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General and digestive surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
C Viana, M Lozano, D Poletto, T Moreno, C Varela, A Toscano
Surgical intervention
6 months ago
2664 views
7 likes
0 comments
15:27
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
B Dallemagne, S Perretta, B Seeliger, D Mutter, J Marescaux
Surgical intervention
1 year ago
952 views
351 likes
0 comments
21:18
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
B Dallemagne, S Perretta, M Diana, F Longo, D Mutter, J Marescaux
Surgical intervention
1 year ago
5177 views
438 likes
0 comments
54:47
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
Concurrent laparoscopic RYGB with a paraesophageal hernia (PEH) repair
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
A Duro, F Wright, PJ Castellaro, A Beskow, D Cavadas, J Montagné
Surgical intervention
1 year ago
995 views
179 likes
3 comments
06:23
Concurrent laparoscopic RYGB with a paraesophageal hernia (PEH) repair
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
Surgical approach to intragastric migrated hiatal mesh
Mesh use in the laparoscopic repair of hiatal hernia is associated with fewer recurrences. However, it may cause some complications such as dysphagia, stenosis or even erosion with esophageal or gastric migration.
A 61-year-old woman with a large type III hiatal hernia underwent a laparoscopic Toupet fundoplication with closure of the hiatal crura with a dual U-shaped mesh.
She was symptom-free for 1 year, subsequently developing dysphagia and weight loss. An esophagogastric barium test revealed minimal contrast passage and endoscopy showed partial intragastric mesh migration.
The patient was submitted to a laparoscopic removal of migrated mesh with a transgastric approach. Hiatus inspection demonstrated significant fibrosis, with plication integrity and no evidence of recurrent hernia. A gastrotomy was performed allowing to identify and remove a migrated intra-gastric mesh. Careful evaluation did not show any gastric fistula and pressure test with methylene blue showed no evidence of leak.
This unusual approach avoided hiatus dissection, decreasing the risks of local complications such as perforation and bleeding. The patient had no postoperative complications, recovered well, and remained asymptomatic.
A Trovão, L Costa, M Costa, R Ferreira de Almeida, M Nora
Surgical intervention
1 year ago
596 views
106 likes
0 comments
09:55
Surgical approach to intragastric migrated hiatal mesh
Mesh use in the laparoscopic repair of hiatal hernia is associated with fewer recurrences. However, it may cause some complications such as dysphagia, stenosis or even erosion with esophageal or gastric migration.
A 61-year-old woman with a large type III hiatal hernia underwent a laparoscopic Toupet fundoplication with closure of the hiatal crura with a dual U-shaped mesh.
She was symptom-free for 1 year, subsequently developing dysphagia and weight loss. An esophagogastric barium test revealed minimal contrast passage and endoscopy showed partial intragastric mesh migration.
The patient was submitted to a laparoscopic removal of migrated mesh with a transgastric approach. Hiatus inspection demonstrated significant fibrosis, with plication integrity and no evidence of recurrent hernia. A gastrotomy was performed allowing to identify and remove a migrated intra-gastric mesh. Careful evaluation did not show any gastric fistula and pressure test with methylene blue showed no evidence of leak.
This unusual approach avoided hiatus dissection, decreasing the risks of local complications such as perforation and bleeding. The patient had no postoperative complications, recovered well, and remained asymptomatic.
Relaxing incision for crural repair in type III paraesophageal hernia
This video shows the laparoscopic repair of a large type III paraesophageal hernia in a 55-year-old woman. After dissection of the hernia sac, partial resection is performed. Very high intramediastinal dissection of the esophagus is performed, taking special care not to injure the posterior and anterior vagal trunk. First, as the hiatal defect is very large, a right relaxing incision is performed. The crural repair is performed by interrupted Ethibond® 2/0 stitches buttressed with a polypropylene mesh. Finally, the diaphragmatic defect is covered with a non-reabsorbable mesh (Physiomesh™) and a 180-degree posterior fundoplication is performed.
