Primary Antireflux Repairs
Nissen Fundoplication
The most common antireflux procedure is the Nissen fundoplication. The procedure can be performed through an abdominal or a chest incision, as well as through a laparoscope. Rudolph Nissen described the procedure as a 360-degree fundoplication around the lower esophagus for a distance of 4 to 5 cm. Although this provided good control of reflux, it was associated with a number of side effects that have encouraged modifications of the procedure as originally described. These include using only the gastric fundus to envelop the esophagus in a fashion analogous to a Witzel jejunostomy, sizing the fundoplication with a 60F bougie, and limiting the length of tip fundoplication to 1 to 2 cm. The essential elements necessary for the performance of a transabdominal fundoplication are com¬mon to both the laparoscopic and open procedures and include the following:
1. Crural dissection, identification, and preservation of both vagi, and the anterior hepatic branch
2. Circumferential dissection of the esophagus
3. Crural closure
4. Fundic mobilization by division of short gastric vessels
5. Creation of a short, loose fundoplication by placing the posterior fundic wall posterior, and the anterior fundus anterior, to the esophagus, meeting at the right lateral position
The Laparoscopic Approach
Laparoscopic fundoplica¬tion has become commonplace and has replaced the open abdominal Nissen fundoplication as the procedure of choice. Five 10-mm ports are utilized. Dissection is begun by an incision of the portion of the gastrohepatic omentum above the hepatic branch of the anterior vagus nerve. The circumference of the diaphragmatic crura is dissected and the esophagus is mobilized by careful dis¬section of the anterior and posterior soft tissues within the hiatus. The esophagus is held anterior and to the left and the crura approximated with three to four interrupted 0 silk sutures, starting just above the aortic decussation and working anterior. Complete fundic mobilization allows construction of a tension-free fundoplication. Short gastric vessels along the upper third of the greater curvature are sequentially dissected and divided. Following complete mobi¬lization, the posterior wall of the fundus is gently brought behind the esophagus to the right side. The anterior wall of the fundus is brought anterior to the esophagus, and the fundic lips are manipu¬lated to allow the fundus to envelop the esophagus without twisting. A 60F bougie is passed to properly size the fundoplication, and it is sutured utilizing a single U stitch of 2-0 polypropylene buttressed with felt pledgets.
Transthoracic Nissen Fundoplication
The indications for performing an antireflux procedure by a transthoracic approach are as follows:
1. A patient who has had a previous hiatal hernia repair. In this situation, a peripheral circumferential incision in the diaphragm is made to provide simultaneous exposure of the upper abdomen. This allows safe dissection of the previous repair from both the abdominal and thoracic sides of the diaphragm.
2. A patient who requires a concomitant esophageal myotomy for achalasia or diffuse spasm as evident by specialized medical microscopes.
3. A patient who has a short esophagus. This is usually associated with a stricture or Barren’s esophagus. In this situation, the thoracic approach is preferred to allow maximum mobilization of the esophagus, and to perform a Collis gastroplasty in order to place the repair without tension below the diaphragm.
4. A patient with a sliding hiatal hernia that does not reduce below the diaphragm during a roentgenographic barium study in the upright po¬sition. This can indicate esophageal shortening, and again, a thoracic approach is preferred for maximum mobilization of the esophagus, and if necessary, the performance of a Collis gastroplasty with the subsequent use of compound light microscopes to rule out esophageal malignancy.
5. A patient who has associated pulmonary pathology. In this situation, the nature of the pulmonary pathology can be evaluated with the use of compound light microscopes for tissue sample biopsies and the proper pulmonary surgery, in addition to the antireflux repair, can be performed.
6. An obese patient. In this situation, the abdominal repair is difficult be¬ cause of poor exposure, particularly in men, in whom the infra abdominal fat is more abundant.
