Preoperative endoscopy | Height hiatal hernia ≤2 cm, reduces fully Transverse dimensions of hiatus <3 cm max |
Preoperative medications | Antiemetics, antibiotics, and anticholinergics |
Anesthesia | General endotracheal |
Position | Semirecumbent |
Initial endoscopy | Transverse dimensions of hiatus <3 cm max Record distance from incisors to hiatal landmark |
Device introduction | Tissue mold handle to left shoulder orients elbow of tissue mold to course of pharynx |
Device retroflexion | Direct vision with endoscope retroflexed. |
CO2 insufflation | Through working channel, pressure 12–15 mmHg |
Identify anatomic landmarks | Lesser curve (12 o’clock); greater curve (6 o’clock) |
Initial helical screw deployment | 12 o’clock insertion at Z-line/GE junction |
Three anterior rotational plication sets | Roll tissue from 6 o’clock anteriorly toward 1 o’clock with tissue mold; tension on helical retractor; gastric desufflation |
Lock helical retractor and tissue mold; apply suction to tissue invaginator for 30 s | |
Advance device to within 1 cm of distance corresponding to measured distance to hiatal landmark; rotate device out of corner to align tissue mold | |
Advance stylet furthest from corner (posterior in this case) first, deploy fastener | |
Complete first rotational plication set by advancing another stylet and deploy second fastener | |
Create two additional anterior rotational plication sets at slightly different depths. This will create plications from 2 o’clock to 4 o’clock at depths up to 3 cm | |
Rotate tissue mold through lesser curve to posterior corner | Advance device with helical retractor cable slack, tissue mold partially closed, and rotate device counterclockwise |
Three posterior rotational plication sets | Similar to the anterior plication sets, but rotation is now clockwise from 6 o’clock toward 11 o’clock, and the anterior stylet is advanced first. Three plication sets will be created from 7 o’clock to 10 o’clock at different depths up to 3 cm |
Rotate tissue mold back through lesser curve back to anterior corner | |
Two anterior longitudinal plication sets at 12:30 to 2 o’clock | Gentle longitudinal advanced caudally with the helical retractor and infolding of tissue with the tissue mold during gastric desufflation to create two anterior longitudinal plication sets of 1–2 cm depth |
Reposition helical retractor to 4 o’clock | This is the second helical retractor placement and is done to aid in caudal retraction for the final longitudinal plication |
One greater curve longitudinal plication set at 5 o’clock | This plication set must be performed carefully with attention to the location of the diaphragm |
One additional plication set | As needed |
Remove device | Release helical retractor and pull back into tissue mold |
Straighten tissue mold under direct visualization | |
Remove device while observing esophagus with endoscope just inside device. Helical retractor should be pulled back; tissue mold knob externally to left shoulder | |
Final endoscopy | Assess plication; assess for bleeding or perforation |
Postoperative care | Pain medication as needed. GI cocktail: viscous Lidocaine, Donnatal, antacids |
Continue PPIs for 2 weeks. Clear to full liquid diet without carbonation. Consider water-soluble contrast study before discharge |
Open Access 01.07.2011 | Technique
Transoral rotational esophagogastric fundoplication: technical, anatomical, and safety considerations
Erschienen in: Surgical Endoscopy | Ausgabe 7/2011