P Vorwald, G Salcedo, M Posada, C Lévano Linares, ML Sánchez de Molina, R Restrepo, C Ferrero
Surgical intervention
3 years ago
2052 views
79 likes
0 comments
09:13
Relaxing incision for crural repair in type III paraesophageal hernia
This video shows the laparoscopic repair of a large type III paraesophageal hernia in a 55-year-old woman. After dissection of the hernia sac, partial resection is performed. Very high intramediastinal dissection of the esophagus is performed, taking special care not to injure the posterior and anterior vagal trunk. First, as the hiatal defect is very large, a right relaxing incision is performed. The crural repair is performed by interrupted Ethibond® 2/0 stitches buttressed with a polypropylene mesh. Finally, the diaphragmatic defect is covered with a non-reabsorbable mesh (Physiomesh™) and a 180-degree posterior fundoplication is performed.
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
S Perretta, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
3 years ago
885 views
31 likes
0 comments
12:26
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
Type III hiatal hernia: stepwise laparoscopic treatment
The surgical treatment of type III hiatal hernia has been thoroughly standardized in the following order: extrasaccular approach, reduction of the entire sac, and esophageal mobilization in order to restore the esophagogastric anatomy. Although it is recommended to combine this with a fundoplication as most authors do, there is still controversy concerning the closure technique of the diaphragmatic defect. Some experts recommend the reinforcement of this closure by means of a synthetic mesh. It is, however, a method which does not prevent recurrence and which can also bring about complications, which can at times be disastrous. As a result, we privilege reinforcement using an absorbable mesh.
B Dallemagne, S Perretta, S Tzedakis, D Mutter, J Marescaux
Surgical intervention
4 years ago
7863 views
279 likes
1 comment
16:21
Type III hiatal hernia: stepwise laparoscopic treatment
The surgical treatment of type III hiatal hernia has been thoroughly standardized in the following order: extrasaccular approach, reduction of the entire sac, and esophageal mobilization in order to restore the esophagogastric anatomy. Although it is recommended to combine this with a fundoplication as most authors do, there is still controversy concerning the closure technique of the diaphragmatic defect. Some experts recommend the reinforcement of this closure by means of a synthetic mesh. It is, however, a method which does not prevent recurrence and which can also bring about complications, which can at times be disastrous. As a result, we privilege reinforcement using an absorbable mesh.
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
2324 views
119 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
4 years ago
3501 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 partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
S Perretta, B Dallemagne, J Marescaux
Surgical intervention
5 years ago
3387 views
35 likes
0 comments
09:11
Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
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
5 years ago
2008 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.
Laparoscopic gastroesophageal resection after mesh migration
In this video, we describe a laparoscopic gastroesophageal resection after a mesh migration in a 47-year-old woman diagnosed with a giant paraesophageal hernia. Preoperatively, a barium esophagogram, an upper endoscopy and an esophageal manometry were performed to define the anatomy of the esophagus, stomach and gastroesophageal junction, the esophageal peristalsis and the function of the lower esophageal sphincter (LES) to confirm the diagnosis of paraesophageal hernia. Additionally, a 24-hour pH-monitoring was performed to determine the magnitude of gastroesophageal reflux.
Five months after the first operation, the patient presented with fever and dysphagia for solids with a 15 Kg weight loss.
She underwent a CT-scan of the thorax and the abdomen, a gastrografin X-ray examination and an upper endoscopy, which showed the presence of a mediastinal fistula secondary to mesh migration.
For that reason, the patient received a second surgical treatment consisting in a laparoscopic gastroesophageal resection.
F Corcione, F Pirozzi, L Barra, V Cimmino, E Minona
Surgical intervention
6 years ago
2171 views
8 likes
0 comments
16:00
Laparoscopic gastroesophageal resection after mesh migration
In this video, we describe a laparoscopic gastroesophageal resection after a mesh migration in a 47-year-old woman diagnosed with a giant paraesophageal hernia. Preoperatively, a barium esophagogram, an upper endoscopy and an esophageal manometry were performed to define the anatomy of the esophagus, stomach and gastroesophageal junction, the esophageal peristalsis and the function of the lower esophageal sphincter (LES) to confirm the diagnosis of paraesophageal hernia. Additionally, a 24-hour pH-monitoring was performed to determine the magnitude of gastroesophageal reflux.
