Principles

Principles of operation:
- Mobilize lower oesophagus
- Wrap fundus of the stomach
- Stabilize new anatomy
Mechanism of effect
- Create floppy valve by opposing oesophagus to gastric fundus
- Exaggeration of angle of His
- Normalises basal pressure of LOS
- Reduction in TLOSR
- Increased gastric emptying

Procedure

Ports = Left rectus optical entry
- Left flank working port
- Right subcostal MCL
- Left subcostal MCL
- Natheson retractor in epigastrium
Steps
- Expose oesophagus and mobilisation
  - Divide the gastrohepatic ligament up to the crus
    - Preserving accessory Left Hepatic artery (Pars flaccida)
- Delineate Crura
  - Identify left crus from the right by lifting oesophagus
    - Preserve epimysium covering muscle
- Mobalise the fundus
  - Divide short gastric vessels along greater curvature
  - Ensure fundus is fully mobilised to perform a wrap without tension
- Sling the oesophagus and ensure enough abdominal length (4cm) – preserve posterior vagal nerve
- Crural repair
  - Tension free (ethibond figure 8)
    - May require biosynthetic mesh if large
- Fundoplication
  - Options as below
  - Short floppy wrap, anchor top to crura, Bougie 52 F

Gives best outcome but more gas bloat & dysphagia
- For the exam you are only going to operate on those really suffering
- Benign disease so err on side of caution before operating
Success rate 90% (good/excellent long-term outcomes)
Predictors of a good outcome from surgery
- Objective pre-op evidence of reflux (? or very typical Sx)
- Normal pre-op pH study is a predictor of poor outcome
- Complete / partial response to PPIs
- Good compliance with anti-reflux meds
Basic elements of the operation
- Exposure of the oesophageal hiatus
- Reduction of Hiatus hernia
- Completely mobilize GOJ
- Exposure of 3-4cm of oesophagus without tension below the diaphragm
- Crural closure (cruroplasty) – important to prevent hiatus hernia
- Fundus mobilization
  - ± Division of short gastrics (→ ↑ fundal length available for fundoplication) but ? not needed
- Creation of a short (< 2cm), loose wrap over a 56-60 F bougie
- Preservation of Vagi (preserves gastric emptying)
  - No benefit; “wind related” Sx ↑ed because nerves damaged

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Nissen
- 10-year symptom free good, best for long term reflux control
- ~ 25% pts will require medication again in long term
- No reduction in rates of oesophageal adenocarcinoma cf anti-acid medication
Partial fundoplication
- Decreased side effects (e.g. dysphagia, gas bloat)
- Increased recurrence
Some new studies claim little difference in recurrence or dysphagia
- Nissen vs. 180 ant partial after 10-yrs f/up
  - Partial posterior has reduced gas bloat/bloating/flatulence
Anterior partial fundoplication:
- Improved dysphagia, less bloating and preservation of belching
- However Nissen’s had better control of reflux and decreased incidence of re-operation for reflux
Take home points
- After either operation 80-90% pts are satisfied with outcome
- Nissen’s has better control of reflux but higher dysphagia, gas related sx
- Partial has less dysphagia/gas related sx but increased chance of re-operation for reflux
- Dividing short gastric does NOT improve reflux symptoms
  - Associated with increased symptoms of gas bloat/flatulence and disruption of fundoplication
  - Also associated with increased risk of sliding hiatus hernia

Convert to open
Pneumothorax 2%
- Injury to left pleural membrane
- CO2 – watch & wait, pneumomediastinum
Perforation of Oesophagus / Stomach < 1%
Bleeding
- Injury to major vessels, liver, short gastrics
- Liver/spleen injury
  - Spleen 2.3%

Gas bloat 30%
- Most settles with time
- Due to gastric inertia – vagal injury
- May need pyloric dilation
  - If improves symptoms, definitive treatment is Antrectomy and Roux-en-y
Dysphagia < 30% early, 5% late
- Higher initially due to oedema
- Use graduated diet over 4-6 weeks; clear fluids after 6 hours, sloppy diet at 24 hours usually okay
- Often tight hiatal repair
  - Requires release of sutures
- Late dysphagia usually due to excessive scaring at hiatal repair
  - Managed by balloon dilation or repeat op and widening hiatus
Slipped Wrap
Acute recurrence
- Crural repair failure
Paraoesophageal hernia (5-7%)
- Increased in laparoscopic repair
- Exacerbated by:
  - Higher thoracic dissection
  - Breach of left pleural membrane
  - Less post op pain, means pts cough > Increased risk of stomach protruding into left hemithorax
  - Routine hiatal repair reduces risk by 80%
  - Avoid lifting/straining for 1 month
PE
- Increased risk with prolonged ops, steep head up, legs in stirrups
- Minimized by mechanical and chemical VTE prophylaxis.
Bilobed stomach - body rather than fundus used for wrap

RYGB may be more appropriate for very obese
Consider PTFE mesh patch for very large hiatus hernia
- Less recurrence than suture alone
Endoscopic Options:
- All poor outcomes and not recommended
- Rx for mild-mod reflux (exclude > 2cm H/H) – currently not recommended
Stretta:
- Burns introduced into oesophagus → Denervates mucosa → Poor outcomes
Endosinch
- Mucosal suturing device → effect limited as sutures disappear
- ≈ 50% at 3mths, ≈ 90% disappeared at 1yr
Full thickness Plicator
- ? more potential: ≈ 70% of patient off PPIs at 1yr
Enteryx
- Bioenert polymer injected into LES
- Complications potentially serious if injections end up outside the wall
- Causes adhesions around oesophagus, making subsequent surgery more difficult