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M. Grasty and V. Gershuni
12 Laparoscopic Nissen Fundoplication (Posterior
360° Plication)
The most superior aspect of gastric fundus is pulled under the esophagus through
the retro-esophageal window with graspers. The anterior and most superior aspect
of the fundus is brought above the esophagus held together. A “shoe-shine” maneuver should be performed to ensure it is not twisted. Then, 2-0 non absorbable braided
sutures are used to create the wrap (Fig.18). Each stitch incorporates a bite of the
left and right sides of the stomach and a bite of the muscular layer of the esophagus.
It is the preference of some surgeons to perform an additional pexy stitch from the
wrap to the crura. In order to ascertain that the fundoplication is adequately “oppy,”
a grasper can be introduced between the left side of the wrap and the esophagus to
ensure the left crus can be visualized (Fig.19).
Fig. 18 Nissen
fundoplication—nal
aspect (A posterior lip of
the fundoplication, B
anterior lip of the
fundoplication, C
esophagus, D liver)
Fig. 19 Nissen
fundoplication (A anterior
lip of the fundoplication, B
GE junction)
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13 Laparoscopic Toupet Fundoplication (Posterior
270° Fundoplication)
The rst steps in a Toupet fundoplication are identical to the rst steps in a Nissen
fundoplication. The wrap, however, differs in that it extends around only 270° of the
esophageal circumference. Once the posterior aspect of gastric fundus is delivered
under the esophagus, the two sides are not approximated together. Instead, 90° of
the anterior esophagus is left uncovered, and each of the two sides of the wrap (right
and left) is separately afxed to the esophagus with three 2-0 non-absorbable
braided sutures, with each stitch including the muscle layer of the esophageal wall.
An additional pexy stitch can be placed between the wrap and crura (Fig.20). Note
that Fig.20 also shows an accessory or replaced left hepatic artery, branching off the
left gastric artery, running in the gastrohepatic ligament altogether with the always
present hepatic branch of the vagus nerve.
Some surgeons perform an alternative modication to the 270° posterior wrap
that incorporates pexy stitches within the wrap itself, with the bilateral bottom two
stitches of the fundoplication incorporating the crura (right: esophagus, crura, stomach, and left: stomach, crura, esophagus) and the bilateral top stitches including the
crura and stomach. The geometry of this wrap creates a sling for the esophagus and
bolsters the crural repair.
Fig. 20 Toupet
fundoplication—nal
aspect (A posterior lip of
the fundoplication, B
esophagus, C anterior lip
of the fundoplication,
Arrow points to a replaced
or accessory left hepatic
artery running in the
gastrohepatic ligament)
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M. Grasty and V. Gershuni
14 Laparoscopic Dor Fundoplication (Anterior
180° Fundoplication)
The Dor fundoplication differs in that it is an anterior, 180° wrap around the esophagus. It is accomplished by suturing the posterior and most superior aspect of the
gastric fundus to the left lateral side of the esophagus with two 2-0 non-absorbable
braided sutures, then two stitches from the most superior aspect of the anterior gastric fundus the right lateral side of the esophagus. Three additional stitches are then
placed from the anterior aspect of the stomach to the superior aspect of the left
crura, right crura and one in between (Fig.21).
Fig. 21 Dor
fundoplication—nal
aspect (A caudate lobe of
the liver, B diaphragm, C
anterior fundoplication)
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15 Tips andTricks
15.1 Intraoperative Endoscopy
The role of endoscopy in the preoperative setting is felt to be imperative in understanding each individual patient’s anatomy and determining the extent of esophageal damage from reux. Similarly, the use of intraoperative endoscopy both
immediately prior to and after fundoplication has become common and allows permits for real-time evaluation of fundoplication morphology and re-establishment of
the anti-reux barrier. The Hill grade classication system, which has been shown
to be associated with the frequency of GERD, response to PPI, LES pressure and
hiatal hernia prevalence, can be assessed at the beginning of the operation and again
after completion of the fundoplication to ensure and document adequate surgical
treatment [31].
16 Endoluminal Functional Lumen Imaging
Probe (EndoFLIP)
Use of endoscopic adjuncts like the esophageal balloon distension study, Endoip
(Medtronic; Dublin, Ireland), can guide surgical management. This device uses
high-resolution impedance planimetry to measure real-time pressure and dimension
of the esophagus and GE junction providing insight into the sphincter competency
[32, 33]. As the balloon is distended, current is conducted between the electrodes to
measure both the pressure generated and the cross-sectional area of the lumen,
which can be used to generate the distensibility index along the length of the catheter. Several recent papers have been published that demonstrate the use of intraoperative EndoFLIP to measure post-fundoplication distensibility and length as
predictors of response to surgery with the Toupet fundoplication having greater distensibility compared to Nissen fundoplication [32, 34]. The use of EndoFlip to measure the post-procedural distensibility index is correlated with statistically signicant
decreased gas bloat, dysphagia and reux [32, 35].
17 Postoperative Care
Patients are generally admitted to a regular oor bed. Narcotic utilization is kept to
a minimum by use of long-acting local anesthesia at the port sites or via bilateral
transversus abdominus plane block and NSAIDs. A strict protocol for prevention of
postoperative Nausea and Vomiting (PONV) is implemented on all patients.
Antiemetics are prescribed standing during the rst 24 h and then can go to as
needed once the patient is discharged home. Patients are started on a soft pureed diet
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on the morning of postoperative day 1 after consulting with a dietitian to review
appropriate food options. This is continued for about 2weeks. During this time
period medications should be converted to liquid or crushed, if able. Patients are
usually discharged after 23–48h.
