Single-Port Laparoscopic Floppy Nissen Fundoplication: A Novel Technique with the Aid of the Cerrahpasa Retractor

Introduction

Fundoplication has become the most commonly performed anti-reflux procedure since its introduction in 1956 by Rudolph Nissen, who worked as the Chief of the First Surgery Clinic in the Cerrahpasa Hospital of our University in Istanbul, Turkey, from 1933 to 1939.^1,2 However, anti-reflux surgery has very much improved since the introduction of laparoscopic fundoplication in 1991 by Dallemagne et al. ³

The popularity of single-port laparoscopy is increasing because most of the instruments used are well known to laparoscopic surgeons. On the other hand, single-port laparoscopic surgery became popular with its benefits of cosmetic potential, better patient satisfaction, faster recovery, and less pain for the patients.

The retraction of the liver without an additional trocar is a problem in single-port upper gastrointestinal surgeries.

In our present study, we aimed to present our short term follow-up experience of single-port laparoscopic floppy Nissen fundoplication (LFNF) with the aid of the Cerrahpasa retractor^® (trademark pending by our medical school) for the retraction of the left liver in 22 patients with symptomatic gastroesophageal reflux disease (GERD).

Subjects and Methods

We performed single-port LFNF on 22 patients with symptomatic GERD between September 2009 and April 2011. The procedure was explained to all the patients, and informed consent was obtained from each patient. The patient was kept in the 30° reverse Trendelenburg position. The operating surgeon stood between the legs in the French position, while the camera assistant operated from the patient's left. For the first 5 cases, the SILS™ (Covidien AG, Norwalk, CT) port was introduced through a 2-cm horizontal incision above the umbilicus, one-third of the distance to the xiphoid process. For the next 17 cases, the SILS port was introduced through a 2-cm vertical umbilical incision. The steps of the operations were exactly the same for both transumbilical and supraumbilical LFNF procedures. One 12-mm and two 5-mm trocars were used through the SILS port. The second step was the introduction of a “hand-made needle liver retractor” (Cerrahpasa retractor), from the midline just below the xiphoid process. The retractor is composed of two parts: The head and the wire. The wire is introduced through a hand-made Seldinger-type needle. The head is introduced through the SILS port, and the two parts are mounted together intracorporeally. The main steps of the operation were dissection of the hepatogastric and Laimer's ligament, dissection and closure of the hiatus, and short, floppy Nissen fundoplication. The phrenoesophageal ligament was divided to obtain at least 4 cm of an abdominal esophagus. The dissection was performed by the help of a 5-mm monopolar hook device and the LigaSure™ 5-mm laparoscopic instrument (Covidien). The short gastric vessels were not divided. For the traction of the tape around the distal esophagus we used the Suture Grasper^® (Proxy Biomedical Ltd., Galway, Ireland) device, introduced from the left upper abdominal quadrant, to pull the tape around the esophagus. Cruroraphy and fundoplication were performed with the Endo Stitch™ 10-mm suturing device with SOFSILK™ size 0 USP and 2-0 USP interrupted sutures (Covidien), respectively. No esophageal dilators were used for the construction of the fundoplication. During the operation, a 5-mm flexible 0° laparoscope (LTF-V3 EndoEye™, Olympus Medical, Tokyo, Japan) was used. It included two nonabsorbable stitches to create a 360° short, floppy wrap and two nonabsorbable stitches to perform the cruroplasty. The first upper stitch on the stomach passed through the esophageal wall. In our technique, we do not fix the fundoplication. At the end of the procedure, a 10-mm laparoscopic device (LigaSure or Endo Stitch) was introduced underneath the esophagus and within the wrap to verify the tightness of the cruroplasty and fundoplication, respectively. Finally, the umbilical fascia was closed, and the skin edges were approximated by intracutaneous stitches. The procedure is demonstrated online on SAGES TV, SAGES 2011 Meeting, Bonus Videos section.

Results

There were 17 (77%) female and 5 (23%) male patients with an average age of 28 years (range, 22–45 years). The body mass index of all the patients was <30 kg/m². Endoscopic findings according to the Los Angeles classification are listed in Table 1. Of the 22 patients, 41% (n=9) had a hiatus hernia. The diagnosis of hiatal hernia was confirmed by the presence of gastric folds ≥3 cm above the diaphragmatic hiatus. Of the 22 patients, 5 were done supraumbilical, and 17 were done transumbilical single-port LFNF. All the procedures were performed without any perioperative complications. The mean duration of the operations was initially 110 minutes (the initial 5 operations) and reduced to 60 minutes (the last 5 operations) throughout the 8-month period. No drains were used. The postoperative period was uneventful. All the patients were given oral fluids 12 hours postoperatively and discharged after 24 hours. Based on the short-term follow-up, no postoperative complications are encountered.

Discussion

Similar to classical laparoscopic surgery, the early adopters of single-incision techniques were in the gynecology world. The first single-port laparoscopic appendectomy was reported by Pelosi and Pelosi ⁴ in 1992. Later, in 1997 Navarra et al. ⁵ reported the first cases of one-wound laparoscopic cholecystectomy. Despite the lack of conclusive studies, potential advantages of single-port laparoscopic surgery are reduction of wound-related complications, reduced postoperative pain, improved cosmesis, and shorter recovery time.

The major drawback to a single-port laparoscopic surgery is that the concept of “triangulation” in terms of both the instruments and scope is absent. Besides, the retraction of the left liver is a vital step making upper gastrointestinal procedures through a single-port or multiport feasible. Possible added complications produced by the retraction of the liver may have critical consequences for the patient. Until now, the procedures described for retraction in single-port surgery use a more or less suturing or silk lace techniques,^6–8 which potentially could tear the liver or other anatomical structures easily. Therefore, as surgeons we should not advocate for slightly improved cosmetic value over safety.

An alternative technique using anything other than suturing or the silk lace technique was described by Gianni et al., ⁹ where the authors used a Veress needle for retraction of the liver.

A publication similar to our technique was reported by Cuesta et al. ¹⁰ in 2008. In their study the authors performed transumbilical laparoscopic cholecystectomy with the use of two transumbilically placed 5-mm trocars and subcostally introduced 1-mm Kirschner wire. The wire was used for gallbladder traction. The Cerrahpasa retractor used in this study to elevate the liver was 1 mm in diameter and made of stainless steel. For the use of this needle-retractor no additional trocar was used. The incision through which it was inserted is virtually “scarless.” Likewise, the Suture Grasper used for esophageal traction has an outside diameter of 14 gauge, which leaves an almost invisible scar.

Although the conventional laparoscopic instruments were all placed at the same level during most of the procedure, we did not encounter any conflicts. Only for the placement of a tape around the distal esophagus we did use the Roticulator Endo Grasp™ 5-mm (Autosuture™, Covidien) instrument during the conduction of the tape behind the gastric cardia.

The mean operative time of this current technique was longer initially but improved throughout the learning curve to a duration time comparable to that of the conventional multiport LFNF. We believe that this possible limitation could be surmounted by increased surgeon experience and enhanced technical means.

Conclusion

New techniques for the retraction of the liver like our technique will ease single-port upper gastrointestinal surgeries. In our technique, the retraction of the left lobe of the liver is easier compared with suture or lace retraction techniques. Further trials are required to assess the long-term results of single-port LFNF and liver retraction techniques introduced for single-port laparoscopic surgery. We believe that with the aid of well-designed surgical instruments like our Cerrahpasa retractor single-port laparoscopy would be easier.