Five months after the first operation, the patient presented with fever and dysphagia for solids with a 15 Kg weight loss.
She underwent a CT-scan of the thorax and the abdomen, a gastrografin X-ray examination and an upper endoscopy, which showed the presence of a mediastinal fistula secondary to mesh migration.
For that reason, the patient received a second surgical treatment consisting in a laparoscopic gastroesophageal resection.
Transumbilical single access laparoscopic Toupet fundoplication
Background: Different procedures have been reported to be feasible and safe through single access laparoscopy (SAL). A transumbilical SAL Toupet fundoplication is demonstrated here.

Video: A young lady sought care for gastroesophageal reflux disease associated with grade B esophagitis, hiatal hernia and esophageal dyskinesia. The SAL procedure was performed by the opening of the umbilicus through Hasson’s technique. An 11mm reusable trocar was inserted for a 10mm, 30-degree angled, non-flexible, and standard length scope. Curved reusable instruments according to Dapri (Karl Storz Endoskope) were introduced through the same scar without trocars. The gastroesophageal junction was exposed thanks to the insertion of a 2mm wire under the xiphoid access. Crura repair and fundoplication were performed using intracorporeal knots, with a curved needle-holder. The umbilicus was finally closed in layers.

Results: No extra-umbilical trocar was necessary, and no intraoperative complications were registered. Operative time was 172 minutes and the final umbilical scar was 15mm. Postoperative pain was kept minimal, and the patient was discharged on the third postoperative day after a satisfying gastrograffin swallow.

Conclusions: Transumbilical SAL Toupet fundoplication is feasible. Use of curved and reusable instruments permits to avoid the conflict between the instruments’ tips intracorporeally or between the surgeons’ hands externally. Thanks to this technique, the cost of SAL is similar to multi-trocar laparoscopy.
G Dapri, L Gerard, S Carandina, GB Cadière
Surgical intervention
6 years ago
2775 views
35 likes
1 comment
08:05
Transumbilical single access laparoscopic Toupet fundoplication
Background: Different procedures have been reported to be feasible and safe through single access laparoscopy (SAL). A transumbilical SAL Toupet fundoplication is demonstrated here.

Video: A young lady sought care for gastroesophageal reflux disease associated with grade B esophagitis, hiatal hernia and esophageal dyskinesia. The SAL procedure was performed by the opening of the umbilicus through Hasson’s technique. An 11mm reusable trocar was inserted for a 10mm, 30-degree angled, non-flexible, and standard length scope. Curved reusable instruments according to Dapri (Karl Storz Endoskope) were introduced through the same scar without trocars. The gastroesophageal junction was exposed thanks to the insertion of a 2mm wire under the xiphoid access. Crura repair and fundoplication were performed using intracorporeal knots, with a curved needle-holder. The umbilicus was finally closed in layers.

Results: No extra-umbilical trocar was necessary, and no intraoperative complications were registered. Operative time was 172 minutes and the final umbilical scar was 15mm. Postoperative pain was kept minimal, and the patient was discharged on the third postoperative day after a satisfying gastrograffin swallow.

Conclusions: Transumbilical SAL Toupet fundoplication is feasible. Use of curved and reusable instruments permits to avoid the conflict between the instruments’ tips intracorporeally or between the surgeons’ hands externally. Thanks to this technique, the cost of SAL is similar to multi-trocar laparoscopy.
Challenges in GERD: Collis fundoplication in a patient with a BMI of 41
Obesity has long been considered a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery and some authors recommend gastric bypass in obese patient with symptomatic GERD. However, some studies reported that preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery and concluded that obesity is not a contraindication for laparoscopic fundoplication (1, 2).
In this video, we present a Collis-Toupet gastroplasty in a woman with a BMI of 41.
References:
1. Winslow ER, Frisella MM, Soper NJ, Klingensmith ME. Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS). Surgical Endoscopy 2003;17:2003-11.
