Techniques for omental retraction during laparoscopic nissen fundoplication.

A laparoscopic Nissen fundoplication is more difficult in patients with excessive omental fat, particularly when the surgeon attempts to ligate the short gastric vessels, mobilizing the greater curvature of the stomach and exposing the left diaphragmatic crura. Most surgeons place the patient in steep reverse Trendelenberg to allow gravity to pull the omentum out of the operative field. Despite this maneuver, the omentum can still drape over the splenic hilum and left subphrenic space. Another alternative is to place an additional trocar for a hand-held retractor or grasper. However, this procedure is unnecessarily traumatic and can be avoided. There is a method of retracting the omentum during laparascopic Nissen fundoplications that uses readily available laparoscopic instruments and does not require the placement of an additional port. This simple technique for retracting the omentum during a laparoscopic Nissen fundoplication makes use of the Surgitie, a pretied laparoscopic suture, and the Endo Close (United States Surgical Corporation, Norwalk, CT, USA). A Surgitie is placed through one of the ports to lasso the offending piece of omentum along the greater curvature of the stomach. The suture is cut to its fullest length outside the body, then pulled through the trocar and into the abdomen. Gentle traction is placed on the free end of the secured suture with a laparoscopic grasper until the omentum is retracted to an optimal position for visualization. At this point, a 1-mm incision is made in the skin, and the Endo Close is placed through the abdominal wall and into the abdominal cavity. The location of the 1-mm incision should be at a site that will maintain adequate retraction on the omental fat but keep the pretied laparoscopic suture out of the operative field (usually along the left costal margin). The free end of the suture is grasped by the Endo Close and pulled back through the abdominal wall. The suture is secured outside the abdominal cavity by grasping it with a hemostat flush to the skin. More than one Surgitie can be used if needed. After completing the fundoplication, the suture is cut intracorporally near the secured knot and removed. During the past year, we have performed laparoscopic Nissen fundoplications in seven patients with morbid obesity (Body Mass Index >35). The technique we describe has allowed for improved visualization during ligation of the short gastric vessels, mobilization of the greater curvature of the stomach, and exposure of the left diaphragmatic crura. It has also obviated the need for another trocar. This will free up a pair of hands, decrease the amount of instrumentation in an already crowded operative field, and reduce the potential morbidity of using additional retractors and graspers.