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Endoscope-guided Nissen fundoplication
Gastroesophageal reflux (GERD) is a common and almost endemic problem in the Western world. Laparoscopic anti-reflux surgery is an effective and durable treatment for GERD in patients who are well-selected. Selection depends on a careful assessment of symptoms and a thorough physiologic evaluation with endoscopy, pH-monitoring and esophageal manometry. In more advanced and difficult cases, additional tests may be indicated. Cases encountered in practice range from straight forward and "everyday" to extremely complex and difficult; both in the decision-making, the operation, and the patient management. The common thread between all cases of anti-reflux surgery, complex or simple, is a stepwise and organized approach that takes into consideration the individual patient's disease and physiology. We present a case in this video that is not complex but which provides a good illustration of the technical steps required to recreate an effective gastroesophageal valve. We emphasize an atraumatic and efficient approach to the operation that ensures optimal outcomes and will minimize intraoperative complications. We discuss the characteristics of a properly formed fundoplication and debate with other experts some of the minor technical details such as suture patterns and materials. We also show how intraoperative endoscopy can serve as a powerful tool for quality control and postulate that surgeons can improve their results if they adopt routine interoperative control by endoscopy. We hope that you will enjoy and benefit from this case…
LL Swanström, A D'Urso, J Marescaux
Surgical intervention
4 years ago
2480 views
123 likes
0 comments
36:15
Endoscope-guided Nissen fundoplication
Gastroesophageal reflux (GERD) is a common and almost endemic problem in the Western world. Laparoscopic anti-reflux surgery is an effective and durable treatment for GERD in patients who are well-selected. Selection depends on a careful assessment of symptoms and a thorough physiologic evaluation with endoscopy, pH-monitoring and esophageal manometry. In more advanced and difficult cases, additional tests may be indicated. Cases encountered in practice range from straight forward and "everyday" to extremely complex and difficult; both in the decision-making, the operation, and the patient management. The common thread between all cases of anti-reflux surgery, complex or simple, is a stepwise and organized approach that takes into consideration the individual patient's disease and physiology. We present a case in this video that is not complex but which provides a good illustration of the technical steps required to recreate an effective gastroesophageal valve. We emphasize an atraumatic and efficient approach to the operation that ensures optimal outcomes and will minimize intraoperative complications. We discuss the characteristics of a properly formed fundoplication and debate with other experts some of the minor technical details such as suture patterns and materials. We also show how intraoperative endoscopy can serve as a powerful tool for quality control and postulate that surgeons can improve their results if they adopt routine interoperative control by endoscopy. We hope that you will enjoy and benefit from this case…
Laparoscopic redo Nissen posterior fundoplication
This video shows a reintervention after laparoscopic Nissen-Rossetti due to failure of the technique in a 70-year-old woman presenting with a history of dysphagia and weight loss beginning short after surgery.
First, dissection of the fundic wrap and esophageal hiatus are completed in order to expose specific anatomical landmarks that would help us understand the possible causes for the failure of the first procedure.
The original fundoplication is then unwrapped, rearranging it to the original anatomical position. This maneuver allows us to understand the causes for the technique’s failure, which can be accounted for by the asymmetrical position of the fundoplication caused by a series of elements. First, the short gastric vessels were not dissected during the first surgery, this probably contributed to the malposition of the right flap, which emerges from the posterior mid-stomach wall, distal to the fundus. On the other hand, the right flap emerges from the para-esophageal proximal edge of the lesser curvature; this causes the “valve” to be angulated and rotated clockwise, “hiding” the fundoplication on the posterior gastric wall.
To complete the procedure, a Toupet fundoplication is performed as a substituting anti-reflux technique.
P Vorwald, E York Pineda, E Bernal, M Posada, S Ayora González, R Restrepo
Surgical intervention
5 years ago
3632 views
75 likes
0 comments
10:37
Laparoscopic redo Nissen posterior fundoplication
This video shows a reintervention after laparoscopic Nissen-Rossetti due to failure of the technique in a 70-year-old woman presenting with a history of dysphagia and weight loss beginning short after surgery.