2. Chisholm JA, Jamieson GG, Lally CJ, Devitt PG, Game PA, Watson DI. The effect of obesity on the outcome of laparoscopic antireflux surgery. J Gastrointest Surg 2009;13:1064-70.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
6 years ago
1539 views
27 likes
0 comments
25:13
Challenges in GERD: Collis fundoplication in a patient with a BMI of 41
Obesity has long been considered a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery and some authors recommend gastric bypass in obese patient with symptomatic GERD. However, some studies reported that preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery and concluded that obesity is not a contraindication for laparoscopic fundoplication (1, 2).
In this video, we present a Collis-Toupet gastroplasty in a woman with a BMI of 41.
References:
1. Winslow ER, Frisella MM, Soper NJ, Klingensmith ME. Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS). Surgical Endoscopy 2003;17:2003-11.
2. Chisholm JA, Jamieson GG, Lally CJ, Devitt PG, Game PA, Watson DI. The effect of obesity on the outcome of laparoscopic antireflux surgery. J Gastrointest Surg 2009;13:1064-70.
Second reoperative antireflux procedure for valve slippage
Redo surgery is technically more demanding than primary fundoplication. In addition, anatomical defects that caused failure may increase technical difficulties. A recent review found that the average success rate after laparoscopic redo operations ranged from 65 to 100 per cent (van Beek D, Auyang E, Soper N. A comprehensive review of laparoscopic redo fundoplication. Surgical Endoscopy: Springer New York; 2010. p 1-7). However, our recent study showed that the failure rate after re-operation is increasing with time, and highlighted the need for accurate preoperative and intraoperative assessment of the causes of failure (Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, et al. Long-term results after laparoscopic reoperation for failed antireflux procedures. Br J Surg 2011;98:1581-7). This video shows a third antireflux procedure in a patient presenting with slippage of the fundoplication.
B Dallemagne, S Perretta, J D'Agostino, J Marescaux
Surgical intervention
6 years ago
1399 views
15 likes
0 comments
29:04
Second reoperative antireflux procedure for valve slippage
Redo surgery is technically more demanding than primary fundoplication. In addition, anatomical defects that caused failure may increase technical difficulties. A recent review found that the average success rate after laparoscopic redo operations ranged from 65 to 100 per cent (van Beek D, Auyang E, Soper N. A comprehensive review of laparoscopic redo fundoplication. Surgical Endoscopy: Springer New York; 2010. p 1-7). However, our recent study showed that the failure rate after re-operation is increasing with time, and highlighted the need for accurate preoperative and intraoperative assessment of the causes of failure (Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, et al. Long-term results after laparoscopic reoperation for failed antireflux procedures. Br J Surg 2011;98:1581-7). This video shows a third antireflux procedure in a patient presenting with slippage of the fundoplication.
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
6 years ago
1813 views
23 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 repair of giant type 4 paraesophageal hernia
Type 4 giant hiatal hernias are not common. The stomach is herniated, as well as viscera in the mediastinum, colon, spleen, and even sometimes in the pancreas. Repair is challenging for different reasons. This type of hernia is frequent in older and fragile patients. Reduction of the sac from the mediastinum is mandatory and must be carried out following stepwise and precise dissection rules: it has to be done outside of the sac, in an anatomical cleavage plane. Crural repair is challenging and must be tailored on the quality of the diaphragmatic musculature and size of the orifice. Anti-reflux repair must be performed as well. The laparoscopic approach has radically improved the clinical outcome of this procedure in old patients.
B Dallemagne, E Marzano, S Perretta, J Marescaux
Surgical intervention
6 years ago
4726 views
79 likes
0 comments
21:43
Laparoscopic repair of giant type 4 paraesophageal hernia
Type 4 giant hiatal hernias are not common. The stomach is herniated, as well as viscera in the mediastinum, colon, spleen, and even sometimes in the pancreas. Repair is challenging for different reasons. This type of hernia is frequent in older and fragile patients. Reduction of the sac from the mediastinum is mandatory and must be carried out following stepwise and precise dissection rules: it has to be done outside of the sac, in an anatomical cleavage plane. Crural repair is challenging and must be tailored on the quality of the diaphragmatic musculature and size of the orifice. Anti-reflux repair must be performed as well. The laparoscopic approach has radically improved the clinical outcome of this procedure in old patients.
