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 Table of Contents  
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 18-20

Single-site, multiple port, antireflux laparoscopic fundoplication is a feasible cost-effective technique: The first case report in the United Arab Emirates

1 Department of Surgery, Burjeel Hospital, Sharjah, United Arab Emirates
2 Department of Surgery, Life Line Rigid Hospital, Chennai, Tamil Nadu, India

Date of Submission02-Feb-2021
Date of Acceptance21-Jun-2021
Date of Web Publication16-Nov-2022

Correspondence Address:
Dr. Rajesh Sisodiya
Department of Surgery, Burjeel Hospital, Maysaloon, Sharjah
United Arab Emirates
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjl.sjl_2_21

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Advances in minimal access surgery have led to the emergence of single-incision laparoscopic surgery. Single-incision laparoscopic fundoplication for gastroesophageal reflux disease is safe and feasible in experienced hands. However, the main drawback of this technique is the increased cost factors considering the port devices and specialized instrumentation required. We did single-incision, multiple port laparoscopic Nissen fundoplication with conventional trocars and instruments.

Keywords: Gastroesophageal reflux, Grade C esophagitis, single-incision multiport laparoscopic fundoplication

How to cite this article:
Sisodiya R, Sankaran RJ, Eraki M, Reddy J, Rajkumar S, Rajkumar A. Single-site, multiple port, antireflux laparoscopic fundoplication is a feasible cost-effective technique: The first case report in the United Arab Emirates. Saudi J Laparosc 2022;7:18-20

How to cite this URL:
Sisodiya R, Sankaran RJ, Eraki M, Reddy J, Rajkumar S, Rajkumar A. Single-site, multiple port, antireflux laparoscopic fundoplication is a feasible cost-effective technique: The first case report in the United Arab Emirates. Saudi J Laparosc [serial online] 2022 [cited 2023 Jun 9];7:18-20. Available from: https://www.saudijl.org/text.asp?2022/7/1/18/361353

  Introduction Top

A 45-year-old male underwent laparoscopic antireflux surgery through single-site, multiple port technique. He underwent a complete workup for severe symptomatic gastroesophageal reflux disease (GERD), and when offered stealth surgery, consented. Accordingly, he underwent successful single-incision laparoscopic Nissen fundoplication with crural repair, remains symptoms arand with a smooth postoperative recovery.[1]

  Case Report Top

A 45-year-old Indian National had been suffering from severe symptoms of heartburn, regurgitation, and change in voice, for 3 years. A previous endoscopy, 1 year back, had shown a hiatus hernia with Grade C esophagitis, in the lower third of the esophagus. There were no changes in Barrett's. His Helicobacter pylori test was repeatedly negative. He was on several courses of proton-pump inhibitors (PPIs) for the past 3 years, each for a period of 6 weeks.

Preoperative upper GI endoscopy showed severe esophagitis in the lower 5 cm of the esophagus. No definite hiatus hernia was made out.

The Z-line was found at 36 cm, and the diaphragmatic impression was found at 39 cm from the incisor teeth.

The patient was offered a 24-h pH study and an impedance; however, due to financial reasons, he preferred not to do the same, opting instead for insurance to the surgical management directly.

Surgical options

We discussed both the multiport laparoscopic conventional fundoplication and the alternative single-incision, multiport fundoplication. The patient was keen on undergoing a scarless kind of surgery.

With a clear informed consent that there would be, if the situation demanded, a conversion to multiport procedure, with one or more additional ports, we proceeded with the planned single-incision, multiport fundoplication.

Operative technique

The circumference of the umbilicus was used, and a curved incision running from 8 o'clock to 4 o'clock was created. The skin was incised, and a 2- to 3-cm flap was raised on the sheath superiorly and both sides [Figure 1].
Figure 1: Shows supraumbilical incision with space created above rectum sheath for three port insertion

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After the Veress needle pneumoperitoneum was created, three 5-mm ports were inserted in the following positions. An optical port, 5 mm, was put 3 cm above the superior circumference of the umbilicus. The left-hand and right-hand working ports were put in the 9 o'clock and the 3 o'clock positions, respectively, both of 5 mm [Figure 2]. A 1.8-mm incision hole was made in the subxiphoid area, and the laparoscopic instrument insert was put for retraction of the left lobe of the liver.
Figure 2: In operative technique

