Robotic Nissen fundoplication for gastro-oesophageal reflux disease with hiatal hernia (with video)

Gastroesophageal reflux disease is a significant public health concern. Antireflux surgery has become an accepted solution for many patients especially since the introduction of minimally invasive procedures [1]. Robotic surgery provides a three-dimensional vision with articulated instruments resulting in greater dexterity for surgeons [2] and [3]. This video shows different steps necessary to perform a posterior fundoplication using Nissen-Rossetti technique. The patient is placed in a supine reversed Trendelenburg position. A 12-mm trocar, for the robotic camera, is positioned in the left paraumbilical region. Two 8-mm robotic ports are inserted into the right hypochondrium and the left subcostal region. A 12-mm extra-port for accessory instruments controlled by the assistant is placed at the supraumbilical region. Mobilisation of the esophagus requires the opening of the upper part of the small omentum (pars condensa). The phrenoesophageal membrane is incised, using the cautery hook. The diaphragm pillars are then visualized. A ribbon is passed around the esophagus, allowing the enlargement of the dissection and lowering the esophagus by 4–5 cm. The left pillar is sutured to the right one avoiding oesophageal stenosis. The dissection of the esophagus must be sufficient to allow the large gastric tuberosity to pass freely at the posterior part of the esophagus. A Nissen fundoplication with the Rossetti modification is carried out, paying attention to the preservation of the vagus nerves. The large tuberosity is sutured onto itself using simple stitches, wrapping the abdominal esophagus with a 360° angle. The height of the fundoplication is expected to be about 2–3 cm. This video is useful for all surgeons having to perform a laparoscopic or robotic Nissen-Rossetti fundoplication.