Laparoscopic Nissen Fundoplication and Heller Myotomy

CHAPTER 7 Laparoscopic Nissen Fundoplication and Heller Myotomy



Some degree of reflux from the stomach into the esophagus is normal, particularly after meals, and is easily cleared by esophageal peristalsis. The high-pressure zone created by the lower esophageal sphincter (LES), diaphragmatic contraction at the esophageal hiatus during periods of increased abdominal pressure (e.g., coughing and bending), and the intra-abdominal positive pressure exerted on the distal esophagus serve to impede reflux. In contrast, migration of the distal esophagus and LES into the chest, as in a hiatal hernia, transient relaxation of the LES, and inhibitors of LES contraction, including caffeine, smoking, and alcohol, may exacerbate reflux. Repetitive injury of the esophageal mucosa by gastric acid results in gastroesophageal reflux disease (GERD) characterized by chronic symptoms (e.g., substernal chest pain and regurgitation) and, sometimes, complications such as Barrett’s esophagus and stricture formation.

Surgical therapy for the treatment of GERD is a relatively recent innovation. Indeed, the gastric fundoplication operations still performed today were introduced in the 1950s by Nissen, Belsey, and others. The application of minimally invasive techniques has led to more rapid recovery and reduced morbidity after antireflux surgery. As a result, the indications for surgery have broadened despite the availability of relatively effective medical therapies. In most cases, the antireflux operation of choice is the Nissen fundoplication, which involves a 360-degree wrap of the fundus of the stomach around the distal esophagus. In selected circumstances (e.g., when esophageal motility is markedly abnormal), a partial wrap may be preferable. Laparoscopic Nissen fundoplication is the focus of the first part of this chapter.


There are few absolute indications for antireflux surgery. A number of relative indications have emerged and must be weighed against associated risks.


See Figure 7-1.

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.

May 26, 2018 | Posted by in GENERAL SURGERY | Comments Off on Laparoscopic Nissen Fundoplication and Heller Myotomy

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