Laparoscopic Fundoplication with the FreeHold Trio Retractor - Case Study

Management of GERD can be divided into life-style modifications, and medical and surgical treatments3. The surgical approaches for GERD include open surgery, laparoscopic surgery and endoscopic interventions. Dr. Rudolf Nissen (1896-1981) was the first one to describe the first fundoplication in the 1950s for the treatment of severe reflux esophagitis. The original procedure has been modified on multiple occasions, but the basic principles have remained the same. Laparoscopic Nissen fundoplication has been shown to have advantages over the open approach, including improved cosmesis. reduced morbidity, shorter hospital stay, decreased respiratory complications, and faster recovery4. In addition, long-term outcomes after laparoscopic Nissen fundoplication are comparable to those after open surgery4-5. Laparoscopic Nissen fundoplication is now considered the standard surgical approach for the treatment of severe GERD4-5.

Over the last 15 years, there has been an impetus to develop even smaller and less invasive techniques compared to traditional laparoscopic surgery. I have dedicated my professional life to the advancement of minimally invasive surgical approaches. We have been one of the early adopters of mini-laparoscopy surgery, also known as micro-laparoscopy or needlescopic surgery, which uses 3mm or smaller ports and instruments instead of the traditional 5- and 10-12mm ones.

Here we describe the use of a hands-free intracorporeal organ retractor system (FreeHold Trio1") for liver retraction during Minilaparoscopic Nissen Fundoplication obviating the need for a mechanical retractor and of an additional incision.

Pathophysiology of GERD
Gastroesophageal reflux disease is not the result of acid overproduction. It is due to mechanical dysfunction in the region around the lower esophageal sphincter (LES) leading to failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus4. Other factors leading or contributing to GERD are a gastric emptying disorder or failed esophageal peristalsis4. Long standing reflux may ultimately lead to esophageal tissue damage with or without further complications including malignancy or airway disease4. The exact composition of the antireflux barrier has not been completely elucidated, it is clear the LES. phrenoesophageal ligament and diaphragmatic crura are essential components7.