Laparoscopic Nissen Fundoplication

Laparoscopic Nissen fundoplication is now considered the standard surgical approach for treatment of severe gastroesophageal reflux disease (GERD).[1] GERD is increasingly prevalent and costly, and it may affect as much as 20% of the US population.[2]

The pathophysiology of GERD is due not to acid overproduction but, rather, to mechanical dysfunction centered around the lower esophageal sphincter (LES). Furthermore, the mainstay of GERD treatment, proton pump inhibitors (PPIs), have come under scrutiny because of worrisome side effects.[3, 4] Laparoscopic magnetic sphincter augmentation of the LES has been proposed as an additional surgical option. Like Nissen fundoplication, it relies on 360° buttressing of the LES, but it may cause fewer long-term adverse effects.[5, 6]

Dr Rudolf Nissen (1896-1981) described the first fundoplication in the 1950s for treatment of severe reflux esophagitis. His original procedure used a 360° wrap of the fundus of the stomach around the esophagus by plication of both the anterior and posterior walls of the gastric fundus around the lesser curvature. Although the standard Nissen fundoplication has been modified many times, laparoscopic Nissen fundoplication is now considered the standard surgical approach for treatment of GERD.[1]

There has been considerable debate about the relative efficacies of antireflux surgery and medical treatment. A systematic review concluded that the two treatment approaches were of similar efficacy.[7] Some of the literature has suggested that long-term outcomes from antireflux surgery may be superior to those of medical treatment.[8, 9]  In appropriately selected patients, laparoscopic reflux surgery may be more cost-effective than lifelong medical treatment.[10, 11]

The 2022 guidelines from the American College of Gastroenterology (ACG)[12]  stated that "modern medical antireflux therapy and laparoscopic fundoplication seem to have similar efficacy in healing the symptoms and endoscopic signs of GERD.... Clearly, antireflux surgery is not a permanent cure for GERD in all patients as it was once touted to be, and the operation occasionally can have severe adverse effects. Nevertheless, most patients obtain long-term benefit from fundoplication, and patient satisfaction with successful surgery seems to be greater than that for chronic medical therapy."

Laparoscopic Nissen fundoplication may have advantages over the traditional open approach, including improved cosmesis, reduced morbidity, shorter hospital stay, decreased respiratory complications, and faster recovery.[13, 14, 15] ; however, it may also be associated with longer operating times.[14] With respect to subjective symptoms, long-term outcomes after laparoscopic Nissen fundoplication are comparable to those after open surgery.[16, 17, 18] Currently, the laparoscopic approach is favored over an open approach unless it is specifically contraindicated.

Robotic-assisted fundoplication was developed as a minimally invasive alternative to conventional laparoscopic fundoplication. A long-term (12 y) study by Lang et al found no significant differences between the two approaches with respect to postoperative symptoms, quality of life, or treatment failure; both were associated with a high rate of patient satisfaction.[19]

A transoral incisionless fundoplication (TIF) procedure has been developed[20]  and is considered to be an acceptable option in selected patients[21] ; however, it has not been shown to be superior to laparoscopic Nissen fundoplication.[22]

Indications for laparoscopic antireflux surgery include the following[12, 23] :

• Failure of medical management
• Need for long-term medical therapy
• Complications of GERD (eg, Barrett esophagus or peptic stricture)
• Patient preference (eg, desire for discontinuance of medical therapy because of quality-of-life concerns, financial concerns, or intolerance to medication)
• Extraesophageal manifestations (eg, asthma, hoarseness, cough, chest pain, aspiration)
• Juvenile esophagitis of long duration without spontaneous remission or refractory to medical management, esophagitis, failure to thrive, or pulmonary compromise
• Mixed and paraesophageal hernia
• Recurrent reflux or complications after previous antireflux surgical therapy

For pediatric patients, the 2018 guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) stated that antireflux surgery, including fundoplication, should be considered in infants and children who have GERD and one or more of the following[24] :

• Life-threatening complications (eg, apnea) after failure of optimal medical treatment
• Symptoms refractory to optimal therapy, after appropriate evaluation to exclude other underlying diseases
• Chronic conditions (eg, neurologic impairment, cystic fibrosis) with a significant risk of GERD-related complications
• Need for chronic pharmacotherapy for control of signs or symptoms of GERD

Magnetic sphincter augmentation

In 2012, the US Food and Drug Administration (FDA) approved the LINX Reflux Management System (Torax Medical, St Paul, MN), a magnetic sphincter augmentation (MSA) system designed to support the LES in much the same way as a fundoplication. Unlike a fundoplication, the device is dynamic, being made up of multiple interlinked titanium-coated rare-earth magnets. Results from initial clinical trials were promising, with a good safety profile, excellent control of reflux, and fewer of the adverse effects (eg, dysphagia, gas-bloat) that may accompany traditional fundoplication.[25, 26, 6]  Early long-term data are also promising.[27]

In some cases, removal of the device may become necessary. A laparoscopic technique for accomplishing this has been described.[28]

Contraindications for laparoscopic antireflux surgery include the following:

• Surgeon inexperience
• Inability to tolerate general anesthesia
• Inability to tolerate a laparotomy
• Advanced cardiopulmonary disease
• Uncorrectable coagulopathy
• Portal hypertension

Relative contraindications include previous upper abdominal surgery and severely shortened esophagus. Fundoplication (open or laparoscopic) should be avoided in morbidly obese patients (body mass index [BMI] >35 kg/m2) because of the high failure rates. Instead of fundoplication, gastric bypass should be considered in these patients. Nissen fundoplication should also be avoided in patients with esophageal motility disorders such as achalasia.

