Laparoscopic Nissen Fundoplication
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:
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Port B is placed subcostally in the right midclavicular line
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Port C is placed subcostally just to the right of the midline
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Port D is placed subcostally just to the left of the midline
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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.
Laparoscopic Nissen fundoplication. View of hiatus after insertion of liver retractor.
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.
Laparoscopic Nissen fundoplication. Penrose drain is placed around esophagogastric junction to retract it anteriorly and laterally to allow improved visualization of 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.
Complications
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]
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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.
