Symptomatic gastroesophageal reflux disease is the most common indication for laparoscopic fundoplication using the floppy 360-degree Nissen technique. The clinical presentation and diagnostic workup are described in detail in Chapter 34. Repeated episodes of aspiration pneumonia or asthma triggered by reflux are significant indications. Intolerance to medical management with proton pump inhibitors, noncompliance with recommended medication regimens, and the cost of lifelong medications represent additional indications for this procedure.
A full general medical evaluation is performed and the usual preanesthesia testing is obtained. Esophageal function studies such as manometry or video esophagography are necessary in order to plan for a full or partial fundoplication and to detect underlying dysmotility not related to reflux. Special emphasis is placed upon the pulmonary workup. Pulmonary function studies are needed in high-risk patients, especially if recurrent episodes of aspiration pneumonia or asthma have occurred. Antacids, acid blockers, and proton pump inhibitors are continued. Perioperative antibiotic coverage is optional.
The patient is placed in the supine split-legged or low lithotomy position with the arms out on arm boards or tucked in at the sides (figure 1). The legs are spread sufficiently for the surgeon to be positioned, but the thighs are only partially elevated. Elastic stockings or pneumatic sequential compression stockings are put on the lower legs. The patient is placed in a reverse Trendelenburg position, with at least 30 degrees of elevation to the head of the table.