First, dissection of the fundic wrap and esophageal hiatus are completed in order to expose specific anatomical landmarks that would help us understand the possible causes for the failure of the first procedure.
The original fundoplication is then unwrapped, rearranging it to the original anatomical position. This maneuver allows us to understand the causes for the technique’s failure, which can be accounted for by the asymmetrical position of the fundoplication caused by a series of elements. First, the short gastric vessels were not dissected during the first surgery, this probably contributed to the malposition of the right flap, which emerges from the posterior mid-stomach wall, distal to the fundus. On the other hand, the right flap emerges from the para-esophageal proximal edge of the lesser curvature; this causes the “valve” to be angulated and rotated clockwise, “hiding” the fundoplication on the posterior gastric wall.
To complete the procedure, a Toupet fundoplication is performed as a substituting anti-reflux technique.
Laparoscopic redo Nissen for failed anterior fundoplication
Nissen fundoplication is the most commonly performed antireflux operation. An alternative is the partial fundoplication, either anterior or posterior to the esophagus, which provides adequate control of reflux. The anterior valve is effective, provided that it is properly constructed. It is not a simple fundic plication but it implies precise dissection parameters to create an effective antireflux mechanism. This video shows a redo fundoplication in a patient with an anterior fundoplication that never controlled GERD, because it was built as a simple fundic plication. This cause of failure is typical in inexperienced surgeons, who are afraid of doing a posterior dissection of the gastroesophageal junction. The video also demonstrates the management of a peri-splenic hemorrhage.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
6 years ago
2080 views
37 likes
0 comments
31:15
Laparoscopic redo Nissen for failed anterior fundoplication
Nissen fundoplication is the most commonly performed antireflux operation. An alternative is the partial fundoplication, either anterior or posterior to the esophagus, which provides adequate control of reflux. The anterior valve is effective, provided that it is properly constructed. It is not a simple fundic plication but it implies precise dissection parameters to create an effective antireflux mechanism. This video shows a redo fundoplication in a patient with an anterior fundoplication that never controlled GERD, because it was built as a simple fundic plication. This cause of failure is typical in inexperienced surgeons, who are afraid of doing a posterior dissection of the gastroesophageal junction. The video also demonstrates the management of a peri-splenic hemorrhage.
Management of persisting dysphagia after laparoscopic Nissen fundoplication
Dysphagia is a normal observation after fundoplication for GERD. It usually lasts for 4 to 6 weeks and results from esophageal motility disorders related to the esophageal dissection and to the outlet obstruction created by the fundoplication. It is managed by appropriate diet. When dysphagia persists after 3 months, there is some concern and need for objective evaluation. This video shows the management of this type of persisting dysphagia after laparoscopic Nissen fundoplication, during which a big hematoma developed on the wrap. This usually does not lead to any long-term problems but, in this patient, dysphagia persisted over a 3-month period of time and led to re-operation.
B Dallemagne, S Perretta, T Piardi, J Marescaux
Surgical intervention
7 years ago
1849 views
24 likes
0 comments
18:17
Management of persisting dysphagia after laparoscopic Nissen fundoplication
Dysphagia is a normal observation after fundoplication for GERD. It usually lasts for 4 to 6 weeks and results from esophageal motility disorders related to the esophageal dissection and to the outlet obstruction created by the fundoplication. It is managed by appropriate diet. When dysphagia persists after 3 months, there is some concern and need for objective evaluation. This video shows the management of this type of persisting dysphagia after laparoscopic Nissen fundoplication, during which a big hematoma developed on the wrap. This usually does not lead to any long-term problems but, in this patient, dysphagia persisted over a 3-month period of time and led to re-operation.
