass them transorally down the throat upon the surgeon's command.
Sizing: Bougie dilators come in a full range of diameter sizes to fit varying patient anatomies and age groups. Anesthesia may pass multiple dilators of increasing sizes until the surgeon is satisfied with the esophageal caliber.
Surgeon Preference Cards:
A preference card is a customized protocol document generated for every surgeon and procedure within a facility.
It lists all required equipment, specialized instruments, and soft goods—down to specific wound dressings such as adhesive bandages, liquid skin adhesive (Dermabond), or Steri-Strips.
Surgical technologists must review the preference card every morning prior to case setup to verify that all necessary supplies are present in the room.
Pre-Incision Equipment Checks:
All electronic equipment, display monitors, and energy systems (such as the harmonic scalpel generator) must be tested and verified operational prior to patient transfer into the operating room and induction of anesthesia.
Patient Positioning, Anesthesia, and Surgical Prep
Anesthesia: The procedure is conducted under general anesthesia.
Patient Positioning:
Initial placement is in the supine position (flat on the back).
The patient must be strapped securely to the operating table to enable intraoperative table manipulation.
Once secured, the patient is transitioned into Reverse Trendelenburg position (head elevated, feet lowered).
Rationally: Elevating the upper body uses gravity to pull the abdominal viscera (gastrointestinal tract and omentum) inferiorly toward the pelvis, maximizing visual exposure and working space around the upper stomach and diaphragmatic hiatus.
Surgical Skin Preparation:
A broad abdominal skin prep is performed, extending from the nipple line down to the thighs.
Port Placement and Laparoscopic Trocar Configuration
Trocar Quantity: A total of five (5) trocar ports are established.
Specific Trocar Locations and Functions:
Umbilical Port: Positioned directly above or at the umbilicus; houses a 30-degree angled laparoscope for primary visualization.
Assisting Port: Located subcostally between the umbilicus and the left subcostal area; used for tissue retraction and pulling back gastric structures.
Working Port 1: Primary surgical manipulation port for the surgeon.
Working Port 2: Secondary surgical manipulation port for the surgical assistant.
Subxiphoid Retracting Port: Positioned immediately beneath the xiphoid process; houses a liver retractor used continuously throughout the procedure to elevate the left lobe of the liver.
Step-by-Step Procedural Technique for Laparoscopic Nissen Fundoplication
Initial Visualization and Retraction:
The 30-degree angled laparoscope is placed through the umbilical trocar to view the upper abdomen.
A liver retractor introduced via the subxiphoid port elevates the left lobe of the liver to expose the underlying esophageal hiatus.
Dissection of the Lesser Omentum and Gastric Vessels:
The lesser omentum is opened to reach the gastric valve branches.
Intervening blood vessels are ligated (tied and cut) or occluded using a clip applier that places small titanium clips to halt blood flow.
Incision and Diaphragmatic Crus Dissection:
An incision is made through the peritoneum overlying the phrenicoesophageal (pharyngeal esophageal) ligaments, and these ligaments are severed.
Dissection moves along the right pillar of the diaphragmatic crus and continues superiorly until reaching the lower left pillar.
Grasping instruments used on gastric tissue during this phase must be strictly atraumatic to prevent puncturing or tearing the stomach wall.
Gastric Retraction and Directional Movement:
Atraumatic forceps grasp and retract the stomach caudally (downward toward the tail/feet) and laterally (toward the outer side) through the uppermost trocar port.
Directional Definitions: Caudal directs toward the feet/tail, whereas cephalic directs toward the head.
Localization of the Left Pillar and Posterior Vagus Nerve:
The left pillar of the crus is fully localized.
The posterior vagus nerve (a major cranial nerve descending from the brainstem through the neck and chest into the abdomen) is identified and carefully preserved.
Clinical Context of the Vagus Nerve: Vagus nerve stimulators (VNS) are permanent electrical implants wrapped around the vagus nerve in the neck, connected to a battery unit in the chest lasting . When activated via a handheld magnet, a VNS can interrupt epileptic seizures or treat sleep apnea.
Retroesophageal Dissection:
Dissection proceeds behind the esophagus in the retroesophageal space to free all posterior attachments.
This detailed phase involves harmonic scalpel dissection, scissors, cautery hooks, and vessel clipping, taking roughly to complete safely.