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
6957 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.
Management of a hiatal hernia during laparoscopic Roux-en-Y gastric bypass: be ready to repair
Here we show the case of a 44-year-old woman with a BMI of 40.5 and a history of gastroesophageal reflux disease. She was presented for a weight reductive surgery evaluation. Preoperative esophagogastroduodenoscopy, barium swallow and esophageal high resolution manometry were performed. They demonstrated a 3cm hiatal hernia as well as a hypotensive lower esophageal sphincter.
The presence of a large hiatal hernia (greater than 5cm) is problematic and may prevent successful weight reductive surgery. Laparoscopic Roux-en-Y gastric bypass is an effective procedure to control symptoms and GERD complications in morbidly obese patients. For this reason, Roux-en-Y gastric bypass is a valid alternative to manage morbidly obese patients with symptomatic hiatal hernia and GERD.
Bsed on the preoperative work-up, decision was made to perform a concomitant paraesophageal hernia repair and a laparoscopic Roux-en-Y gastric bypass.
S Perretta, J Marescaux
Surgical intervention
7 years ago
1807 views
15 likes
0 comments
14:28
Management of a hiatal hernia during laparoscopic Roux-en-Y gastric bypass: be ready to repair
Here we show the case of a 44-year-old woman with a BMI of 40.5 and a history of gastroesophageal reflux disease. She was presented for a weight reductive surgery evaluation. Preoperative esophagogastroduodenoscopy, barium swallow and esophageal high resolution manometry were performed. They demonstrated a 3cm hiatal hernia as well as a hypotensive lower esophageal sphincter.
The presence of a large hiatal hernia (greater than 5cm) is problematic and may prevent successful weight reductive surgery. Laparoscopic Roux-en-Y gastric bypass is an effective procedure to control symptoms and GERD complications in morbidly obese patients. For this reason, Roux-en-Y gastric bypass is a valid alternative to manage morbidly obese patients with symptomatic hiatal hernia and GERD.
Bsed on the preoperative work-up, decision was made to perform a concomitant paraesophageal hernia repair and a laparoscopic Roux-en-Y gastric bypass.
Paraesophageal hernias and controversies
There are several advanced situations in antireflux surgery: these include giant hiatal hernias (PEH), the short esophagus and the use of meshes to minimize recurrences.
PEH is a disease of the diaphragm more than one of the esophagus, recurrence rates at 5 to 10 years are very high (>50%) due to intrinsic defects of the connective tissue of the diaphragm. Keys to surgical repair include: reduction of the mediastinal hernia sac, extensive mobilization of the esophagus to bring the GE junction into the abdomen, reinforced repair of the diaphragm. Gastropexy can occasionally be a useful adjunct. Reinforced repair of the diaphragm can involve pledgets, relaxing incisions, or mesh. Mesh remains a controversial subject. The lowest reherniation rates in the literature are with plastic mesh but such a mesh is associated with esophageal erosions. The existence of the short esophagus is controversial, most agree it exists 3 to 5% of the time. The optimal treatment is extensive mediastinal mobilization and, if that fails, to perform a laparoscopic Collis gastroplasty. There are several techniques for Collis including transthoracic or wedge gastroplasty. All result in good functional results but the ectopic gastric mucosa that results often secretes acid and requires the patient to stay on anti-acid medication.
LL Swanström
Lecture
7 years ago
4712 views
29 likes
0 comments
42:08
Paraesophageal hernias and controversies
There are several advanced situations in antireflux surgery: these include giant hiatal hernias (PEH), the short esophagus and the use of meshes to minimize recurrences.
