Open Nissen Fundoplication

Dr Rudolf Nissen (1896-1981) described the first fundoplication in the 1950s for treatment of severe reflux esophagitis. His original procedure created a 360º wrap of the fundus of the stomach around the esophagus by plicating both the anterior and posterior walls of the gastric fundus around the lesser curvature. Although Nissen fundoplication has been modified many times, this procedure remains the preferred surgical treatment of esophageal reflux.

Patients may present with typical or atypical symptoms of gastroesophageal reflux disease (GERD). Typical symptoms, also known as esophageal GERD symptoms, include heartburn, regurgitation, waterbrash, and dysphagia. Reflux can lead to complications, including esophagitis, ulcers, esophageal strictures, and Barrett esophagus.

Atypical symptoms, also referred to as extraesophageal symptoms, include sore throat, dental erosions, cough, asthma, dysphonia, laryngitis, laryngeal stenosis, chronic cough, bronchitis, pulmonary fibrosis, laryngeal polyps, laryngeal cancer, and chest pain.

Empiric medical therapy, using proton pump inhibitors (PPIs), for GERD is typically initiated with complaints of dyspepsia.[1] The literature shows different levels of support when comparing the efficacy of antireflux surgery with that of medical treatment. A systematic review found these two treatment options to be similar in efficacy.[2] Studies in the literature have suggested that long-term outcomes from antireflux surgery may be superior to those from medical treatment.[3, 4, 5]  

However, Emken et al, in a randomized prospective study comparing the effect of antireflux surgery with PPI therapy in terms of the effect on lower esophageal sphincter (LES) function and esophageal acid exposure in patients with chronic GERD, found that at 10 years, there was no significant difference in acid reflux control.[6]  A 2011 UK randomized controlled trial revealed that antireflux surgery may be more cost-effective than PPI use in the long term.[7]  A 2021 meta-analysis found that fundoplication is more effective than PPI therapy for treating GERD and does not significantly increase the risk of adverse events.[8]

Further testing is indicated in patients who have ongoing symptoms despite appropriate medical management, warning symptoms (eg, dysphagia, anemia, or guaiac-positive stools), or atypical symptoms, as well as in any patient whose 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.

Indications for an antireflux operation include the following[9] :

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

Currently, a laparoscopic approach is used for most antireflux procedures; it is generally considered to be associated with lower morbidity and mortality, shorter hospital stays, and lower healthcare costs.[10] Indications for an open approach include the following:

• Lack of expertise in or equipment for laparoscopic surgery
• Patient preference
• Intraoperative difficulties during laparoscopic fundoplication necessitating conversion
• Reoperation following previous laparoscopic or open procedures

Fundoplication should be avoided in morbidly obese patients (body mass index [BMI] >35 kg/m2) because of the high failure rates. Rather than fundoplication, gastric bypass should be considered in these patients. Concerns have been expressed about bypass in patients who have previously undergone nonbariatric foregut procedures such as Nissen fundoplication, but despite the increased technical difficulty and the higher perioperative morbidity, long-term symptom resolution and robust weight loss can be achieved.[11]

Open Nissen fundoplication should also be avoided in patients with esophageal motility disorders such as achalasia.

Mortality after open 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 cardia. This often resolves with small meals and prokinetic drugs. A liquid diet should be started 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.

Gas bloat syndrome is described as fullness and or pain due to 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, leads 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 medically treated with 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.

Ongoing dysphagia that persists for longer than 12 weeks postoperatively indicates the need for further evaluation. Dysphagia may be due to wrap failure. Wrap failure 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.[12]

To achieve consistently excellent outcomes and avoid the above complications, the esophageal surgeon should have a thorough understanding of the pathophysiology of each patient’s disease process. He or she should also be familiar with several modifications (eg, Rossetti) and other partial fundoplications that can be performed to meet the needs of the patient and goals of the operation. A surgeon’s particular training and application of technique, along with patient selection, will determine the overall outcome.

Some patients may require redo Nissen fundoplication because of Nissen failure, ongoing symptoms, or recurrent symptoms. The need for recurrent surgery is less in patients undergoing open Nissen fundoplication than it is in those undergoing the equivalent laparoscopic operation.[13]  The lower incidence of recurrence after open fundoplication has been observed in pediatric as well as adult patients.[14, 15, 16]

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

It is important 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.[17]

Before surgical intervention, patients must undergo anatomic or physiogic testing to confirm that there is objective evidence of gastroesophageal reflux disease (GERD). Anatomic examination includes the use of esophagogastroduodenoscopy (EGD) with or without biopsy and contrast radiography (eg, upper gastrointestinal [GI] series). Physiologic examination may include 24-hour esophageal pH assessment, esophageal manometry, intraluminal impedance monitoring, gastric emptying testing, and the Bernstein acid test.

Esophagogastroduodenoscopy

EGD can be used to visualize evidence of reflux esophagitis (see the video below).

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").[18]  Endoscopic evidence of biopsy-proven benign peptic stricture or Barrett esophagus is also considered diagnostic evidence of GERD.

