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,
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
- 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
actually improve dysphagia in many anyway).
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
- and may be associated with fewer treatment failures than medical
- so an excellent alternative with durable results.
- perforation (~1%), may be repaired easily laparoscopically, may
require extensive therapy, repeat operation/s, prolonged hospital
- 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
- other complications in up to 10%, including urinary retention,
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
- place liver retractor
5. Divide gastro-hepatic ligament with harmonic.
- open only the pars
condensa (more collagenous / transparent upper part of lesser
* --> 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
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
- 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
- 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
- can take a small bite of the anterior phreno-oesophageal membrane
14. Check operative field and spleen for bleeding.
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
No lifting >8 lb, vigorous straining or activity for 2 months to
protect the hiatal closure.
80-90% long term relief rate for acid symptoms
Long term cure 70-90%
5-10% dysphagia rate persisting past 60d; mostly mid and treated by
Gas and bloating complaints common, but little impact on QOL; 80-95%
would undergo surgery again.