Task Analysis of Laparoscopic and Robotic Procedures

Laparoscopic Nissen Fundoplication
General Surgery / Oct 22nd, 2016 12:06 pm     A+ | a-
Task analysis of Laparoscopic Nissen Fundoplication

1. Place patient in dorsal lithotomy position

2. Reverse Trendelenburg to about 30 degree

3. Camera—insert port one third from the umbilicus to xiphoid just left of midline

4. Examine abdomen—search for abnormal pathology, injuries from port placement

5. Surgeon’s left hand—insert port at right subcostal margin, midaxillary line

6. Surgeon’s right hand—insert port at left subcostal, midaxillary line

7. Assistant retractor—insert port at left anterior axillary line, level of umbilicus

8. Liver retractor—insert port at subxiphoid or at right anterio axillary line at level of umbilicus

9. Visualize insertion of trocars

10. Retract left lobe of liver anteriorly and toward the patient’s right Assistant retract stomach towards left foot

11. Distract gastrohepatic ligament on tension

12. Incise gastrohepatic ligament(cautery or harmonic)

13. Identify right crus

14. Dissect right crus from esophagus

15. Assistant retract stomach caudally and posteriorly

16. Dissect anterior aspect of esophagus from crus

17. Identify/protect anterior vagus nerve

18. Assistant retract stomach caudally and to the right

19. Identify left crus

20. Dissect left crus from esophagus

21. Dissect posteriorly down left crus toward crural decussation

22. Dissect fundus from left crus

23. Assistant regrasp near gastroesophageal junction and retract anteriorly and to the left

24. Complete dissection of right crus down to inferior crural decussation Identify/protect posterior vagal nerve

25. Develop posterior esophageal window

26. Pass penrose drain through created window to use as retractor

27. Secure both penrose tails together with suture

28. Assistant retract esophagus with penrose anteriorly and to the left Complete posterior window and left and right crural

29. Dissect into mediastinum around esophagus to obtain a minimum of 2 cm intra-abdominal length

30. Develop 2nd window posterior to esophagus

31. Pass a 2nd penrose through this new window

32. Secure both tails of 2nd penrose together with suture and remove 1st penrose

33. Place multiple figure of 8 sutures to close crura

34. Place most inferior suture first and proceed anteriorly

35. Complete all sutures now or add last suture after creation of fundoplication

36. Suspend gastrosplenic omentum between assistant’s retractor and surgeon’s left hand

37. Pick a point 1/3 down the greater curve to incise gastrosplenic omentum

38. Sequentially ligate short gastric arteries moving towards gastroesophageal junction

39. Dissect any posterior fundic gastric attachments

40. Complete dissection of any remaining gastric attachments to crus or diaphragm

41. Retract greater curve of stomach anteriorly towards liver

42. Measure 6 cm along greater curvature from GE junction and 2 cm from the edge of the curvature down the posterior fundic

43. Mark this location with a loosely tied 3-0 silk suture

44. Pass suture and posterior fundic wall of stomach through posterior esophageal window

45. Grasp anterior fundic wall of stomach and drag anteriorly towards patient’s right

46. Kissing/shoeshine maneuver to orient fundoplication into final position—fundic edges meet on right side without twisting and
with short gastric in natural position

47. Relax penrose retraction of GE junction

48. Pass 60 French bougie

49. Re confirm configuration of wrap

50. Insert first suture into abdominal cavity—a double armed, pledgeted suture

51. first suture (1st needle) through anterior fundus then esophagus at 11 o’clock then posterior fundus

52. Pass 2nd arm of 1st suture as above

53. Place 2nd pledget and tie

54. Pass 2nd suture through anterior fundus then posterior fundus cranial to 1st suture

55. Pass 3rd suture through anterior fundus then posterior fundus caudal to 1st suture

56. Remove bougie

57. Examine crural closure, insert final suture to a gap of approximately 5mm(one instrument pass)

58. Remove penrose retractor

59. Pass nasogastric tube

60. Remove ports under direct visualization and close ports sites
Dr. Raghu
Nov 4th, 2016 7:44 am
Good job Dr. Ok Wael Abu Siam
Nov 17th, 2016 4:22 am
Laparoscopic Nissen Fundoplication knowledge is good FOR the growth .....
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