Laparoscopic Nissen fundoplication for atypical symptoms
Patients with gastro-esophageal reflux sometimes present with conflicting preoperative studies or atypical symptoms. This case had a primary complaint of pain and a normal 24-hour pH study. In this case, there were other indications for surgery - esophagitis and a type I hiatal hernia. Because medications offered no relief, it was elected to proceed with a Nissen fundoplication. A standard 2cm floppy fundoplication and repair of the hiatal hernia was performed in a stepwise fashion: hiatal dissection, esophageal mobilization, gastric fundus mobilization, posterior crural closure, and finally a short 360-degree fundoplication well fixed to the esophagus.
LL Swanström, J Marescaux
Surgical intervention
7 years ago
7066 views
106 likes
0 comments
16:36
Laparoscopic Nissen fundoplication for atypical symptoms
Patients with gastro-esophageal reflux sometimes present with conflicting preoperative studies or atypical symptoms. This case had a primary complaint of pain and a normal 24-hour pH study. In this case, there were other indications for surgery - esophagitis and a type I hiatal hernia. Because medications offered no relief, it was elected to proceed with a Nissen fundoplication. A standard 2cm floppy fundoplication and repair of the hiatal hernia was performed in a stepwise fashion: hiatal dissection, esophageal mobilization, gastric fundus mobilization, posterior crural closure, and finally a short 360-degree fundoplication well fixed to the esophagus.
Collis Nissen fundoplication in a patient with Barrett's esophagus
This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15-year history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
8 years ago
3582 views
87 likes
0 comments
17:25
Collis Nissen fundoplication in a patient with Barrett's esophagus
This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15-year history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.
Laparoscopic redo Nissen for recurrent GERD not responding to PPIs
This video demonstrates a redo laparoscopic Nissen fundoplication in a 34-year-old man with recurrent gastroesophageal reflux symptoms. A first laparoscopic Nissen-Rossetti procedure was performed ten years ago, and was taken down 2 months after surgery for severe dysphagia and important weight loss.
The success rate of laparoscopic Nissen fundoplication depends on the proper creation of a floppy and symmetric wrap together with a suitable crural repair. Most failures and complications due to technical mistakes during antireflux surgeries are related to an incomplete or inadequate intraoperative evaluation of the wrap and crural repair. Development or persistence of dysphagia after fundoplication is among the most common complications occurring in up to 30% of patients. Surgical factors responsible for de novo dysphagia are mainly related to the degree, tightness, length of the fundoplication and technical errors leading to wrap misconstruction -below the anatomical gastroesophageal junction or by a distortion of the esophageal diameter and orientation at the level of the crural repair.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
8 years ago
1567 views
27 likes
0 comments
09:41
Laparoscopic redo Nissen for recurrent GERD not responding to PPIs
This video demonstrates a redo laparoscopic Nissen fundoplication in a 34-year-old man with recurrent gastroesophageal reflux symptoms. A first laparoscopic Nissen-Rossetti procedure was performed ten years ago, and was taken down 2 months after surgery for severe dysphagia and important weight loss.
The success rate of laparoscopic Nissen fundoplication depends on the proper creation of a floppy and symmetric wrap together with a suitable crural repair. Most failures and complications due to technical mistakes during antireflux surgeries are related to an incomplete or inadequate intraoperative evaluation of the wrap and crural repair. Development or persistence of dysphagia after fundoplication is among the most common complications occurring in up to 30% of patients. Surgical factors responsible for de novo dysphagia are mainly related to the degree, tightness, length of the fundoplication and technical errors leading to wrap misconstruction -below the anatomical gastroesophageal junction or by a distortion of the esophageal diameter and orientation at the level of the crural repair.
Unusual cause of new onset persistent dysphagia after Nissen fundoplication
Persistent troublesome dysphagia develops in a small percentage of patients after Nissen fundoplication. Mild transient solid food dysphagia is an unavoidable side-effect of the operation. However, severe persistent dysphagia is probably related to poor patient selection, inadequate preoperative evaluation or technical errors, in most cases, excessively tight or long fundoplication. If dysphagia persists after dilatation, an outflow obstruction different to too tight or too long a wrap should be suspected as in this case. Re-operation may be needed if evidence of a poorly constructed wrap is apparent during the evaluation.
