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Laparoscopic antireflux surgery
HISTORY
Rudolph Nissen popularized a fundoplication that bears his name in 1956, following the discovery that a fundal patch, used to reinforce an esophageal suture line, also corrected gastroesophageal reflux. In 1991, two almost simultaneous publications were released describing the adaption of Nissen’s technique laparoscopically. The principles of the operation closely followed the open technique, with division of the short gastric vessels, posterior closure of the diaphragmatic hiatus, and creation of a 1-2 cm 360-degree wrap, calibrated by at least a 52 Fr bougie. Although the initial reports included very good levels of reflux control, adverse effects—such as dysphagia, inability to belch, gas bloat, and increased flatulence—were not uncommon.
In an attempt to achieve an effective antireflux barrier with fewer side effects, a number of partial fundoplications have been proposed over the years. We will concentrate on the two most popular of these: the posterior 270-degree fundoplication and the anterior 180-degree fundoplication. The laparoscopic posterior 270-degree wrap was first described by Cushieri et al. in 1993, closely mimicking Toupet’s original description in 1963. Reports of laparoscopic anterior 180-degree wrap began to emerge in the early to mid-1990s, from our group in Adelaide, Australia, based on Dor’s reports, in 1962, of an anterior 180-degree wrap designed to control reflux in patients undergoing cardiomyotomy for achalasia.
Minimally invasive techniques have revolutionized surgery. Comparisons between open and laparoscopic fundoplication have conclusively demonstrated that a laparoscopic approach has clear advantages in terms of reduced complications and quicker recovery. Furthermore, this is not at the cost of less durable reflux control. It is now the standard surgical approach, and most large medical centers offer laparoscopic fundoplication.
PRINCIPLES AND JUSTIFICATION
The ideal antireflux operation would alleviate reflux by replicating normal physiological function of the lower esophageal sphincter. Surgery creates a mechanical barrier to reflux between the stomach and the esophagus, which is independent of the constituent of the refluxate, whether this is acid based or duodeno-gastric in nature. The effect is immediate and does not limit normal activity and is often permanent, but is not without consequences. Although the operative risks are low and laparoscopic approaches have lessened the insult to the abdominal wall, which in turn reduces postoperative pain, surgery is never painless and comes with the potential for morbidity. Also, the surgical reflux barrier sometimes works in both directions, so that patients can develop dysphagia: limiting diet in one direction and gas release in the other—that is, belching and vomiting may not be possible.
The aims of surgery include the following:
- To reduce a hiatal hernia (for large hiatal hernia, see Chapter 39, “Laparoscopic large hiatus hernia repair”)
- To repair a hiatal defect by tightening the diaphragmatic crural pillars
- To restore 3-4 cm of the esophagus below the diaphragm
- To create a valve at the gastroesophageal junction to prevent acid reflux
How does it work?
As stated, most surgeons now perform a variant of one of three eponymous abdominal operations: a Nissen 360-degree fundoplication, a Dor 180-degree anterior fundoplication, and a Toupet 270-degree posterior fundoplication. The exact mechanism of action of all three antireflux operations is not completely clear but they all bear similarities. The main reason is probably the creation of a “physical” valve. Surgery ensures that the distal esophagus is placed intra-abdominally,
at the same time exaggerating the sharpness of the angle between it and the adjacent gastric fundus. This forms a flap-like valve that closes in two situations: (1) a rise in intragastric pressure, which leads to gastric fundal expansion and thus compression of the adjacent esophagus, and (2) a rise in intra-abdominal pressure, which directly collapses the intra-abdominal esophagus. As well, repair of the diaphragm allows it to contribute to its normal antireflux activity via contraction of the crura.
PREOPERATIVE ASSESSMENT AND PREPARATION
History and workup
It is important to take a careful history for reflux. “Reflux” can mean a great many things to patients. One common approach is to divide presenting symptoms under typical and atypical headings. Typical (or classic) symptoms include retrosternal burning or pain and acid regurgitation (also referred to as “water brash” or “volume reflux”). Atypical symptoms (considered extra-esophageal manifestations of reflux) include cough, hoarseness, aspiration pneumonia, dental erosions, and globus. It is important to define response of symptoms to antireflux medication, and to document type of medication, amount, and timing of medication.