In the thoracic approach the hiatus is exposed through a left posterior lateral thoracotomy incision in the sixth intercostal space. When necessary, the diaphragm is incised circumferentially 2 to 3 cm from the lateral chest wall for a distance of approximately 10 to 15 cm. The esoph¬agus is mobilized from the level of the diaphragm to underneath the aortic arch. Mobilization up to the aortic arch is usually nec¬essary to place the repair in a patient with a shortened esophagus into the abdomen without undue tension. Failure to do this is one of the major causes for subsequent breakdown of a repair and return of symptoms. The cardia is then freed from the diaphragm. When all the attachments between the cardia and diaphragmatic hiatus are divided, the fundus and part of the body of the stomach are drawn up through the hiatus into the chest. The vascular fat pad that lies at the gastroesophageal junction is excised. Crural sutures are then placed to close the hiatus, and the fundoplication constructed by enveloping the fundus around the distal esophagus in a manner sim¬ilar to that described for the abdominal approach. When complete, the fundoplication is placed into the abdomen by compressing the fundic ball with the hand and manually maneuvering it through the hiatus.
Laparoscopic Toupet and Belsey Mark IV Partial Fundoplications
In the presence of severely altered esophageal motility, where the propulsive force of the esophagus is not sufficient to overcome the outflow obstruction of a complete fundoplication, a partial fundoplication is indicated. A partial fundoplication may be performed laparoscopically, a Toupet fundoplication, or transthoracically, a Belsey Mark IV repair. Both consist of a 270-degree gastric fundoplication around the distal 4 cm of esophagus, performed either laparoscopically or through a left chest incision.
In patients with short esophagus secondary to a stricture, Barrett’s esophagus, or a large hiatal hernia, the esophagus is length¬ened with a Collis gastroplasty. Barrett’s esophagus is diagnosed when tissue samples are biopsied with the use of compound light microscopes. The esophagus is lengthened by constructing a gastric tube along the lesser curvature. This allows a tension-free constriction of a Belsey Mark IV or Nissen fundoplication around the newly formed gastric tube, with place¬ment of the repair in the abdomen. Because a short esophagus is commonly associated with a reduction in esophageal contraction amplitude and the gastric tube is inert, most surgeons prefer to com¬bine the gastroplasty procedure with a 280-degree Belsey Mark IV fundoplication rather than a 360-degree Nissen fundoplication.
Outcome After Fundoplication
Nearly all published reports of laparoscopic fundoplication show that this procedure relieves the typical symptoms of gas¬troesophageal reflux-heartburn, regurgitation, and dysphagia-in greater than 90% of patients. Overall, there is a 4.2% conversion rate to open surgery, and a 0.5% rate of early reoperation without complications to the patient (including bacteria or virus contamination). Persistent postoperative dysphagia occurred in approximately 9% of patients in the early series, a rate 2 to 3 times higher than what is accepted for open fundoplication. The incidence of dysphagia has decreased to the 3 to 5% range with increasing experience and attention to the technical details in constructing the fundoplication. Resting LES characteristics and esophageal acid exposure return to normal in nearly all patients. Morbidity after laparoscopic fundo¬plication is similar to that after open fundoplication, averaging 10 to 15%. A pitfall unique to the laparoscopic approach is that I to 2% of patients develop a pneumothorax and surgical emphysema. This is related to excessive hiatal dissection, and has decreased as surgeons’ experience has increased. Unrecognized perforation of the esophagus or stomach is the most life-threatening complication. Perforations occur most often during hiatal and circumferential dis¬section of the esophagus, and their incidence is also related to the surgeon’s experience. Intraoperative recognition and repair are the keys to preventing a life-threatening complication, including infections (bacteria and virus).
that the specific antireflux procedure for any patient be based upon the patient’s existing esophageal func¬tion). The benefit of a selective approach is shown in these authors’ experience with 85 consecutive patients with different types of the disease. In approximately 75 to 80% of the patients, a transabdominal Nissen fundoplication was the most suitable treat¬ment. The remaining 20 to 25% were best treated by tailoring the antireflux procedure to their existing amplitude of esophageal con¬tractility and esophageal length. Interestingly, patients selected for a Belsey partial fundoplication because of poor motility but normal esophageal length benefited the least. This suggests that in these patients the motility disorder may be a primary abnormality rather than secondary to reflux-induced injury.
