Laparoscopic Nissen Fundoplication

This is the case of a 63-year-old man with a long-standing history of gastroesophageal reflux disease, refractory to medical management with high-dose proton pump inhibitors and H₂-blockers. The preoperative workup consisted of: 1) an upper endoscopy, which was normal; 2) a barium swallow, which showed a normal anatomy (no hiatal hernia or diverticula); and 3) esophageal function tests, including high-resolution esophageal manometry, which showed normal peristalsis, and 24-hour pH monitoring, which confirmed the presence of gastroesophageal reflux disease. Considering the amount of pathologic reflux, and the normal anatomy and esophageal peristalsis, it was decided to proceed with a laparoscopic Nissen (360°/total) fundoplication. The operation went well and lasted less than 90 minutes. The patient was discharged the following morning after resuming a light diet, and recovered quickly. With this surgical approach, complete control of reflux was achieved, and the patient was able to discontinue his treatment with proton pump inhibitors.

The patient is a 63-year-old man with a history of refractory gastroesophageal reflux disease (GERD), which was managed conservatively with high-dose proton pump inhibitors (PPIs) and H₂-blockers. Considering the persistence of symptoms, such as heartburn and regurgitation, he was sent for further workup.

This is the case of a patient with GERD refractory to high-dose medical treatment. As suggested by the Esophageal Diagnostic Advisory Panel Consensus, we performed the following workup:^1-9

1. An upper endoscopy, which was normal.
2. A barium swallow, which showed normal anatomy (no hiatal hernia or diverticula).
3. Esophageal function tests, including high-resolution esophageal manometry (HRM), which showed normal peristalsis, and 24-hour pH monitoring, which confirmed the presence of GERD.

Although the vast majority of patients with GERD have a normal physical exam and are diagnosed through an upper endoscopy and/or pH monitoring, they may present with epigastric pain and pharyngeal erythema. In addition, they may present with typical symptoms, such as heartburn, dysphagia, and regurgitation, and atypical symptoms, such as globus sensation, chronic cough, and hoarseness.^{2, 5, 6, 7}

In 2012, at Digestive Disease Week in San Diego, world-renowned experts who manage GERD, including gastroenterologists and surgeons, were assembled as the Esophageal Diagnostic Advisory Panel to achieve a consensus on the preoperative diagnostic evaluation before anti-reflux surgery. According to the recommended testing suggested by this panel, we performed the following workup:⁹

1. An upper endoscopy.
2. A barium swallow.
3. High-resolution esophageal manometry.
4. pH testing.

The primary treatment option for GERD is medical therapy, with PPIs and/or H₂ receptor antagonists. Despite adequate acid suppression, some patients present with persistent symptoms. Anti-secretory medications may reduce or eliminate symptoms, such as heartburn, by increasing gastric pH; however, this therapy does not address the anatomical defect, and some episodes of weak acidic esophageal exposure may endure. A poorly-treated GERD may lead to Barrett’s esophagus, a precancerous condition, which can ultimately develop into esophageal adenocarcinoma. The goal of anti-reflux surgery (total or partial fundoplication) is to recreate a unidirectional valve between esophagus and stomach, resolving reflux and achieving symptomatic resolution.^5, 8

The following are the options currently available to treat GERD:

• Lifestyle modifications: Elevate the head of the bed and avoid late-night meals; avoid alcohol, tobacco, and some foods, such as chocolate, coffee and carbonated beverages; weight loss for overweight/obese patients.
• Medical therapy: H₂ antagonists and PPIs have been the mainstay of therapy for the last 20 years. Today, PPIs are preferred because they are more effective in alleviating symptoms.
• Endoscopic therapy: Over the last 20 years, many different types of endoscopic devices have been used to treat GERD, but most of them have been removed from the market because of a lack of safety or because they were not effective. At the present time, only the radiofrequency ablation of the lower esophageal sphincter (LES) and the endoscopic suturing of the LES (transoral incisionless fundoplication) are used. Both procedures require a very careful patient selection, excluding patients with hiatal hernia, esophageal motility disorders, Barrett’s esophagus, esophagitis, esophageal stricture, and obese patients.
• Surgery: Preoperative workup and patient selection are critical to achieve good outcomes. As of today, the most commonly performed procedures are:
• Laparoscopic Nissen (360°/total) fundoplication: Primarily for patients with normal esophageal peristalsis.
• Laparoscopic Dor (anterior) or Toupet (posterior) partial fundoplication: Reserved for patients with GERD associated with esophageal motility disorders.
• Roux-en-Y gastric bypass (RYGB): In morbidly obese patients fundoplication has an increased risk of failure. Therefore, a RYGB is the procedure of choice, as it achieves both weight and reflux control.