PEH is a disease of the diaphragm more than one of the esophagus, recurrence rates at 5 to 10 years are very high (>50%) due to intrinsic defects of the connective tissue of the diaphragm. Keys to surgical repair include: reduction of the mediastinal hernia sac, extensive mobilization of the esophagus to bring the GE junction into the abdomen, reinforced repair of the diaphragm. Gastropexy can occasionally be a useful adjunct. Reinforced repair of the diaphragm can involve pledgets, relaxing incisions, or mesh. Mesh remains a controversial subject. The lowest reherniation rates in the literature are with plastic mesh but such a mesh is associated with esophageal erosions. The existence of the short esophagus is controversial, most agree it exists 3 to 5% of the time. The optimal treatment is extensive mediastinal mobilization and, if that fails, to perform a laparoscopic Collis gastroplasty. There are several techniques for Collis including transthoracic or wedge gastroplasty. All result in good functional results but the ectopic gastric mucosa that results often secretes acid and requires the patient to stay on anti-acid medication.
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
3466 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
1536 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.
Collis Nissen for slipped fundoplication with recurrent GERD symptoms
Hiatal hernia recurrence is a dreaded postoperative complication after surgery for gastroesophageal reflux. This video presents a live surgery performed in a patient presenting with recurrent symptoms and dysphagia after a previous Nissen fundoplication that was performed 5 years ago. All the preoperative work-up demonstrates the recurrent reflux, mixed ascites, and alkaline reflux associated with an intrathoracic migration of the proximal stomach, and probably a slippage of the valve on the upper part of the stomach. This patient has a manometry, which confirmed the weakness of the lower esophageal sphincter (LES) associated with some dysmotility disorders in the lower esophagus.
B Dallemagne, J Marescaux
Surgical intervention
9 years ago
1876 views
15 likes
0 comments
17:24
Collis Nissen for slipped fundoplication with recurrent GERD symptoms
Hiatal hernia recurrence is a dreaded postoperative complication after surgery for gastroesophageal reflux. This video presents a live surgery performed in a patient presenting with recurrent symptoms and dysphagia after a previous Nissen fundoplication that was performed 5 years ago. All the preoperative work-up demonstrates the recurrent reflux, mixed ascites, and alkaline reflux associated with an intrathoracic migration of the proximal stomach, and probably a slippage of the valve on the upper part of the stomach. This patient has a manometry, which confirmed the weakness of the lower esophageal sphincter (LES) associated with some dysmotility disorders in the lower esophagus.
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
9 years ago
601 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 re-operation for severe dysphagia following fundoplication and prosthetic reinforcement of the hiatus
Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported with no apparent relationship between mesh type and mesh configuration. The aim of this video is to show a case of mesh repair complication.
A 50-year-old woman presented with severe dysphagia and important weight loss one year after redo laparoscopic Nissen fundoplication with prosthetic crural repair. At re-operation, important esophageal stenosis and angulation was found arising from the key-hole-shaped polypropylene mesh with pseudodiverticular dilatation of the distal esophagus. The esophagus was freed from the dense fibrotic capsule surrounding the prosthesis and a myotomy was performed.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
10 years ago
370 views
10 likes
0 comments
19:50
Laparoscopic re-operation for severe dysphagia following fundoplication and prosthetic reinforcement of the hiatus
Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported with no apparent relationship between mesh type and mesh configuration. The aim of this video is to show a case of mesh repair complication.
A 50-year-old woman presented with severe dysphagia and important weight loss one year after redo laparoscopic Nissen fundoplication with prosthetic crural repair. At re-operation, important esophageal stenosis and angulation was found arising from the key-hole-shaped polypropylene mesh with pseudodiverticular dilatation of the distal esophagus. The esophagus was freed from the dense fibrotic capsule surrounding the prosthesis and a myotomy was performed.
Laparoscopic partial fundoplication after lung transplant in a patient with severe esophageal motility disorders (scleroderma)
Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease before and after lung transplantation. In addition to problems with the lower esophageal sphincter, systemic diseases such as scleroderma and cystic fibrosis can diminish esophageal and gastric motility. After thoracic transplantation, esophageal and gastric motility often are negatively affected by damage to the vagus nerve and certain medications. Remodeling of the thoracic cavity also may alter the mechanics of esophageal muscle contraction. After transplantation, fundoplication may improve pulmonary function and prevent complications such as bronchiolitis obliterans syndrome.
