TSRA Content:
Author: Sadhvika Ramji, MD
This is a revision and update from the previous edition of the TSRA Primer in Cardiothoracic Surgery written by Carlos Anciano, MD and Roman Petrov, MD
Introduction
The primary goal of a fundoplication is to recreate the high-pressure zone and valve at the level of the gastroesophageal junction (GEJ) to act as a barrier against abnormal reflux of gastric contents into the esophagus. Despite treatment with proton pump inhibitors, some patients with GERD continue to have refulx symptoms or endoscopic evidence of esophagitis and are considered for a surgical management. A fundoplication causes compression of the GEJ by the plicated segment of gastric fund us. The most commonly performed fundoplications include the Nissen and Belsey Mark N (270-degree circumferential wraps), the Toupet (270-degree posterior wrap), and the Dor (180-degree anterior wrap).
Different fundoplications present an array of options of "tightness" that sit at one end or the other of the dysphagia-to-reflux spectrum. Objective data from testing of esophagus in addition to symptoms are required to evaluate the presence and severity of GERD and determine the indication and best approach.
Those with a primary complaint of dysphagia and/or ineffective esophageal motility (i.e. achalasia or large paraesophageal hernias in the elderly) will typically benefit from a looser or partial wrap, while those with relatively normal esophageal motility and primary complaints of typical reflux symptoms will likely receive more benefit from a tighter or complete wrap.
A transabdominal approach is used for the Nissen, Toupet, and Dor, while the Belsey:Mark N is done via a transthoracic approach. Transabdominal approaches can be performed laparoscopically or open, however the Belsey Mark JV has only successfully been described by an open approach. The approach may be influenced by surgical history, ability to tolerate pneumoperitoneum, and surgeon expertise.
In all patients before the antireflux surgery, an upper GI endoscopy, pH testing, manometry and barium esophagram should be performed.
Transabdominal Approach
The patient is placed supine in the Fowler position or in the lithotomy reverse-Y position. Upper midline laparotomy – from the tip of the xiphoid process to 3-4cm above the umbilicus or laparoscopic with 5 ports is performed.
For the laparoscopic approach, the lower chest should be prepped into the field in case a tube thoracostomy is needed to treat a tension pneumothorax caused by violation of the mediastinal pleura during mediastinal dissection. The camera port is typically placed in the lower third of the epigastrium to the left of umbilicus. A mirror image port is placed through the right side of the rectus. Subcostal margin ports are placed in the midclavicular line on the right and left. Retract liver after dividing the left triangular and falciform ligaments.
Ports size varies depending on the camera scope (5 vs. 10mm) and suturing technique (Endostitch vs. intra- or extracorporeal knot tying).
First, the gastrohepatic ligament is opened, looking for a replaced/accessory left hepatic artery.If a diminutive aberrant left hepatic artery is seen - ligate it, if the artery is substantial – preserve it. The phrenoesophageal membrane is then opened between the right crus and the esophagus. It is important to enter the correct plane when opening the membrane, as dissection too close to the crus will cause stripping of the peritoneal lining of the crus and dissection too close the esophagus may lead to a myotomy, perforation, or injury to the anterior vagus. Care should be taken to preserve the fascial investiture on the crural pillars.
to maintain the strength needed when reapproximating the crus after performing the wrap. Dissection is carried along the right crus, from right to left across the arch of the crus anteriorly, and then along the left crus. During this dissection it is important to take small bites and to take tissue planes one at a time to avoid dividing the vagus nerves, which should be swept toward the esophagus. The esophagus is then mobilized with thorough dissection in the mediastinum as described in the previous chapter.
Next, the retroesophageal window is created by elevating the esophagus and dissecting posteriorly from right to left of the esophagus, identifying the posterior vagus and sweeping it toward the esophagus. Penrose drain looped around the esophagus between the crura and the left gastric artery rostrocaudally. Retract the esophagus anteriorly to expose the posterior aspect of the hiatus. Circumferential en bloc dissection of the esophagus should be obtained at the hiatus up to the level of the inferior pulmonary vein. Take care to avoid injury to the vagus nerves and the pleura. Accidental entry into the pleural space is generally benign but should be communicated to the anesthesia team.
Then, beginning no more proximal than the termination of right gastroepiploic vessels, mobilization of the fundus is performed by dividing the short gastric vessels along the greater curve from distal to proximal. Typically, only the upper third of the short gastrics need be divided. Splenic and retrogastric attachments are also divided to provide a freely mobile fundus. The GE junction fat pad is incised and sent for a routine pathological evaluation. Confirm if there is adequate length of intraabdominal esophagus – at least 2 – 3 centimeters without traction. After extensive mobilization, if inadequate esophageal length persists, a lengthening procedure should be considered (Collis gastroplasty vs. wedge fundectomy).
At this point, the fundoplication is ready to be performed. The subsequent steps vary depending on the type of wrap to be performed, but there are a few points that should be kept in mind regardless of the type of fundoplication. The line of the short gastrics is the point of reference and should always be grasped when passing the fundus around the esophagus and when placing stitches through the fundus. Passing the fundus or starting your stitches too close to angle of His twists the esophagus, while passing the fundus too far from the angle generates a bulky, distorted wrap. The fundoplication should be performed around a bougie (typically 54F, although 60F may be used for a "floppy" version of the fundoplication) to avoid excessively tight wraps. Alternatively, esophagus + 1 finger width or an EGD can be used to confirm if the hiatal diameter is adequate. Mesh can be used but is generally not preferred in many centers. Again, the patient's symptoms and esophageal motility dictate the type of wrap performed. (Nissen > Floppy Nissen > Toupet > Dorin order of decreasing "tightness"). After completing the fundoplication, the hiatus is reapproximated as described in the previous chapter.