A poorly-treated GERD may lead to Barrett’s esophagus, a precancerous condition that can ultimately develop into esophageal adenocarcinoma. GERD control can be achieved with a medical management. However, for refractory GERD, further workup and a surgical intervention is recommended in order to achieve resolution and avoid progression to cancer.

This is the case of a patient who complained of refractory heartburn and regurgitation. He was placed on acid-reducing medications for years, but was still symptomatic. Before considering him for surgery, he underwent the following workup:

• Barium swallow: It provides important anatomical information, such as the presence of esophageal strictures or hiatal hernia.
• Upper endoscopy: It helps confirming the diagnosis and also provides more detailed information, such as presence of esophagitis, ulcers, strictures, and cancer.
• HRM: It facilitates the proper placement of the pH monitoring probe and excludes the presence of achalasia or other esophageal motility disorders.
• 24-hour pH monitoring: It is considered the gold standard for the diagnosis of GERD. It is possible to quantify the amount of reflux and to correlate the episodes of reflux with symptoms.

All these tests were performed according to the general guidelines that were set forth in 2012 by the Esophageal Diagnostic Advisory Panel. Once the workup was complete, we took the patient to the operating room.

The patient lies supine on the operating table in low lithotomy position with the lower extremities extended on stirrups with knees flexed 20–30°. A foam bed is used to avoid sliding of the patient. An orogastric tube is placed to decompress the stomach. The surgeon stands between the patient's legs, while first and second assistants stand on the right and left side respectively. A 5-trocar technique is used for this procedure: the first trocar is placed 14 cm inferior to the xiphoid process, in the midline, for a 30-degree scope; a second trocar is placed in the left midclavicular line, at the same level with the first trocar, to introduce a Babcock clamp; a third trocar can be placed in the right midclavicular line, at the same level of the other 2 trocars, and can be used for the insertion of a retractor to lift the liver; a fourth and a fifth trocar are placed under the right and left costal margins and they are used for the dissecting and suturing instruments. Excluding placement and removal of trocars, we can consider 7 major steps for this surgery:

1. Division of gastrohepatic ligament; identification of the right crus of the diaphragm and posterior vagus nerve.
2. Division of peritoneum and phrenoesophageal membrane above the esophagus; identification of the left crus of the diaphragm and anterior vagus nerve.
3. Division of short gastric vessels.
4. Creation of a window between gastric fundus, esophagus, and diaphragmatic crura; placement of a Penrose drain around the esophagus, incorporating anterior and posterior vagus nerves.
5. Closure of the crura with interrupted 2-0 silk suture.
6. Insertion of the bougie (56 Fr) into the esophagus and across the esophageal junction.
7. Wrapping of gastric fundus around the lower esophagus; the 2 edges of the wrap are secured by three 2-0 silk interrupted sutures placed 1 cm away from each other. The wrap should be no longer than 2–2.5 cm.

The operation went well and lasted less than 90 minutes. The patient was discharged the following morning, after resuming a light diet, and recovered quickly. With this surgical approach we were able to achieve complete control of reflux, and the patient was able to discontinue his treatment with PPIs.

• Minor surgical tray
• Laparoscopic tray:
• 5- or 10-mm 30° laparoscope
• 5- and 12-mm trocars
• Grasping instruments: atraumatic, fenestrated, Babcock-type, toothed, curved dissecting (Maryland), curved 45-degree and 90-degree forceps
• Suction and irrigation kit
• Dissecting scissors (Metzenbaum)
• Needle holders
• Other laparoscopic devices:
• Hasson blunt port system
• Endo Stitch suturing device
• Nathanson liver retractor or Endo Retract 10 mm
• 0.25-inch Penrose drain
• Electrosurgical instruments: monopolar (hook, EndoShears, etc.), ultrasonic device (LigaSure, Harmonic scalpel, UltraCision, etc.)
• Clip applier
• Endoscopic Kittner
• Maloney tapered Tungsten-filled esophageal bougie 56 Fr
• Carter-Thomason laparoscopic port-site closure system

No disclosures.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.