Current reviews in gastrointestinal, minimally invasive, & endocrine surgery

Laparoscopic fundoplication

Indications

Most GERD patients are managed medically, initially with lifestyle modification, weight loss, and proton pump inhibition. Indications for surgical intervention generally fall into 3 categories: medical intractability, medical intolerance (side effects or cost), and complications of GERD (ulceration, stricture, bleeding, and Barrett’s esophagus). Relative contraindications to the laparoscopic approach include previous surgery, absolute contraindications include high-grade dysplasia (suggestive

Preoperative evaluation

The goal of preoperative evaluation in patients with suspected GERD is 3-fold: to establish the correct diagnosis, to identify those who would most benefit from surgical intervention, and to plan the most appropriate surgery. Multiple modalities are employed to these ends, including endoscopy, esophageal manometry, and 24-hour ambulatory esophageal pH monitoring. The first 2 are essential in establishing the diagnosis of esophagitis or hiatal hernia. Manometry can help the surgeon identify

Surgical options

Advances in videoscopic technology, the development of advanced laparoscopic techniques, and improvement of instrumentation have been important in maximizing the minimally invasive treatment of GERD. The laparoscopic Nissen (360° fundoplication) is probably the most often employed technique, although it certainly does not stand alone. The Rosetti modification of the Nissen fundoplication secures the wrap with sutures in the anterior fundus, while preserving the short gastric vessels. This

Technique

The critical portions of the laparoscopic Nissen fundoplication are crural dissection and hiatal encirclement (with reduction of any hiatal hernia contents), crural reapproximation, fundic mobilization (including division of the short gastric vessels), and creation of the wrap.5 The authors’ approach will be described, but many different approaches are used.

The patient is positioned supine on an operating table capable of steep reverse-Trendelenberg position. A “bean-bag” stabilization device

Outcomes

Overall, the experience with laparoscopic fundoplication has been very good. Patients experience excellent rates of symptomatic relief (98%) and physiological resolution of their disease. Most patients are discharged within 48 hours of surgery, patient satisfaction is high, and complications are rare.1, 4, 5 Technical failure of the repair is very low, with less than 2% requiring reoperation. Some patients may have symptoms of bloating, diarrhea, chest pain, heartburn, or dysphagia. These

Complications

Among the complications of laparoscopic fundoplication are those related to any laparoscopic procedure. Examples include Veress needle injury, effects of pneumoperitoneum, deep venous thrombosis, trocar site herniation, and so on. Secondly, there are those specific to the operation. Retraction of the left lobe of the liver can cause hematoma with significant morbidity.24 Damage to the vagi, esophagus, or stomach are obvious hazards of the operation. Bleeding can occur from multiple sites,

Future

Laparoscopic fundoplication is technically challenging, but accomplishes symptomatic relief in 98% of patients. It offers the typical advantages of minimally invasive surgery over open procedures: shorter hospital stay, less need for pain medication, quicker return to normal activities, and only minor scars. As more surgeons gain a high degree of competence, and advancements in instrumentation and videoscopic technology continue, it is likely that an increasing percentage of GERD cases will be