# Reflux and Foregut Surgery — GCMD Library living collection

Updated: n/a · 6 episodes · 34 cited statements

## Episodes
### Nissen fundoplication
- [Laparoscopic Nissen Fundoplication Using the 5 mm CoolSeal Trinity](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931) — video · 5:55 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931.md)
- [Laparoscopic Nissen Fundoplication in an 8 kg Patient](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-in-an-8-kg-patient-11990) — video · [machine version](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-in-an-8-kg-patient-11990.md)
- [Two decades Nissen IPEG](https://library.globalcastmd.com/watch/two-decades-nissen-ipeg-11977) — article · [machine version](https://library.globalcastmd.com/watch/two-decades-nissen-ipeg-11977.md)

### Redo and complex reflux
- [Laparoscopic Redo Nissen Fundoplication in a 30 kg Child with the 3 mm Percuvance System](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993) — video · 5:16 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993.md)

### Achalasia, pylorus and gastric pacing
- [Laparoscopic Pyloromyotomy with a Reusable Handle and Disposable Blade](https://library.globalcastmd.com/watch/laparoscopic-pyloromyotomy-with-a-reusable-handle-and-disposable-blade-11996) — video · [machine version](https://library.globalcastmd.com/watch/laparoscopic-pyloromyotomy-with-a-reusable-handle-and-disposable-blade-11996.md)
- [Telementoring During Gastric Pacer Placement](https://library.globalcastmd.com/watch/telementoring-during-gastric-pacer-placement-11971) — video · 0:10 · [machine version](https://library.globalcastmd.com/watch/telementoring-during-gastric-pacer-placement-11971.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=0) Patient positioning, trocar placement, and initial adhesiolysis (Ep 1)
- [1:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=90) Division of gastrohepatic ligament and creation of retroesophageal window (Ep 1)
- [3:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=180) Division of short gastric vessels and fundal mobilization (Ep 1)
- [4:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=270) Crural repair and wrap construction (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=0) Port placement and Percuvance instrument insertion technique (Ep 4)
- [1:30](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=90) Takedown of previous fundoplication wrap (Ep 4)
- [2:30](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=150) Hiatal hernia repair with crural closure (Ep 4)
- [3:30](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=210) Creation of 360-degree fundoplication wrap (Ep 4)
- [4:40](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=280) Removal of Percuvance instruments (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The case is a redo fundoplication in a 30 kg child using the 3 mm Percuvance system (clinical) [Ep 4 · 0:00](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=0)
- The Percuvance instrument is inserted by first inserting a needle tip on the shaft, then inserting through a 5 mm trocar placed in the left mid quadrant, then attaching the grasper (clinical) [Ep 4 · 0:20](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=20)
- Three Percuvance instruments are used, supplying both liver retraction and stomach manipulation (clinical) [Ep 4 · 1:00](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=60)
- The stomach retractor needle tip is inserted directly through the abdominal wall and then a grasper is attached to retract on the stomach (clinical) [Ep 4 · 1:15](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=75)
- The 5 mm effector tips allow for atraumatic manipulation of the stomach in this larger child (clinical) [Ep 4 · 2:00](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=120)
- The previous wrap appears to be intact but is loosened, and there is a small hiatal hernia (clinical) [Ep 4 · 2:15](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=135)
- Complete takedown of the wrap and exposure of the left crus is a key maneuver in redo fundoplication (opinion) [Ep 4 · 2:30](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=150)
- A two-stitch crural repair was performed using 2-0 Ethibond suture (clinical) [Ep 4 · 3:00](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=180)
- It is extremely important in redo fundoplication to completely take down the previous wrap so that the hiatal defect can be well visualized and repaired appropriately (opinion) [Ep 4 · 3:15](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=195)
- The stomach is retracted down to further lengthen the esophagus to ensure there is adequate length (clinical) [Ep 4 · 3:45](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=225)
- The wrap is formed going from stomach to the anterior wall of the esophagus, with the top stitch also including the anterior diaphragmatic rim (clinical) [Ep 4 · 4:00](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=240)
- Including the anterior diaphragmatic rim in the top stitch helps lock the wrap into the abdomen and hopefully will prevent recurrent herniation (opinion) [Ep 4 · 4:15](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=255)
- Three sutures are placed, each incorporating a bite of the stomach, a bite of the esophagus, and a bite of the wrap portion of the stomach (clinical) [Ep 4 · 4:30](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=270)
- Removal of the three Percuvance tips took approximately one minute (clinical) [Ep 4 · 4:55](https://library.globalcastmd.com/watch/laparoscopic-redo-nissen-fundoplication-in-a-30-kg-child-with-the-3-mm-percuvanc-11993?t=295)
- The Coseal Trinity 5mm device functions as both an excellent dissector with tips almost as fine as a Maryland and a vessel sealer. (clinical) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=0)
- The Trinity device can seal and divide blood vessels up to 7 millimeters in size. (clinical) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=180)
- The Trinity device produces almost no heat spread, which prevents injury to the stomach, spleen, or surrounding organs. (clinical) [Ep 1 · 3:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=180)
- Care is taken not to carry dissection high into the hiatus to avoid increased risk of hiatal hernia. (clinical) [Ep 1 · 1:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=90)
- The anterior vagus nerve must be identified and preserved during retroesophageal dissection. (clinical) [Ep 1 · 1:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=90)
- A 2-0 Ethibond suture on RB1 needle is used for crural repair in patients ranging from 2 kg to 100 kg. (clinical) [Ep 1 · 4:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=270)
- Establishing good length of intraabdominal esophagus is key to developing a good wrap and preventing a slip Nissen. (clinical) [Ep 1 · 4:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=270)
- The wrap should be tension-free and brought around behind the esophagus. (clinical) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=300)
- A small anterior bite of the esophagus is taken at the 10 and 11 o'clock position during wrap construction. (clinical) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=300)
- Three stitches are used to complete the wrap. (clinical) [Ep 1 · 5:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=330)
- The wrap is generally under 2 centimeters in length to ensure that an obstructive force is not created. (clinical) [Ep 1 · 5:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=330)
- Great care is taken to make sure that the wrap is loose and there is no twisting of the esophagus. (clinical) [Ep 1 · 5:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=330)
- The patient is started on clear liquids immediately after the procedure and discharged the following morning. (clinical) [Ep 1 · 5:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=330)
- Trocar placement includes 3 millimeter ports in the epigastrium for retraction and a 3 and 5 millimeter port in the left and right hand respectively for ancillary instruments. (clinical) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=0)
- The surgeon stands between the patient's legs with the cameraman on the surgeon's left. (clinical) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=0)
- The gastrohepatic ligament is taken down to expose the right crus and create a safe retroesophageal window. (clinical) [Ep 1 · 1:30](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=90)
- The retroesophageal window is developed to eliminate the risk of injury to the esophagus or the posterior wall of the stomach. (clinical) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=240)
- The left crus is slightly cleaned to better allow for crural repair. (clinical) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=240)
- A small amount of peritoneum overlying the upper esophagus is taken to allow for proper placement in the wrap. (clinical) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=240)
- The stomach retractor is used to lengthen the esophagus by pulling downward, ensuring the wrap is above the GE junction. (clinical) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/laparoscopic-nissen-fundoplication-using-the-5-mm-coolseal-trinity-11931?t=300)

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