A double-blind randomized clinical trial by Analatos et al compared long-term (>15 y) outcomes of posterior partial fundoplication (PF; 270°) vs total fundoplication (TF; 360°) with respect to mechanical complications, reflux control, and patient quality of life.[29]

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.

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.

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.

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.

Numerous options exist for port placement during a laparoscopic Nissen fundoplication. The authors' preferred technique makes use of five ports, labeled A through E for ease of reference (see the image below).

Either of two techniques may be used to insert port A, which serves as the camera port. The first technique involves insertion of a 10-mm trocar via the Hasson technique in the supraumbilical location. The second, commonly used at the authors' facility, uses a 5-mm Optiview system (Ethicon, Norderstedt, Germany) to insert the supraumbilical trocar. Four 5-mm trocars are inserted subcostally under direct visualization, as follows:

• Port B is placed subcostally in the right midclavicular line
• Port C is placed subcostally just to the right of the midline
• Port D is placed subcostally just to the left of the midline
• Port E is placed subcostally in the left midclavicular line

An atraumatic liver retractor should be inserted into port B. This allows the left hemiliver to be retracted so as to expose the hiatus (see the image below). This retractor may be held by an assistant or a self-retaining system. Ports C and D are used for the dissection. Port E can be used as needed for insertion of various instruments, including graspers, clamps, and electrocautery.

The dissection is carried out in much the same fashion as in an open Nissen fundoplication. With the liver retractor inserted, the hiatus should now be visible. Typically, the left triangular ligament is left in situ, but it may be divided for further mobilization if needed. A laparoscopic atraumatic Babcock grasper may be inserted through port E to grasp the stomach or epiphrenic fat pad and retract it caudally.

The lesser omentum (also known as the gastrohepatic ligament) is opened above and below the hepatic branch of the anterior vagus nerve, which should be preserved (see the image below).

Dissection continues toward the diaphragm to expose the right crus. Blunt dissection should be used to separate the right crus from the esophagus. The posterior vagus nerve should be identified and preserved. The dissection can be continued superiorly over the anterior surface of the esophagus and down the left crus. Care should be taken to avoid a possible accessory left gastric artery running with the hepatic branch of the anterior vagus nerve.

The phrenoesophageal ligament is the reflection of the subdiaphragmatic fascia onto the transversalis fascia of the anterior abdominal wall (see the image below). This ligament is divided. The anterior vagus nerve should be identified and preserved.

To gain appropriate intra-abdominal esophageal length, it may be necessary to free up to 6 cm of the intrathoracic esophagus. All branches of the vagus nerves should be preserved. The anterior branches have numerous anatomic variations and are included in the fundoplication. Blunt dissection can be used to free the distal esophagus from its posterior attachments.

Once the esophagus has been freed circumferentially, a nylon tape, Penrose, or instrument can be inserted through port E and used to encircle the esophagus (see the image below). The esophagus can then be retracted anteriorly through to expose the posterior hiatus.

The hiatus should be dissected meticulously to delineate the diaphragmatic crus. The distal 6 cm of the posterior esophagus should be fully mobilized. Care should be taken to preserve the inferior phrenic artery; rarely, this vessel is damaged during mobilization of the anterior surface of the fundus. In approximately 5% of patients, the left inferior phrenic artery arises from the left gastric artery and runs along the edge of the right hiatal pillar. In this case, it must be ligated to facilitate hiatal mobilization.

Some surgeons elect to repair the hiatus as needed, whereas others repair it routinely. Sutures should be placed from posterior to anterior and should narrow the hiatus to approximately 2.5 cm in diameter. In patients without a hernia or with only a small hernia, one or two interrupted 0-0 nonabsorbable sutures will usually suffice; in those with larger hernias, more sutures may be needed. Sutures may be tied intracorporeally or extracorporeally, according to the surgeon's preference. Some surgeons may place additional sutures anteriorly or use mesh for repair of large hiatal hernias.

After hiatal repair, the surgeon should be able to freely insert a 10-mm instrument adjacent to the esophagus. Patterson et al recommended the use of a 56-French bougie across the esophagogastric junction (EGJ) during the hiatal repair and fundoplication to decrease the risk of postoperative dysphagia.[40] Other literature found equivalent outcomes without the use of bougies.[41, 42]

The Penrose drain/nylon tape or instrument used to encircle the esophagus may now be removed. Laparoscopic atraumatic Babcock forceps are used to grasp the fundus of the stomach and bring it behind the esophagus.

