Preprocedural Planning
Empiric medical therapy for gastroesophageal reflux disease (GERD) using proton pump inhibitors (PPIs) is typically initiated with symptoms of dyspepsia. [30] Further testing is indicated in patients who have ongoing symptoms despite appropriate medical management, warning symptoms (dysphagia, anemia, guaiac-positive stools), or atypical symptoms, as well as in any patient in whom the diagnosis remains unclear. Diagnostic testing is also indicated before surgical intervention.
Patients with typical symptoms of GERD should have at least one additional positive objective test for diagnostic purposes. Patients with atypical symptoms should have at least two positive objective tests for diagnosis.
It is essential to obtain a detailed history and physical examination. Clinical predictors of response to antireflux surgery are lacking; thus, a thorough preoperative evaluation is needed for appropriate patient selection to ensure the best clinical outcome. [31] Before surgical intervention, patients must undergo testing to ensure objective evidence of GERD.
Patients may undergo anatomic testing, physiologic testing, or both. Anatomic examination includes the use of esophagogastroduodenoscopy (EGD) with or without biopsy and contrast radiography (eg, upper gastrointestinal [GI] series). Physiologic examination includes 24-hour esophageal pH assessment, intraluminal impedance monitoring, gastric emptying testing, Bernstein acid test, and esophageal manometry.
Anatomic examination
Esophagogastroduodenoscopy
EGD can be used to visualize evidence of reflux esophagitis. Lundell et al confirmed GERD in patients with typical symptoms accompanied by endoscopic evidence of a mucosal break defined as "an area of slough or erythema clearly demarcated from adjacent normal-appearing mucosa." [32] Endoscopic evidence of biopsy-proven benign peptic stricture or Barrett esophagus is also considered evidence of GERD. [32] EGD can be used to obtain biopsies, which may help to determine the extent of esophagitis, Barrett esophagus, or other pathology. Interestingly, EGD may yield normal findings in as many as 70% of patients with GERD.
Contrast radiography
An upper GI series may be useful for anatomic delineation of the esophagogastric junction (EGJ) in relation to the hiatus. This facilitates detection of hiatal hernias, strictures, or shortened esophagus. Esophageal peristalsis can also be qualitatively assessed. [23]
Physiologic examination
24-Hour pH testing
Although pH testing is considered the criterion standard for diagnosis of GERD, routine use may be of only marginal benefit. This test is best used in the absence of endoscopic evidence of reflux or when the diagnosis is unclear. [33] This tests allows the physician to quantify the number and duration of reflux episodes, differentiate between upright and supine reflux, and correlate these events with subjective symptoms. Either 24-hour ambulatory esophageal pH-metry or the 48-hour wireless esophageal pH-monitor probe can be used.
Esophageal manometry
Esophageal manometry is a test of the function of the esophagus evaluating peristalsis and lower esophageal sphincter (LES) pressure. Specifics about LES length, location, and tone can be characterized. This test also helps to diagnose underlying motility disorders, which may be a contraindication for fundoplication.
Some discrepancies exist in the literature supporting preoperative manometry. Many physicians advocate preoperative manometry, noting that approximately 10% of manometry findings alter surgical planning. [33] A study by Kapadia et al found that inadequate LES relaxation with swallowing, signaled by elevated integrated relaxation pressure (IRP) on preoperative high-resolution manometry, was a significant predictor of worse long-term postoperative outcomes (eg, dysphagia). However, no literature supports mandatory preoperative manometry. Manometry may be considered in patients who do not respond to empiric medical treatment and have normal findings on endoscopy. [34, 35, 36]
Impedance monitoring
Impedance monitoring helps in the evaluation of esophageal motility and function by assessment of directional bolus transit within the esophagus. This test is particularly helpful in evaluation of nonacidic reflux. [37]
Gastric emptying test
Gastric emptying tests may be considered in patients who have a history of diabetes, severe nausea or vomiting, or postprandial bloating. In addition, this study may be helpful in cases of reoperation. Gastric emptying studies should not be routinely ordered, because there is only limited evidence in the literature to support the correlation of gastric emptying test results with postoperative outcomes from fundoplication.
Equipment
Standard laparoscopic equipment is needed, in addition to atraumatic graspers and a laparoscopic needle driver. Five trocars are commonly used. The authors prefer to use either one 10-mm trocar and four 5-mm trocars or five 5-mm trocars, depending on the insertion technique chosen. An angled or articulating laparoscope is ideal.
An atraumatic liver retractor is necessary to elevate the liver for exposure of the hiatus. A self-restraining device is needed to hold the liver retractor if an additional assistant is not available. An appropriately sized bougie may be used by some surgeons.
A coagulation device of choice (monopolar, bipolar, or ultrasonic) should be available. A flexible endoscope should be available for emergency use, should the need arise need for endoscopic evaluation of the esophagus or stomach. A curved instrument of choice or Penrose drain can be used to encircle the esophagus.
Patient Preparation
Anesthesia
General endotracheal anesthesia will be used. As in all laparoscopic procedures, adequate muscle relaxation is essential for establishment of pneumoperitoneum and exposure. A nasogastric or orogastric tube is often placed to assist in decompression of the stomach during the procedure.
It has been suggested that perioperative supplementation with high-concentration oxygen during laparoscopic Nissen fundoplication may reduce the postoperative inflammatory response and possibly help avoid postoperative immunosuppression. [38]
A Mayo Clinic study of 448 patients undergoing laparoscopic Nissen fundoplication compared a newer treatment protocol consisting of total intravenous anesthesia (TIVA) plus triple antiemetic therapy (n = 54) with standard inhalational anesthesia (n = 394) to assess the potential effect of TIVA on hospital length of stay (HLOS). [39] TIVA was significantly associated with reduced HLOS and a 7.8% reduction in cost of care. Female sex, length of surgery, and older age all were negatively associated with HLOS.
Positioning
Patients are placed in the lithotomy position with legs either in stirrups or abducted on split leg holders. Some surgeons use a beanbag for patient positioning. The bed should be placed into the reverse Trendelenburg position to displace the bowel inferiorly. Monitors are placed at the head of the bed. The surgeon is positioned between the patient's legs, the first assistant is on the patient's left, and the camera driver is on the patient's right.
Monitoring & Follow-up
Patients are most commonly discharged on postoperative day 1. The authors recommend that patients abstain from lifting anything heavier than 10 lb for 4 weeks postoperatively. Patients are seen in the clinic 1-4 weeks postoperatively, depending on the surgeon's preference.
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Laparoscopic Collis-Nissen fundoplication. Video courtesy of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).
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Nissen-Rossetti modified fundoplication.
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Lower esophageal sphincter.
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Original Nissen fundoplication as described by Dr Rudolf Nissen.
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Port placement for laparoscopic Nissen fundoplication.
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Laparoscopic Nissen fundoplication. View of hiatus after insertion of liver retractor.
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Laparoscopic Nissen fundoplication. Division of gastrohepatic ligament.
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Laparoscopic Nissen fundoplication. Penrose drain is placed around esophagogastric junction to retract it anteriorly and laterally to allow improved visualization of hiatus.