M. Grasty and V. Gershuni
18 Perioperative Complications
A feared complication of ARS is esophageal or gastric perforation (0–2.2%)
[36–38], which may result either from traction applied with a grasper to the esophagus or the stomach (particularly when the stomach is pulled under the esophagus) or
from inadvertent thermal injury during any part of the dissection. A leak will manifest during the rst 48h. Signs of peritonitis will be noted if the spillage is limited
to the abdomen; shortness of breath and a pleural effusion will be noted if spillage
also occurs in the chest. The site of the leak should always be conrmed by a contrast study with a water-soluble contrast agent. Optimal management depends on
timing, clinical stability, and size of the defect, but may warrant re-operation and
direct repair. If a perforation is detected intra-operatively, it should be closed
laparoscopically.
Other known complications in the immediate postoperative period include pneumothorax/capnothorax (0–3.5%) and splenic and/or hepatic injury (0–2.2%)
[37–39].
Almost every patient experiences some degree of dysphagia postoperatively.
This problem usually resolves after 4–6weeks, during this period patients receive
necessary medications in an elixir form and are maintained on a dedicated mechanical soft diet. Patients should be counselled pre-operatively to expect a degree of
dysphagia and educated on the post-operative diet advancement plan. Ideally, a
member of the clinical team should reach out to the patient a few days after discharge to check in with their oral intake.
19 Magnetic Augmentation oftheLES
In 2012, another device was introduced into the surgical armamentarium for minimally invasive antireux surgery. The LINX is a magnetic ring of beads that can be
placed at the inferior border of the lower esophageal sphincter to restore the sphincter’s competency (LINX Reux management system, Torax Medical, Shoreview,
MN, USA) (Fig. 22). The device is designed for patients that do not have large
diaphragmatic hiatal hernia defects or advanced mucosal injury such as BE or strictures. It is not recommended for patients with morbid obesity or esophageal dysmotility. As with standard ARS, patients offered LINX should have well documented
pathologic reux by 24-h pH monitoring. It is recommended that patients should
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Fig. 22 LINX device
placed at gastroesophageal
junction
159
undergo an esophageal manometry and have normal esophageal body motility. The
theoretical advantages of the LINX device over a standard fundoplication are ease
of insertion and fewer associated side effects; however high quality comparative
studies with all fundoplications are still lacking.
The device has been studied prospectively in a group of 100 patients with chronic
GERD and results showed decreased esophageal acid exposure, improvement in
reux symptoms, and decreased use of proton-pump inhibitors. Data on the device’s
safety prole was recently reported for 1000 patients operated worldwide [40, 41].
When followed for 5years post operatively, those with magnetic sphincter augmentation have reduced bloating in the long term [42]. Compared to laparoscopic Nissen
fundoplication, magnetic sphincter augmentation results in similar improvement in
quality of life related to their GERD symptoms. Of note, a proportion of patients
will require removal of their magnetic sphincter augmentation device; this can be
due to a variety of reasons and typically occurs <6years after placement [43]. Intra
and perioperative complications occurred in 0.1% of the patients, with 5.6% requiring endoscopic dilations, and 3.4% requiring reoperation (all elective, non-urgent).
Erosions occurred in one patient (0.1%). While more long-term data is still needed,
results with the LINX device are promising for appropriately selected patients.
20 Final Considerations
ARS has proven to be a safe and effective treatment for chronic GERD in the short
and long term as it pertains to symptom control and quality of life [44, 45]. Critical
elements to a successful procedure are appropriate patient selection and preoperative workup together with surgeon expertise.
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Acknowledgement This chapter is based on a previous edition entitled “Laparoscopic AntiReux Surgery” written by Francesco Palazzo MD, FACS, Jad Khoraki MD, and Guilherme
M.Campos MD, FACS.
M. Grasty and V. Gershuni
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Laparoscopic Paraesophageal Hernia
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Repair
AmberL.Shada
1 Indications
PEH are often asymptomatic with acute symptoms occurring in 0.7–7% of patients
[1]. Historic teaching was immediate repair of all PEH [2, 3] but more recent studies
nd that asymptomatic PEH can be managed expectantly or electively and that the
annual risk of progression to gastric volvulus with incarceration and necrosis is low,
near 1% [4, 5]. Elective repair is reasonable for patients who do not have obstruction
as a result of incarceration or volvulus. Asymptomatic paraesophageal hernias identied incidentally can be offered watchful waiting or elective repair.
Paraesophageal hernias can cause a wide range of symptoms, from epigastric
and chest pain, shortness of breath, heartburn, dysphagia, regurgitation, vomiting,
early satiety, recurrent pneumonia, and anemia [6]. Notably, anemia occurs due to
Cameron erosions or ulcerations of the stomach where it is compressed by the diaphragm [7]. Occasionally paraesophageal hernias do present with acute gastric outlet obstruction and will need urgent decompression (often with a nasogastric tube
and/or an endoscope). This occurs when the stomach volvulizes around the long
axis (organoaxial) or short axis (mesoaxial). This can create ischemia and obstruction, and typically presents with severe chest pain and intolerance of oral intake [8].
Urgent paraesophageal hernia repair is indicated in the setting of necrosis and strangulation, and is associated with higher morbidity and mortality [9]. In cases where
decompression can relieve the obstruction, it is reasonable to decompress the stomach and perform paraesophageal hernia repair semi-electively [10].
A. L. Shada (*)
Department of Surgery, University of Wisconsin, University of Wisconsin School of Medicine
and Public Health, Madison, WI, USA
e-mail: shada@surgery.wisc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_15
163© The Author(s), under exclusive license to Springer Nature
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