With a goal of 100% satisfaction among our patient population (however unattainable!), potential candidates for antireflux surgery must be properly assessed. In our opinion, this involves a minimum of endoscopy, ambulatory pH monitoring (in the absence of Grade II esophagitis or higher on endoscopy), and esophageal manometry. In our practice, the operating surgeon generally repeats the endoscopy to look at the gastroesophageal junction and anatomy, rule out Barrett’s esophagus/peptic stricture, and document the presence/absence of esophagitis (see Chapter 27, “Endoscopy”). If esophagitis is present, a postoperative endoscopy is prudent to rule out subsequent development of Barrett’s esophagus. The surgeon should document the percentage of time acid is in the lower esophagus, and, in particular, the temporal correlation between symptoms and episodes of reflux (either reported as the symptom index or symptom association probability). A barium swallow is a useful adjunct in a patient with a hiatus hernia.
Selection criteria for surgery
Classic teaching dictates that a patient with typical symptoms of reflux, a good response to antireflux medication and a positive 24-hour pH study will have a good result with 90% certainty. So, who are the 10% of patients who will do poorly? Studies have shown that the following patient characteristics are associated with poorer outcomes:
- Female
- Atypical symptoms, especially the patient with cough as their sole symptom
- Poor response to antireflux medication
- Low symptom index or symptom association probability on 24-hour pH study
- No hiatus hernia
- Poor esophageal motility
- Public hospital treatment
TAILOR THE WRAP TO THE PATIENT
The Nissen 360-degree fundoplication is termed a “total” fundoplication as the wrap completely encircles the distal esophagus. This offers good and durable reflux control but this sometimes comes at the expense of an “overcompetent” barrier; that is, one that is too tight and leads to dysphagia with solids, and/or gas bloat and increased flatulence from an inability to belch and release swallowed air. Partial repairs, both anterior 180 degree and posterior 270 degree, are cited as causing fewer of these competency problems. A number of randomized studies have attempted to clarify this. The evidence to date suggests that “wind”-related side effects and postfundoplication dysphagia are less common following a partial fundoplication but that this may be offset by a slightly higher risk of recurrent reflux.
In the authors’ practice, young patients with good esophageal motility are offered a 360-degree fundoplication, with the knowledge that adverse effects will be better tolerated in these individuals, and then subside over time. A 360-degree fundoplication is also used in patients with Barrett’s esophagus, and in those with a peptic stricture from severe reflux. In most other patients, especially elderly patients with a primary complaint of large hiatus hernia, a partial fundoplication is performed. In our institutions, this tends to be a 180-degree fundoplication.
Preoperative preparation
The vast majority of our patients undergo 3-4 weeks of a very low calorie diet prior to surgery. The reason for this is a dramatic reduction in liver volume, which optimizes the surgeon’s access to the hiatus for successful laparoscopic surgery. Patients also meet a dietician prior to surgery for education regarding a suitable postfundoplication diet. In general terms, this is a minced and moist diet and excludes foods likely to obstruct at the gastroesophageal junction, such as bread, pasta, and chunky pieces of meat.
The anesthetic is tailored to minimize postoperative nausea and/or vomiting. This involves avoidance of volatile agents (e.g., isoflurane, sevoflurane, nitrous oxide) and morphine. In our institution, the anesthetists prefer total intravenous anesthesia with propofol infusion. Dexamethasone 4 mg intravenous (IV) is administered, and a 5-HT3 antagonist (e.g., ondansetron) is commenced. All patients wear stockings in addition to pneumatic compression stockings, and receive appropriate antibiotic prophylaxis.
OPERATIVE TECHNIQUE
Position of patient and port placement
We prefer to work between the patient’s legs (with the patient in lithotomy), with the right arm tucked, and left arm abducted. A pneumoperitoneum is established using a Veress technique under the left subcostal margin. Carbon dioxide is insufflated to a maximum pressure of 14 mmHg. A 10-12 mm port is then placed just to the left of midline, 15 cm from the xiphoid process. A 30-degree camera is inserted and all ports thereafter are placed under direct vision: 10-12 mm port in the left upper quadrant (11 cm from xiphoid under the left subcostal margin) and a further two 5 mm lateral ports and a subxiphoid Nathanson retractor to retract the left lobe of the liver. The patient is tilted in a steep reverse Trendelenburg position prior to positioning of the liver retractor. The surgeon moves between the patient’s legs, the assistant sits on a stool to the patient’s left side, and the monitor is positioned over the head of the patient with an extra monitor (if available) to the right side of the patient’s head. (See Figure 38.1.)
38.1
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