EGD can be used to obtain biopsies that may help to determine the extent of esophagitis, Barrett esophagus, or other pathology. Interestingly, the EGD findings may be normal in as many as 70% of patients with GERD.

24-hour pH testing

Although pH testing is considered the criterion standard for diagnosis of GERD, routine use may be of only marginal benefit. It is best used in the absence of endoscopic evidence of reflux or when the diagnosis is unclear.[19]  This test 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 tests the function of the esophagus by evaluating peristalsis and lower esophageal sphincter (LES) pressure. Specifics about the length, location, and tone of the LES can be characterized. This test also helps diagnose underlying motility disorders, which may be a contraindication to fundoplication.

Preoperative manometry testing suggestions vary. Many physicians advocate preoperative manometry testing, noting that approximately 10% of manometry findings alter surgical planning.[19]  However, the literature does not support mandatory preoperative manometry testing. Rather, manometry may be considered in patients who do not respond to empiric medical treatment and have normal findings on endoscopy.[9, 20, 21, 22]

Contrast radiography

An upper GI series may be useful for anatomic delineation of the esophagogastric junction (EGJ) in relation to the hiatus. This allows detection of hiatal hernias, strictures, or shortened esophagus. Esophageal peristalsis can also be qualitatively assessed.[9]

Impedance monitoring

Impedance monitoring evaluates esophageal motility and function through assessment of directional bolus transit within the esophagus. This test is particularly helpful in evaluation of nonacidic reflux.[23]

Gastric emptying tests

Gastric emptying tests may be considered if patients have a history of diabetes, severe nausea or vomiting, or postprandial bloating. In addition, they may be helpful in cases of reoperation. Gastric emptying studies should not be routinely obtained, because there is only limited evidence in the literature to support a correlation between gastric emptying test results and postoperative outcomes from fundoplication.[9]

An atraumatic liver retractor is necessary to elevate the liver for exposure of the hiatus. A self-retraining 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 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 is used. A nasogastric or orogastric tube is often placed to assist in decompression of the stomach during the procedure.

Positioning

In the transabdominal approach, patients are placed in the supine position, with the arms tucked. Some surgeons ensure that patients are stable by using a beanbag or egg-crate foam. The bed is placed in the reverse Trendelenburg position to displace the bowel inferiorly. The surgeon is positioned between the patient’s legs, and the first assistant is on the patient’s left.

In the transthoracic or thoracoabdominal approach, the patient is positioned with the left side raised so that a midline laparotomy can be supplemented by a left anterolateral thoracotomy.

Patients are most commonly discharged between postoperative days 2 and 5. The authors recommend that patients abstain from lifting anything heavier than 10 lb for 6 weeks postoperatively.

Close follow-up is necessary to ensure patient compliance with diet and early identification of potential complications. In the authors' practice, patients are seen at 1 week, 2 weeks, 4 weeks, and 8 weeks postoperatively, then yearly after that.

The purpose of the Nissen fundoplication is to restore competency to the lower esophageal sphincter (LES) while preserving normal swallowing and belching. All procedures are performed with the patient under general endotracheal anesthesia.

Nissen fundoplication can be performed with either an open or a laparoscopic technique. Currently, laparoscopic Nissen fundoplication is considered the criterion standard.[24, 25, 26]  Transoral incisionless fundoplication is another alternative being studied.[27]

The following discussion addresses open Nissen fundoplication. This procedure may be approached either transabdominally or transthoracically, as described below.

The patient is positioned as previously described (see Patient Preparation). An upper midline laparotomy is performed in most cases. Bilateral subcostal incisions may be appropriate in patients who are obese with a wide costal angle. Use of a sternal retractor or various abdominal-wall retractors of choice is necessary. The liver should be retracted anteriorly and to the right with a liver retractor. If the liver is exceptionally large, the left triangular ligament can be divided for further mobilization of the liver.

The upper stomach and esophageal diaphragmatic hiatus can now be visualized (see the image below), and the hiatal dissection can begin.

The stomach is retracted 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. The incision can be continued superiorly over the anterior surface of the esophagus and down the left crus of the esophageal hiatus. The caudate lobe of the liver and the right hiatal pillar are now visualized. 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. This ligament is divided.

Freeing the intrathoracic esophagus up to 6 cm may be necessary to gain appropriate intra-abdominal esophageal length. All branches of the vagus nerves should be preserved. The anterior branches have numerous anatomic variations and are included in the fundoplication.

Blunt finger dissection can be used to free the distal esophagus from its posterior attachments. Once the esophagus has been freed circumferentially, it can be encircled with a nylon tape, Penrose drain, or instrument. The esophagus can then be retracted anteriorly to expose the posterior hiatus (see the image below).

The hiatus is dissected meticulously to delineate the diaphragmatic crus. The distal 6 cm of the posterior esophagus is fully mobilized. Care should be taken to preserve the inferior phrenic artery; in rare cases, this vessel can be 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 as a matter of routine. Sutures should be placed from posterior to anterior and should narrow the hiatus to approximately 2.5 cm in diameter. (See the images below.) In patients without a hernia or with only a small hernia, one or two interrupted 0-0 nonabsorbable sutures will suffice. More sutures may be needed for larger hernias. 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 fingertip 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.[28] Other authors have reported equivalent outcomes without the use of bougies.[29]

The Penrose drain, nylon tape, or instrument used to retract the esophagus may now be removed. Atraumatic Babcock forceps are used to grasp the fundus of the stomach and bring it behind the esophagus (see the image below).