Suture Preparation:
The left pillar is dissected caudally.
The scrubbed surgical technologist prepares a laparoscopic needle holder with a silk suture.
Suture Properties: silk is a natural, braided, non-absorbable (permanent) suture derived from silkworm fibers. It is thicker than a skin suture, but substantially larger than an ophthalmic suture.
Indication for Non-Absorbable Suture: Because the wrapped portions of the stomach do not vascularly fuse together over time, non-absorbable permanent suture is required to hold the fundoplication intact permanently (unlike absorbable sutures like Vicryl, which break down over 90 days to a year).
Mobilization and Fundic Wrap Construction:
Counter-traction is applied to the stomach to expose the gastrosplenic ligaments.
Splenic and gastric vessels are isolated with a cautery hook and clipped to maintain hemostasis.
Anesthesia inserts the rubber bougie dilator transorally down the esophagus into the stomach.
The surgeon grasps the freed gastric fundus, draws it posteriorly behind the esophagus through the retroesophageal window, and regrasps it on the anterior side.
The bougie dilator ensures the fundus is wrapped around the esophagus without causing structural torsion or excessive tightness.
Using the silk suture, the surgeon places stitches through the stomach wall and the anterior esophageal wall to create and anchor the gastric wrap.
Once the fundic wrap is secured, anesthesia gently removes the bougie dilator.
Hemostasis and Closure:
Hemostasis is verified throughout the operative field to confirm the absence of bleeding.
All laparoscopic instruments and trocars are extracted.
Port site incisions are closed; small trocar wounds typically require minimal skin closure using skin adhesive (Dermabond) or simple adhesive bandages.
Clinical Considerations, Complications, and Postoperative Recovery
Postoperative Care and Recovery:
Following skin closure, the patient is transferred to the Post-Anesthesia Care Unit (PACU).
Uncomplicated recoveries allow patients to resume normal daily activities within .
Potential Intraoperative and Postoperative Complications:
Perforation: Accidental tearing or puncture of the stomach or esophagus during sharp or blunt dissection.
Tissue Necrosis: Ischemic tissue death of the wrapped fundus if the wrap is executed under excessive tension, cutting off regional blood supply.
Esophageal Stricture: Severe difficulty swallowing due to an overly tight fundic wrap, despite intraoperative bougie dilator sizing.
Surgical Wound Classification Systems and Clinical Case Examples
Wound Classification Overview:
Surgical cases are assigned a standardized wound classification (Clean, Clean-Contaminated, Contaminated, or Dirty) by perioperative staff to determine postoperative infection risks and guide prophylactic antibiotic therapy.
Classification System Categories:
Class I (Clean): Uninfected operative wounds with no active inflammation, in which the respiratory, alimentary, genital, or uninfected urinary tracts are not entered.
Class II (Clean-Contaminated): Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions without unusual spillage.
Class III (Contaminated): Open, fresh, accidental wounds, or surgical procedures involving major breaks in sterile technique or gross spillage from the gastrointestinal tract.
Class IV (Dirty / Infected): Retained devitalized tissue, existing clinical infections, or perforated abdominal viscera (e.g., perforated bowel).
Classification of Nissen Fundoplication:
An uncomplicated laparoscopic Nissen fundoplication is categorized as a Clean (Class I) surgical wound.
Pathological Basis: Although the stomach and esophagus are manipulated and mobilized, the lumen of the alimentary canal is never incised or entered.
Exception: If an accidental perforation of the stomach or esophagus occurs during dissection, the case reclassifies immediately to a Dirty / Contaminated wound category, requiring extensive irrigation and systemic antibiotic coverage.
Traumatic and Environmental Dirty Case Examples:
Open Traumatic Fractures: Severe open fractures sustained during accidents (e.g., motorcycle crashes) are classified as Dirty due to immediate contamination with road debris, dirt, and unknown environmental bacteria.
Environmental Fungal Contamination Case: During a major tornado in Joplin, Missouri (~10 years prior), a patient thrown into an open field sustained multiple compound fractures. Despite successful orthopedic fixation, the wound was exposed to displaced lake sediment (pulled from regional Ozark lakes such as Beaver Lake by the tornado). The patient subsequently developed a rare, deep-water flesh-eating fungal infection, demonstrating the extreme antimicrobial and antifungal challenges associated with environmental traumatic wounds.