CHAPTER 7 Laparoscopic Nissen Fundoplication and Heller Myotomy
LAPAROSCOPIC NISSEN FUNDOPLICATION
INDICATIONS FOR SURGERY
I. Intractability of symptoms despite maximal medical therapy with proton pump inhibitors and H2 receptor blockers is the most common indication for surgery. Although the presence of typical primary symptoms (e.g., heartburn) is generally predictive of good outcomes after antireflux surgery, patients with pulmonary manifestations attributable to GERD (e.g., cough, pharyngitis, and recurrent pneumonia) may benefit from surgery as well, assuming other etiologies have been excluded. Patient age is an important factor in identifying appropriate surgical candidates; the benefits of surgery over lifelong proton pump inhibitor therapy are greatest in younger patients with severe disease. When patients receive no benefit from proton pump inhibition, diagnoses other than GERD should be considered. In general, such patients benefit little from antireflux surgery.
II. Peptic strictures are areas of fibrotic narrowing in the distal esophagus. Patients typically present with dysphagia and obstruction. The presence of a stricture suggests severe, repetitive esophageal injury from acid exposure. After evaluation, including endoscopy and biopsy to exclude malignancy, consideration should be given to antireflux surgery to reduce esophageal acid exposure and promote healing. Strictures are sometimes accompanied by a shortened esophagus. In such cases, fundoplication should be performed with an esophageal lengthening procedure (e.g., Collis gastroplasty).
III. Barrett’s esophagus, columnar metaplasia of the distal esophagus, is a premalignant condition that predisposes to the development of esophageal adenocarcinoma. Delayed progression or even regression of Barrett’s esophagus has been documented after antireflux surgery. However, whether surgery influences the subsequent risk of esophageal cancer remains controversial. Barrett’s esophagus with high-grade dysplasia is associated with undiagnosed esophageal adenocarcinoma in 38% to 72% of cases and should be treated with a resection (i.e., esophagectomy) rather than antireflux surgery.
PREOPERATIVE EVALUATION
I. History: The timing and chronicity of symptoms, modifying factors, and the effect of reflux symptoms on the patient’s lifestyle should be elicited. Response to acid suppression medications should be determined and is predictive of outcome after fundoplication.
II. Upper gastrointestinal fluoroscopy with barium allows for the diagnosis of a shortened esophagus, hiatal hernia, or mass, which may influence the surgical approach (e.g., the addition of an esophageal lengthening procedure).
III. Esophagogastroduodenoscopy allows for an assessment of the degree of esophageal injury. Specifically, esophagitis can be graded, and the presence of Barrett’s esophagus, dysplasia, and neoplasm can be identified.
IV. Twenty-four–hour pH monitoring is the gold standard for documentation of acid reflux into the distal esophagus. After the patient undergoes a 1-week hiatus from acid suppression therapy, pH probes are passed through the nose into the stomach, the distal esophagus above the LES, and the upper esophagus. Symptoms that correlate with episodes of acidification of the distal esophagus are more likely to improve with antireflux surgery.
V. Esophageal manometry provides information about the function of the LES and contractile properties of the esophageal body. Patients with abnormal peristalsis of the esophageal body will likely experience dysphagia when a 360-degree fundoplication is used and are better served by a partial fundoplication.
COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY
I. Preoperative Considerations
A. Prophylactic antibiotics to cover gram-positive and enteric organisms are administered within 1 hour before skin incision.
II. Patient Position and Preparation
A. The patient is placed in the modified lithotomy or split-leg position, allowing the operating surgeon to stand between the patient’s legs. The table is placed in the reverse Trendelenburg position (i.e., the bottom of the table tilted down) so that intra-abdominal fat falls away from the esophageal hiatus. The video monitor is positioned at the patient’s head so that the surgeon’s body, the instruments, and the video screen form a straight line, to optimize the surgeon’s spatial orientation.
III. Port Placement
A. A 10-mm port is placed 15 cm inferior to the xiphoid process (Fig. 7-2), just to the left of the midline. Either an open technique or a Veress needle technique may be used to access the peritoneal cavity; however, the former should always be used if the patient has had previous abdominal surgery. After port insertion, pneumoperitoneum is established with insufflation of CO2.
B. Four additional ports (see Fig. 7-2) are placed under laparoscopic visualization. The left and right subcostal ports, placed in the midclavicular lines, function as the primary operative ports and correspond to the surgeon’s left and right hands, respectively. A lateral right subcostal port is placed to allow for the insertion of a self-retaining liver retractor, and a lateral left subcostal port provides access through which an assistant can retract.
IV. Exposure
A. A liver retractor is inserted through the right lateral port and positioned to elevate the left lateral segment of the liver, exposing the esophageal hiatus.
B. The avascular portion of the gastrohepatic ligament (pars flaccida) is divided, exposing the right crus of the diaphragm. Care is taken to avoid injury to the hepatic branch of the vagus nerve or a replaced left hepatic artery arising from the left gastric artery.
C. The phrenoesophageal ligament is incised and attachments to the esophagus are swept down toward the gastroesophageal (GE) junction to allow for visualization of the left and right crura (Fig. 7-3). The anterior vagus nerve is identified and preserved.