In the traditional Nissen fundoplication (see the image below), 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. One or two stitches should include the wall of the esophagus to prevent slippage of the cardia. It should be noted that the short gastric vessels are not divided in the traditional Nissen fundoplication.

Once the fundoplication is complete, the abdomen should be inspected for adequate hemostasis. All instruments should be removed. The fascia should be closed with a nonabsorbable suture of the surgeon's preference. The skin is closed with surgical staples.

Technical modifications

Because of side effects associated with the original Nissen fundoplication, several modifications have arisen. The Rossetti modification uses the anterior wall of the fundus alone to construct a 360º wrap around the distal esophagus. In the initial Nissen-Rossetti modification, dividing the short gastric vessels was not recommended. 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 images below).

DeMeester and Donohue described a floppy Nissen technique in which the short gastric vessels are divided.[30, 31]

DeMeester et al described three intraoperative measures for decreasing the risk of postoperative complications, as follows[31] :

• A larger bougie (60 French) decreased the incidence of early postoperative dysphagia
• Shortening the fundoplication from 4 cm to 1 cm reduced the incidence of persistent dysphagia
• Mobilization of the gastric fundus allowed improved distal esophageal sphincter relaxation during swallowing

Several other alternative fundoplications are recognized. The Belsey Mark IV partial fundoplication is a 270º anterior transthoracic fundoplication. Dor described a 180-200º anterior fundoplication. Toupet described a posterior 270º fundoplication ideal for patients with motor abnormalities (see the image below). A Thal partial fundoplication is described as a 90º anterior wrap. A Watson partial fundoplication is described as a 120º anterolateral wrap.

Other modifications include narrowing of the esophageal hiatus posterior to the esophagus, repair of associated hiatal hernias using mesh, anchoring of the fundoplication to the preaortic fascia, and the addition of a highly selective vagotomy.

Intraoperative complications

Iatrogenic splenic injury may occur during transabdominal fundoplication. Perforation of a severely inflamed esophagus is also a risk. Care should be taken during mobilization of the esophagus to prevent perforation.

Because of concerns about morbidity, a thoracic approach is rarely used. The main advantages of the transthoracic approach are that it provides direct vision of the lower and middle esophagus and easier mobilization of the middle esophagus. This approach may be appropriate for the following patients:

• Those who have previously undergone previous hiatal hernia surgery
• Those with a need for concomitant esophageal myotomy for achalasia or diffuse spasm
• Those who have a short esophagus
• Those who have a nonreducible sliding hiatal hernia
• Those who have concomitant pulmonary pathology that can be inspected simultaneously

A left posterior lateral thoracotomy between the sixth and eighth intercostal spaces is used for the transthoracic approach. In the thoracoabdominal approach, the patient is positioned with the left side raised so that a midline laparotomy can be supplemented by a left anterolateral thoracotomy.

Selective deflation of the left lung with a double-lumen endotracheal tube may assist in visualization. Mobilization of the esophagus begins with incision of the mediastinal pleura and encircling of the esophagus with a Penrose drain. Mobilization of the esophagus to the aortic arch is necessary to allow a tension-free repair and to achieve adequate esophageal length in the abdomen. If the length is not adequate, then an esophageal-shortening procedure (eg, a Collis gastroplasty) is performed.[32]

The left superior and inferior bronchial arteries comes directly off the descending thoracic aorta to the lower esophagus and are ligated. The cardia of the stomach is dissected free from the diaphragm. Usually, this can be accomplished by dissecting transhiatally. If necessary, however, the diaphragm can be circumferentially incised for additional visualization. The abdomen is entered through the phrenoesophageal membrane along the anterior left crus. Care should be taken to avoid the gastric vessels.

The left hand is inserted through the diaphragmatic hiatus around the esophagus. A combination of blunt and sharp dissection can be used to free the esophagus distally. Next, a portion of the body of the stomach is retracted up through the hiatus into the chest with Babcock clamps. Often, this requires ligation of four to six short gastric vessels. Once the fundus is elevated, the posterior gastric artery is visualized and ligated. The vascular fat pad localized on the anterior lateral surface of the cardioesophageal junction is excised.

Depending on the surgeon's preference, crural sutures may be placed as described above for the transabdominal approach. These sutures may be placed either before or after the fundoplication. If these crural sutures are placed before creation of the fundoplication, they should be tied after creation of the fundoplication has been completed.

The fundoplication is created next, in much the same fashion as with the transabdominal approach. The fundoplication is then placed into the abdomen. The hiatus is inspected to confirm that the repair remains completely intra-abdominal. If the fundoplication does not stay intra-abdominal, excess tension on the repair is likely, and revision by further mobilization of the fundus is indicated. If crural sutures were placed, they should be tied once the fundoplication is satisfactory. Otherwise, crural sutures can be placed at this point in the procedure.