Laparoscopic Nissen fundoplication: get it right everytime

Clinical Case

Recurrence rates following successful surgery varies from different centres but can account for as high as 30% of all Nissen Fundoplications over time.

Despite the fact that nowhere in surgery the pre-operative patient is more thoroughly evaluated and surgeons strictly adhere to the indications for surgery, as well as following all mandatory surgical steps, an increase in re-do hiatus hernia repairs has been documented in almost every major high volume centre where surgery of the upper G.I.T. has been performed.

A successful approach to anti-reflux surgery requires that the surgeon must have a clear understanding of the pathophysiology of gastro-esophageal reflux disease and of the complex, contributing anatomical factors, anomalies and their mechanical sequels.

A critical analysis of the reasons for recurrence of hernias demonstrates the fact that the majority of failures can be attributed to crural disruption.

This prompted me to compile a video in which I will highlight the reasons why anti-reflux surgery fails, and how failures can be avoided.

Meticulous surgical technique is the surest way to prevent recurrence and this will be highlighted in the compilation video that follows a presentation on the pathophysiology, anatomy, anomalies, patient selection, choice of suture material and mandatory surgical steps.

The video will begin with the O R setup, and emphasis will be placed on the importance of the positioning of the patient on the O R table, the direction of the trochar placements, and the positioning of the surgical team and the scrub assistant.

The surgery will be completed with the assistance of only one surgical assistant -camera operator, focusing on the relevant anatomy and anatomical variations and will illustrate how to effectively perform a Nissen Fundoplication, using a chronologically ordered approach, minimising unnecessary movements. All mandatory technical steps, including the three crucial steps, will be demonstrated, namely:

• The return of the intra-abdominal esophagus, and ensuring that it remains intra-abdominally.
• The reconstruction of the crural support
• The reproduction of a competent L.E.S, proximal to the gastro-esophageal junction. This Fundoplication, or new sphincter must provide a competent barrier to gastro-esophageal reflux whilst allowing effective esophageal clearance and remain intact and in place below the diaphragm.

Although only Type I and type III hernias are seen in this video it is important to understand that the techniques and principles are relevant to all four types of hernias. The take-away messages are: The surgeon must realise that:

• An in depth knowledge of the pathophysiology, anatomy and anomalies is imperative.
• They must be well trained in laparoscopic surgical techniques.
• They must adhere strictly to all indications for surgery and follow all surgical principles.
• Not all patients who qualify for surgery should be offered a surgical repair.
• Re-do surgery should preferably be performed in high volume upper G.I.T. surgical units.
• Despite the surgeon’s best efforts and compliance to all surgical principles –

UNFORTUNATELY RECURRENCES DO OCCUR!