Fundoplication

Objective
To strengthen the LOS
If there is a hiatus hernia, it should be reduced.
Prevent need for PPIs.

See GORD for indications

Pts should be carefully selected: proven GORD.

Prior investigations include:
i) Barium oesophagram & upper GI series: shows reflux, stricturing or shortening.
ii) Upper GI endoscopy; shows mucosa & possibly Barrett’s, motility, length of oesophagus 
iii) Manometry: rules out motility disorders.
iv) 24hr pH test (off PPIs)
- determines degree of GORD objectively.
- especially for pts with atypical symptoms

Laparoscopic Nissen Fundoplication

- the 360o posterior wrap should be the procedure of choice for most and is the most widely used procedure
- anterior wraps considered when oesophageal motility is poor to prevent obstruction to bolus propagation (though posterior wrapping may actually improve dysphagia in many anyway).

Outcomes
Response rate 90-94%, some stay same, 5% are failures.
- majority of failures can be treated with PPIs and investigated.
- re-operation may be appropriate if a wrap is shown to be poor, or even if the wrap looks to be ok.
Spechler et al showed 10yr surgical outcome remained good (Sabiston).
- and may be associated with fewer treatment failures than medical therapy.
- so an excellent alternative with durable results.

Risks include:
- perforation (~1%), may be repaired easily laparoscopically, may require extensive therapy, repeat operation/s, prolonged hospital stay, serious illness.
- bleeding (rare, 1% need a splenectomy with attending implications / vaccinations), possibly blood transfusion.
- pneumothorax requiring a chest tube.
- vagal nerve injury, very rarely post-operative stomach dysfunction.
- other complications in up to 10%, including urinary retention, wound infection, venous thromb-oembolism (mitigated by prevention), ileus.

Post-operatively, bloating is common (up to 1/3), but <4% have symptoms beyond 2months.
- few will require nasogastric decompression
- diet will be graduated from liquid to soft over 4-6weeks.

Failure rate is ~1%.
- some of these patients may have worse symptoms
- one third of these patients receive another operation.

360o Fundoplication : Approach

1. Patient supine, arms tucked, padded. 
- need R arm tucked to allow the liver retractor in.

2. Steep head-up, so footboards in position / strapping.
- stand to right, assistant on left.
- or between legs with pt in modified lithotomy.

3. 5 ports.
- 12mm port in midline well above umbilicus to view stomach
- 4 other ports across upper abdomen, left and right working ports,  epigastric / R anterior axillary line for liver retractor and far left abdo for retraction.

4. Check peritoneal cavity.
- note anatomy and risks
- a fat pad usually obscures view of the oesophagus and marks its position.
- place liver retractor

5. Divide gastro-hepatic ligament with harmonic.
- open only the pars condensa (more collagenous / transparent upper part of lesser omentum)
* --> access first landmark which is the right crus.
*BE AWARE that the vena cava is sitting off behind the right of the right crus; do not work there.
- look at it and note its relationship to the R crus.

6. Hold R crus to the right, opening the space over the oesophagus.
- now work very close to the medial margin of the R crus
--> blunt dissection to enter the mediastinum through gentle traction and counter-traction of instruments
*DEFINE the oesophagus.
* Keep peritoneum on the R crus.
* Start inferiorly, where crura cross, thus avoiding working just cranial to the inferior aspect of the left crus where plural space is easily entered.

7. Continue blunt dissection under the phreno-oesophageal membrane
- elevate the membrane with the left hand, and clear the margin of the L crus.
* BE AWARE that the vagal trunk can travel on the medial aspect of the left crus
--> clearly identify the crus and membrane, then divide the membrane.

8. Identify the vagal trunk in on the L crus,
* --> Clear it from your field, bluntly, gently pushing it down to the L of the oesophagus and away from the phreno-oesophageal ligament.
- divide remainder of the ligament.

9. Elevate the oesophagus on the R, free it up from the R crus
*- LOCATE the posterior vagal trunk at the back of the oesophagus from this aspect.
*- View key landmarks of the right and left crus from the window on the posterior aspect of the oesophagus.
- thus freeing the whole oesophagus from the crus and mobilising it, while preserving the vagii. No blind manoeuvrings
- sling the oesophagus and pass to assistant to retract to patient's left, continue working through the window / aspect of the R crus.

10. Mobilise mediastinal oesophagus
* - get a appropriate good length of oesophagus to pull back into the abdomen.
- mix of blunt dissection (traction / counter-traction) and ligasure of the strands containing oesophageal vessels.
- take care to follow and preserve the vagus trunk; no coagulation, take and divide with harmonic
- upper limit of the dissection is usually the pulmonary vein.

11. Mobilize the fundus.
- start at a flimsy fat pad (present even in very thin patients) at the free upper border of the gastrosplenic ligament.
- work down to the key attachments fixing the upper fundus at the top of the short gastrics; anterior and posterior; at the gastro-phrenic ligament covering the left crus
- will see R crus through the window.
- isolated by blunt dissection and take upper short gastrics.
*- do NOT dissect down onto the body of the stomach or wrap the body of the stomach
* note that the short gastrics very closely appose stomach to spleen at their most cranial extent; avoid injuring the spleen in particular (the stomach you can oversew).

12. Repair the crus defect.
BE CAREFUL of the aorta and IVC; control by going superficially through the crus.
- interrupted ethibond sutures
- 2-3 posterior +/- one anterior
- use a bougie (50 or typically 60 Fr); enables correct wrap and reduces oesophageal injury rate to <1%.

13. Wrap posterior fundus 360o, taking only the fundus.
- with good mobilization, can calibrate the wrap by back and forth positioning
- suture wrap - interrupted ethibond, good bites, x3 sutures.
- not too tight, not too loose, a short wrap valve of 2cm or so.
- gloppy on the oesophagus, no tightening, no twisting of oesophagus.
- can take a small bite of the anterior phreno-oesophageal membrane over oesophagus.

14. Check operative field and spleen for bleeding.
Close.


Post-Op Care

Start on liquids (non-carbonated) within 2 h.
Advanced to soft dysphagia diet if tolerated.
Discharged on that diet; no beef, fish, chicken, fruit or uncooked vege.
No lifting >8 lb, vigorous straining or activity for 2 months to protect the hiatal closure.

Complications
Outcomes
80-90% long term relief rate for acid symptoms
Long term cure 70-90%
Off PPIs
5-10% dysphagia rate persisting past 60d; mostly mid and treated by diet modification.
Gas and bloating complaints common, but little impact on QOL; 80-95% would undergo surgery again.