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The patient was put in the steep Trendelenburg position, and the dissection was first commenced in the pars flaccida of the gastrohepatic ligament and continued until the right crus was exposed. Then, the border between the right crus and the right edge of the esophagus was further defined, and the esophagus was gently lengthened into the abdominal cavity. The vagus nerve was identified and preserved. The posterior vagus nerve was identified and preserved. The retroesophageal window, between the anterior surface of the left crus, and the posterior vagus nerve was developed by a combination of blunt and sharp dissection. After the entire left crus was dissected out, the patient was rotated into a steep left side-up position, and dissection was commenced in the upper one-third of the gastrosplenic ligament. The short gastric vessels were taken down with the LigaSure. The dissection was proceeded with, and the left crus was exposed. Dissection of the phrenoesophageal ligament exposed the left crus completely. An umbilical tape was passed behind the esophagus to emerge anterior to the left crus on the left side. This was given traction by a suture passer, which was used to bring in the needle and the thread for the crural suturing. With traction on the umbilical tape and retraction of the left lobe of the liver with the insert, the left and right crura were approximated with sutures of 1/0 polypropylene. Then, the posterior aspect of the fundus was approached through the retroesophageal window and brought to the right of the esophagus. Fundofundal sutures were performed, again with 1/0 polypropylene sutures, and the fundoplication was completed with the gastric calibration tube being pushed into the stomach.

The entire operation took 112 min. There was no hemorrhage during the procedure, and the only ergonomic difficulty was the freeing of the stomach from the spleen, in the upper reaches of the gastrosplenic ligament. The patient had a smooth postoperative period and was discharged on the second postoperative day.

At the follow-up, he is not on PPIs and has minimal dysphagia to solid food. (1-month follow-up)

  Discussion Top

Hamzaoglu et al. performed the first single-incision laparoscopic surgery (SILS) Nissen in 2010.

A publication by Hamzaoglu, of the so-called Istanbul technique, reported a new method of retraction of the liver in totally laparoscopic single-port Nissen Fundoplication.[2]

However, most SILS utilized expensive single-port device, either a gel port, R Port, or frequently, the SILS port from Covidien and specialized articulating instruments.[3]

Several studies comparing SI laparoscopic fundoplication to the conventional multiport approaches reported an increased operation duration and high rates of multiport conversion and incisional hernia.[4]

SILN + 1 can be performed entirely same as the conventional fashion, and its cosmetic outcome is permissible; it seems that SILN + 1 (Single-incision laparoscopic Nissen fundoplication with thin additional hole) is superior to P-SILN (pure single-incision laparoscopic Nissen fundoplication).[5]

Single-incision Nissen fundoplication cost can be reduced with the use of conventional laparoscopic instruments and the direct multipuncture technique.[6] In this case, we have utilized the regular laparoscopic instruments and the regular trocars, without the need for a special device for the single-port insertion. The retractor for the left lobe of the liver was the 1.8-mm insert of the laparoscopic instruments, again available in the standard set of laparoscopic instruments.

In this technique of single-incision, multiport laparoscopic Nissen fundoplication, we have shown that with standard instruments, at no extra cost (except for the increase in operating room time), this procedure is technically feasible.

The ease with which PPIs were available for long-term use is going to be negatively impacted by the new studies indicating interstitial nephritis and kidney damage in patients on long-term PPIs. Patients suffering from severe and unrelenting GERD symptoms will, therefore, prefer to have a laparoscopic fundoplication, then accept long-term proton-pump inhibition. In this context, if the procedure can be performed scarlessly and with less pain, they would certainly be a large move toward this type of surgery.

  Conclusion Top

A single-incision, multiport, transumbilical, totally laparoscopic floppy Nissen fundoplication is a feasible, cost effective, and safe technique using conventional laparoscopic instruments in expert hands.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sharp NE, Vassaur J, Buckley FP 3rd. Single-site Nissen fundoplication versus laparoscopic Nissen fundoplication. JSLS 2014;18:e2014.00202.  Back to cited text no. 1
Hamzaoglu I, Karahasanoglu T, Aytac E, Karatas A, Baca B. Transumbilical totally laparoscopic single-port Nissen fundoplication: A new method of liver retraction: The Istanbul technique. J Gastrointest Surg 2010;14:1035-9.  Back to cited text no. 2
Pafitanis G, Loizides S, Patel B. The effect of different single ports on performance in single-incision laparoscopic surgery. J Surg Simul 2015;2:6-11.  Back to cited text no. 3
Perivoliotis K, Sarakatsianou C, Tepetes K, Baloyiannis I. Single incision laparoscopic fundoplication: A systematic review of the literature. World J Gastrointest Surg 2019;11:179-90.  Back to cited text no. 4
Tanoue K, Okino H, Nozoe Y, Kanazawa M, Ueno K. Single Incision Laparoscopic Nissen Fundoplication in 11 Patients with GERD. Ueno Hospital, Fukuoka, Japan. Sages; 2012.  Back to cited text no. 5
Palanivelu C, Senthilnathan P, Praveen Raj P, Parthasarthi R, Rajan PS, Vaithiswaran V. Single Incision Laparoscopic Fundoplication-Using Conventional Trocars and Instruments. GEM Hospital & Research Centre, SAGES; 2012.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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