This is the case of a 57-year old patient with scleroderma 8 months after lung transplantation for idiopathic pulmonary fibrosis (IPF). The patient presented with typical GERD symptoms, not responsive to a high dose of PPI. The trocar placement is the same as for a standard Nissen fundoplication. The video shows each surgical step carefully and demonstrates how to correctly perform esophageal and mediastinal dissection in case of a previous lung surgery.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
10 years ago
1389 views
22 likes
0 comments
06:21
Laparoscopic partial fundoplication after lung transplant in a patient with severe esophageal motility disorders (scleroderma)
Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease before and after lung transplantation. In addition to problems with the lower esophageal sphincter, systemic diseases such as scleroderma and cystic fibrosis can diminish esophageal and gastric motility. After thoracic transplantation, esophageal and gastric motility often are negatively affected by damage to the vagus nerve and certain medications. Remodeling of the thoracic cavity also may alter the mechanics of esophageal muscle contraction. After transplantation, fundoplication may improve pulmonary function and prevent complications such as bronchiolitis obliterans syndrome.
This is the case of a 57-year old patient with scleroderma 8 months after lung transplantation for idiopathic pulmonary fibrosis (IPF). The patient presented with typical GERD symptoms, not responsive to a high dose of PPI. The trocar placement is the same as for a standard Nissen fundoplication. The video shows each surgical step carefully and demonstrates how to correctly perform esophageal and mediastinal dissection in case of a previous lung surgery.
Giant hiatal hernia: acute presentation with gastric volvulus
Hiatal hernia is a common disorder of the digestive tract. Most patients are elderly and with significant co-morbidities. Historically, the surgical repair of paraesophageal hernias (PHH) has been advocated regardless of the presence of symptoms. In fact, despite patients being symptom-free, the development of potentially life-threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the stomach mucosa, is well-known and has proven to be fatal in 27% of cases. Nevertheless, patients with asymptomatic PHH are likely to develop symptoms needing emergency surgery in only 1.16% of cases with a 5.4% mortality rate. Recently, several authors have questioned the indication for repair in asymptomatic patients and prefer to monitor asymptomatic or minimally symptomatic PHH by ‘watchful waiting’. Our current practice is to operate only in the case symptoms or complications. The laparoscopic repair of PHH is certainly technically challenging. It requires considerable experience with minimally invasive surgery of the foregut, and a complete understanding of esophageal pathophysiology. The basic principles of surgical repair are the reduction of herniated stomach and distal esophagus into the abdominal cavity with tension-free repositioning of 2cm of lower esophagus in a subphrenic position, complete excision of the peritoneal hernia sac from the mediastinum and the repair of the diaphragmatic hiatus.
This is the case of a woman admitted to the emergency room for complete acute dysphagia associated with type IV paraesophageal hernia. The preoperative work-up (CT-scan, upper GI series) showed the migration of the stomach, left transverse colon and omentum into the chest.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
10 years ago
2593 views
74 likes
0 comments
15:02
Giant hiatal hernia: acute presentation with gastric volvulus
Hiatal hernia is a common disorder of the digestive tract. Most patients are elderly and with significant co-morbidities. Historically, the surgical repair of paraesophageal hernias (PHH) has been advocated regardless of the presence of symptoms. In fact, despite patients being symptom-free, the development of potentially life-threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the stomach mucosa, is well-known and has proven to be fatal in 27% of cases. Nevertheless, patients with asymptomatic PHH are likely to develop symptoms needing emergency surgery in only 1.16% of cases with a 5.4% mortality rate. Recently, several authors have questioned the indication for repair in asymptomatic patients and prefer to monitor asymptomatic or minimally symptomatic PHH by ‘watchful waiting’. Our current practice is to operate only in the case symptoms or complications. The laparoscopic repair of PHH is certainly technically challenging. It requires considerable experience with minimally invasive surgery of the foregut, and a complete understanding of esophageal pathophysiology. The basic principles of surgical repair are the reduction of herniated stomach and distal esophagus into the abdominal cavity with tension-free repositioning of 2cm of lower esophagus in a subphrenic position, complete excision of the peritoneal hernia sac from the mediastinum and the repair of the diaphragmatic hiatus.