B Dallemagne, J Marescaux
Surgical intervention
10 years ago
613 views
34 likes
0 comments
18:38
Unusual cause of new onset persistent dysphagia after Nissen fundoplication
Persistent troublesome dysphagia develops in a small percentage of patients after Nissen fundoplication. Mild transient solid food dysphagia is an unavoidable side-effect of the operation. However, severe persistent dysphagia is probably related to poor patient selection, inadequate preoperative evaluation or technical errors, in most cases, excessively tight or long fundoplication. If dysphagia persists after dilatation, an outflow obstruction different to too tight or too long a wrap should be suspected as in this case. Re-operation may be needed if evidence of a poorly constructed wrap is apparent during the evaluation.
Laparoscopic Nissen fundoplication: a perfect case to start
This video of laparoscopic Nissen fundoplication is suitable for surgeons learning to perform this procedure. The patient is young with very few adhesions and the operative steps are very clearly presented by Dr. Dallemagne. Critical points and technical tips are emphasized throughout the procedure.

The author describes this as an ideal case for surgeons learning the procedure because this young patient with severe reflux has few adhesions. Working with a zero-degree scope, the author examines the peritoneal cavity. The dissection begins at the caudate lobe of the liver and moves toward the right crus of the diaphragm. After identifying the right and left crura, the author opens the lesser omentum to gain access to the right crus. It is important to identify the inferior vena cava as a landmark.
B Dallemagne, J Marescaux
Surgical intervention
12 years ago
8965 views
205 likes
0 comments
17:29
Laparoscopic Nissen fundoplication: a perfect case to start
This video of laparoscopic Nissen fundoplication is suitable for surgeons learning to perform this procedure. The patient is young with very few adhesions and the operative steps are very clearly presented by Dr. Dallemagne. Critical points and technical tips are emphasized throughout the procedure.

The author describes this as an ideal case for surgeons learning the procedure because this young patient with severe reflux has few adhesions. Working with a zero-degree scope, the author examines the peritoneal cavity. The dissection begins at the caudate lobe of the liver and moves toward the right crus of the diaphragm. After identifying the right and left crura, the author opens the lesser omentum to gain access to the right crus. It is important to identify the inferior vena cava as a landmark.
Redo Nissen fundoplication with stapled-wedge Collis gastroplasty
This video demonstrates a redo laparoscopic Collis-Nissen gastroplasty in a patient with recurrent gastroesophageal reflux symptoms and short esophagus. The first step of this redo procedure consists in taking down the previous fundoplication in order to identify the mechanism underlying the failure of the initial repair. The surgeon demonstrates an extensive mobilization of the esophagus through the hiatus to achieve an adequate length of intra-abdominal esophagus. Despite this, the esophagus was too short and the surgeon performs a Collis gastroplasty using the wedge gastrectomy technique over a 50 French bougie. A 2.5cm of tension-free intra-abdominal esophagus is achieved. The hiatus is repaired with interrupted non-absorbable sutures. A standard Nissen fundoplication is performed.
B Dallemagne
Surgical intervention
12 years ago
1170 views
9 likes
0 comments
12:05
Redo Nissen fundoplication with stapled-wedge Collis gastroplasty
This video demonstrates a redo laparoscopic Collis-Nissen gastroplasty in a patient with recurrent gastroesophageal reflux symptoms and short esophagus. The first step of this redo procedure consists in taking down the previous fundoplication in order to identify the mechanism underlying the failure of the initial repair. The surgeon demonstrates an extensive mobilization of the esophagus through the hiatus to achieve an adequate length of intra-abdominal esophagus. Despite this, the esophagus was too short and the surgeon performs a Collis gastroplasty using the wedge gastrectomy technique over a 50 French bougie. A 2.5cm of tension-free intra-abdominal esophagus is achieved. The hiatus is repaired with interrupted non-absorbable sutures. A standard Nissen fundoplication is performed.