Lap Nissen trinity narrated

This video demonstrates a laparoscopic niss and fundoplication using the Coseal Trinity 5 millimeter device. The patient is placed at the end of the table with the surgeon standing between the patient's legs. The cameraman is on the patient, on the surgeon's left. Here you see the trochar placement with 3 millimeter ports in the epigastrium used to provide retraction and a 3 and a 5 millimeter port in the left and right hand respectively for ancillary instruments. Upon entering the abdomen, we find adhesions between the lesser sac and the left lobe of the liver. These are taken down using the cool seal device without difficulty. The advantage of the cool seal is that it is an excellent dissector, as you can see as the tips are almost as fine as the Maryland in the left hand. Once these adhesions are taken down. We can see the caudate lobe and also. The right cruise. The next move is to take down the gastrooppatic ligament, thereby exposing the right roots so that we can create a safe retroesophageal window. This ligament is taken down without any problem. The tips of the cool seal then allow us to dissect. Just inside of the right cruise. Without taking down the frontoesophageal ligament. The plane is easily developed along the right side of the esophagus. Going up over the top of the hiatus. Care is taken to identify and preserve the anterior vagus nerve which you see here briefly. The section is not carried up into the hiatus so as to not cause an increased risk of hiatal hernia. The stomach is then retracted medially using the 3 millimeter grasper, which is in the left upper quadrant. And then the short gastric vessels are easily taken using the trinity again, the ability to grasp tissue, dissect, and then seal and divide. Blood vessels up to 7 millimeters in size are greatly enhanced by this device. You can also see there is almost no heat spread, which prevents injury to the stomach, the spleen, or surrounding organs. This dissection is carried up until the left cruise is clearly seen. The ability to dissect. Down behind the stomach with a single hand because of the grasping abilities and the dissecting abilities of the trinity make this portion of the procedure much easier. Again, care is taken not to breach the hiatus so as not to create an increased risk for a hiatal hernia. This completed, a retroesophageal window can now safely be. Developed. This eliminates the risk of injury to the esophagus or the posterior wall of the stomach. The left cruise is slightly clean to better allow for a cruel repair. And a small amount of the peritoneum overlying the upper esophagus is also taken to allow for proper placement in the wrap. In this case, only a single stitch is required to buttress the hiatus. This is a 20ethebo suture on RB1, which we use for any size patient over 2 kg all the way up to 100 kg. You can see that we have established a good length of intraabdominal esophagus, which is key to developing a good wrap and preventing a slip missing. The stomach is now brought around behind the esophagus, and it is a tension-free wrap. Stitches are then placed to form the wrap going from the. Curved portion of the stomach. Up over the anterior esophagus. The stomach retractor is now used to lengthen the esophagus by pulling downward, again, making sure that the wrap is above the GE junction. A small anterior bite of the esophagus is taken at the 10 and 11 o'clock position, and then a small bite from the crew. Up near that. Hiatus. And then The wrapped portion of the stomach is grasped. And the stitches tied to complete the wrap. During this maneuver. He left up And Grasper can be used to retract down on the GE junction to better expose the esophagus. We use 3 stitches to complete the wrap. The rap is generally under. 2 centimeters in length to ensure that we do not create an obstructive force. Great care is taken to make sure that the. Wrap is loose and there is no twisting of the esophagus. Here you can see the 3rd stitch being placed. Patient is started on clear liquids immediately and followed discharged the following morning.