Nissen:
Laparoscopic Nissen fundoplication can offer significant advantages over open approach in terms of efficacy and safety and is the gold standard of all antireflux procedures. The gastric fundus is pulled posteriorly using Babcock forceps for a 360-degree wrap around the esophagus preserving appropriate orientation. When the fundus is no longer held in position, it should not fall back to the left side. If it does, it indicates inadequate dissection along the greater curvature. A shoeshine maneuver is performed by grasping the line of the short gastrics on both sides of the esophagus and rocking the fundus back and forth to ensure there is no torsion. It is helpful to place the bougie after passing the fundus, as the weight of the bougie makes this maneuver more difficult. Suture the wrap incorporating the anterior wall of the distal esophagus just above the proximal cardia within the wrap. 3- 4 interrupted 2-0-silk sero-muscular sutures are placed anteriorly on the fundus on both sides of the wrap with incorporation of the esophageal muscle in-between.The ideal length of the wrap anteriorly is 2 centimeters as longer wraps tend to cause obstructive symptoms. The wrap should encircle the distal esophagus, not the stomach. Sutures are generally placed 1cm apart. When completed, the fundoplication should look like a symmetric collar on the outside and a stack of coins when viewed endoscopically in retroflexion.
Toupet:
After the fundus is brought through the retroesophageal window, stitch the anterior portion of the wrapped fundus to the right lateral wall of esophagus just anterior to the anterior vagus. Next, stitch the posterior portion of the wrapped fundus to the right crus. On the left, stitch the gastric fundus to the left esophagus, just anterior to posterior vagus and posterior portion to left crus. Leave a gap of 1-2cm from the right gastric segment, completing a 270-degree wrap
Dor:
A retroesophageal window is not required for a Dor, but short gastric division may need to be more extensive, but not always necessary. Construction of a partial anterior fundoplication begins with placement of a nonabsorbable 0 suture which passed from the greater curvature of the stomach to left crus, close to its superior limit. This suture is tied with an intracorporeal technique that forms the left edge of the fundoplication. The right side of fundoplication is formed by a suture passed from gastric fundus approximately 5 - 6 cm medial to previous suture in greater curvature to the right crus. This suture is placed from the superior aspect of the midportion of fundoplication to the apex of esophageal hiatus.
Hill Gastropexy:
This procedure involves imbricating the anterior and posterior collar sling muscular fibers at the level of the GEJ around the esophagus with tethering of complex to the median arcuate ligament and closure of the diaphragm. Intraoperative manometry is used to achieve a desired LES pressure. This also involves reconstruction of angle of his and preserving the gastroesophageal valve to prevent reflux.
Transthoracic Approach
A standard left lateral thoracotomy is used, typically entering through the 8th ICS (7th on obese patients) preferably with lung isolation. Selective deflation of left lung with a double lumen endotracheal tube may assist in visualization. Mobilize the esophagus circumferentially as high as the superior pulmonary vein and inferiorly into the abdomen past the GEJ. Watch for diaphragmatic-gastric vessels (Belsey) to avoid difficult intra-abdominal bleeding. After separating the left lobe of the liver, mobilize the stomach and bring it into the chest dividing short gastrics as they come into view. Resect the gastric fat pad to identify GEJ and assess length of future intra-abdominal esophagus. Place your large braided crural sutures at the hiatus and then perform your Nissen wrap as above over a bougie. Reduce the wrap in the abdomen gently and uniformly tie down your crural stitches. If the hiatus is still too wide, place lateral sutures on the hiatus instead of mincing your crura with tension and blindly distorting your wrap.
For a partial fundoplication, Belsey Mark IV, two rows of U stitch sutures are used. The first row starts on stomach 1 cm distal to the GEJ, to the esophagus 1 cm proximal to the GEJ, and back on esophagus and stomach. Three stitches are placed, one just anterior to anterior vagus, one just anterior to posterior vagus, and one in between, then tied. The second row starts by including the diaphragm (start on pleural side to keep knot above), then stomach 1 cm distal to the previous stitch, esophagus 1 cm proximal to the previous stitch, and then back again at the same relationship with the vagus nerves. Reduce the wrap, then tie the second row and crural stitches.
Postoperative Care
Extensive dissection, an open approach, long operative time, history of gastroparesis and surgeon preference determine the need for NGT placement. Postoperative esophagrams are considered on an individual basis depending on intraoperative concerns or in the presence of clinical deterioration. Usually, a barium esophagram is done on postop Day 1 to look for any leak or obstruction. A non-carbonated clear liquid diet is started after that and advanced to soft solids over a period of a week. Anticipate and discuss gas bloat syndrome and inability to belch (less in floppier wraps) or vomit. The most common postoperative complication is dysphagia. Dysphagia that persists more than 12 weeks needs evaluation with a barium swallow to assess the anatomic placement of fundoplication. The causes of dysphagia are broad. Early edema or technical errors are the most common causes early, while underlying motility problems, an excessively tight or long wrap, and a herniated or slipped fundoplication are usual suspects later. Perforation, bleeding, and ulcerations are also possible. Technical failures include disruption of the wrap, herniation of an intact wrap above the diaphragm, and a slipped wrap with part of the stomach above the fundoplication.