In the traditional Nissen fundoplication, the posterior and anterior walls of the stomach are united anteriorly around the gastric fundus to provide a complete 360º 4- to 5-cm wrap around the lower esophagus containing a large intraesophageal bougie (see the image below). One or two stitches should include the wall of the esophagus to prevent slippage of the cardia.

Notably, no division of the short gastric vessels occurs in the traditional Nissen fundoplication. Because of the side effects associated with the original Nissen fundoplication, several modifications have arisen.

In the Nissen-Rossetti modified fundoplication, the anterior wall of the fundus alone is used to construct a 360º wrap around the distal esophagus. Dividing the short gastric vessels was not recommended in the initial Nissen-Rossetti modification. However, if a tension-free wrap cannot be obtained, the short gastric vessels can be divided. The complete fundoplication should be 2-3 cm in length (see the image below).

DeMeester and Donohue described a floppy Nissen technique in which the short gastric vessels are divided.[43, 44] This can be accomplished by using insertion of an ultrasonic coagulation device through port D to come across these vessels. An atraumatic grasper should be used in port B to grasp the greater curvature of the stomach and apply countertraction.

A randomized trial aimed at evaluating late outcomes (up to 20 years' follow-up) of division vs no division of short gastric vessels during laparoscopic Nissen fundoplication found that division of the short gastric vessels did not yield any significant reduction in side effects and was associated with persistent epigastric bloating symptoms.[45]

After inspection of the abdomen to ensure hemostasis, all instruments and ports should be removed under direct visualization. The fascia of any 10-mm ports used should be closed with nonabsorbable sutures. The skin of all five ports may be closed with an absorbable suture in a subcuticular fashion.

The procedure for a laparoscopic Nissen fundoplication is shown in the video below.

Early postoperative complications

Complications after laparoscopic Nissen fundoplication are similar to those after the equivalent open procedure.

Mortality after laparoscopic Nissen fundoplication is extremely rare. Immediately after the procedure, patients often experience abdominal fullness, mild dysphagia, or even postprandial discomfort. These symptoms are consistent with edema formation at the fundoplication. This often resolves within 2-6 weeks. Most surgeons use a liquid diet postoperatively to assist patients with this common transient dysphagia. Pneumothorax or surgical emphysema may occur and is likely related to excessive hiatal dissection.

If severe postoperative pain, intractable emesis, fever, tachycardia, or leukocytosis occurs in the immediate postoperative period, perforation of the esophagus or stomach should be suspected. Disruption of the fundoplication may also cause similar symptoms. Acute paraesophageal herniation is an uncommon complication. An upper gastrointestinal (GI) series should be obtained immediately.

Injury to surrounding structures (eg, vagus nerves, spleen, or other abdominal viscera) is possible. Hemorrhage, ileus, urinary retention, wound infection, and dehiscence have also been described.

Late postoperative complications

Gas bloat syndrome is described as fullness or pain due the sensation of intestinal gas. Although rare, it can be troublesome to accurately diagnose and treat. The exact pathophysiology is unknown. However, difficulty belching, combined with subconscious aerophagia, and transient or permanent delayed gastric emptying seem to lead to increased intraluminal gas, creating the uncomfortable sensation.

Patients are often counseled on dietary changes, including avoidance of carbonated beverages and use of straws. Mild symptoms may be treated medically with use of simethicone, metoclopramide, or erythromycin. Rarely, severe symptoms may necessitate surgical intervention. If symptoms are thought to be due to gastroparesis, a pyloroplasty can be considered. Other surgical options include conversion of a 360º fundoplication to a partial fundoplication.

Dysphagia lasting longer than 12 weeks postoperatively indicates the need for further evaluation. Such dysphagia may be due to wrap failure, a term that includes disruption, slippage, herniation into the chest, or a wrap that is too tight. Dysphagia that presents late may be due to excessive scar formation or wrap migration. A barium swallow should be obtained to assess the fundoplication. Approximately 6-12% of patients may require dilation,[46]  which has shown good long-term efficacy and safety in this setting.[47]

Some studies have suggested that patients undergoing laparoscopic Nissen fundoplication may have a higher incidence of postoperative dysphagia than those undergoing an equivalent open procedure.[48]

Other late postoperative complications include small-bowel obstruction due to adhesions and hernias.

Redo procedures

One meta-analysis reported a higher incidence of redo reflux procedures in patients who underwent laparoscopic Nissen fundoplication.[15] Approximately 5-10% of patients may require redo procedures after laparoscopic Nissen fundoplication because of ongoing or recurrent symptoms.[49] Granderath et al described indications for revision surgery, including dysphagia (48%), reflux (33%), paraesophageal herniation (15%), and atypical symptoms (4%).[50]

Redo Nissen fundoplication has been found to have a significantly higher failure rather than primary procedures, with about 10% of patients having ongoing symptoms despite revision. A multicenter analysis by Al Hashmi et al found Toupet fundoplication preferable to Nissen fundoplication for redo antireflux surgery after an initial Nissen fundoplication.[51]