This is the case of a woman admitted to the emergency room for complete acute dysphagia associated with type IV paraesophageal hernia. The preoperative work-up (CT-scan, upper GI series) showed the migration of the stomach, left transverse colon and omentum into the chest.
Laparoscopic Collis-Nissen procedure for failed fundoplication
This video shows a laparoscopic Collis-Nissen gastroplasty in a patient with a previous Nissen fundoplication which was performed using an open approach.
Despite an extensive mobilization, it was not possible to achieve an adequate length of intra-abdominal esophagus. A short esophagus was diagnosed and the surgeon performs a Collis gastroplasty. The hiatus is repaired with interrupted non-absorbable sutures. A Nissen fundoplication is performed.
This patient had a previous Nissen fundoplication using an open approach. After extensive mobilization, the surgeons diagnose a short esophagus and perform a Collis gastroplasty. They repair the hiatus with interrupted non-absorbable sutures, and perform a Nissen fundoplication. Once they complete the dissection, the authors assess the length of the esophagus. The video shows the authors placing tape around the gastroesophageal junction at the level of the hiatus. The junction between the stomach and the esophagus is at the level of the hiatus, a sign evocative of a short esophagus.
B Dallemagne, C Solano
Surgical intervention
11 years ago
2278 views
11 likes
0 comments
14:36
Laparoscopic Collis-Nissen procedure for failed fundoplication
This video shows a laparoscopic Collis-Nissen gastroplasty in a patient with a previous Nissen fundoplication which was performed using an open approach.
Despite an extensive mobilization, it was not possible to achieve an adequate length of intra-abdominal esophagus. A short esophagus was diagnosed and the surgeon performs a Collis gastroplasty. The hiatus is repaired with interrupted non-absorbable sutures. A Nissen fundoplication is performed.
This patient had a previous Nissen fundoplication using an open approach. After extensive mobilization, the surgeons diagnose a short esophagus and perform a Collis gastroplasty. They repair the hiatus with interrupted non-absorbable sutures, and perform a Nissen fundoplication. Once they complete the dissection, the authors assess the length of the esophagus. The video shows the authors placing tape around the gastroesophageal junction at the level of the hiatus. The junction between the stomach and the esophagus is at the level of the hiatus, a sign evocative of a short esophagus.
Laparoscopic Collis Nissen: GERD with short esophagus
This live video demonstrates the Collis-Nissen procedure performed by Dr. Bernard Dallemagne during a surgical course. The patient presented with gastro-esophageal reflux disease and was only discovered intraoperatively to have a short esophagus. The confirmation of this diagnosis and the esophageal lengthening procedure are presented in detail. This video is recommended to surgeons with an interest in upper gastro-intestinal surgery.
The author places 5 trocars, directed by plain film findings that raise suspicion of a lipoma of the lower mediastinum. The author eschews the umbilical port for a port slightly above the umbilicus to accommodate the 0-degree scope. The optical port for the left hand is in the direction of hiatus. First, the author must gain traction on the gastroesophageal junction, then examine anatomy. He starts on the lesser omentum to help identify important landmarks, the first of which is the right crus.
B Dallemagne
Surgical intervention
11 years ago
2131 views
56 likes
0 comments
29:31
Laparoscopic Collis Nissen: GERD with short esophagus
This live video demonstrates the Collis-Nissen procedure performed by Dr. Bernard Dallemagne during a surgical course. The patient presented with gastro-esophageal reflux disease and was only discovered intraoperatively to have a short esophagus. The confirmation of this diagnosis and the esophageal lengthening procedure are presented in detail. This video is recommended to surgeons with an interest in upper gastro-intestinal surgery.
The author places 5 trocars, directed by plain film findings that raise suspicion of a lipoma of the lower mediastinum. The author eschews the umbilical port for a port slightly above the umbilicus to accommodate the 0-degree scope. The optical port for the left hand is in the direction of hiatus. First, the author must gain traction on the gastroesophageal junction, then examine anatomy. He starts on the lesser omentum to help identify important landmarks, the first of which is the right crus.
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
11 years ago
8839 views
202 likes
1 comment
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.