Laparoscopic control of short gastric vessels

The Nissen fundoplication is currently the most commonly performed antireflux surgery whether performed as an open procedure or through the laparoscope. Extensive experience with open Nissen fundoplication has shown that dividing the short gastric vessels to mobilize the fundus ensures that the wrap will be loose and without tension. The standard laparoscopic technique for fundal mobilization is dissecting out the short gastric vessels, applying hemoclips, and then dividing them. For surgeons new to laparoscopic surgery, this can be an intimidating task. Introduction of the ultrasonic coagulating shears, a new energy source technology, offered the possibility of making this process quicker and easier.

We present a randomized prospective study comparing two methods of ligating the short gastric vessels during laparoscopic fundoplication. Thirty-one patients were enrolled and randomized into two groups: those who underwent short gastric ligation by dissection, clipping, and dividing, and those in whom the ultrasonic laparoscopic coagulating shears were used. The results were tabulated and subjected to statistical analysis.

Fifteen patients had laparoscopic fundoplication with ligation of the short gastric vessels by using clips and 16 by using the ultrasonic coagulating shears. There was no demographic difference between the two groups and the number of short gastric vessels ligated was the same in both groups. Significance was seen for the median operating time for short gastric control (22 minutes for clipping versus 12 minutes for coagulating shears), median blood loss (70 mL for clipping versus 2.5 mL for the ultrasonic coagulating shears), and technical difficulty (93 percent with clipping versus 19 percent with the coagulating shears).

Based on the results from this randomized prospective study, the ultrasonic coagulating shears are easier to use and less prone to intraoperative "complications" and postoperative morbidity. We believe that this new technology will make it easier and more desirable for surgeons to mobilize the gastric fundus during laparoscopic fundoplication.