Laparoscopic Nissen Fundoplication

The laparoscopic Nissen fundoplication is carried out under general anesthesia. After optimal positioning of the patient a pneumoperitoneum with carbon dioxide is established using a Verres needle and five 10 mm ports should be placed as shown in Figure 1. The best position for the surgeon is between the legs of the patient, to allow comfortable access to the abdominal esophagus through the upper midline and left midsubcostal ports. The surgeons will be helped by one assistant on the right to handle the camera and retract the liver and another assistant on the left side of the patient to retract the stomach and esophagus.
The first step is to divide the gastrohepatic omentum close to the liver and to make an incision into the peritoneum along the free edge of the right crus, the circumference of the diaphragmatic crura and onto the left crus. Knowledge of the presence of an aberrant left hepatic artery is very important for this step. It may be found in about 12% of the patients. Ligation of this vessel may result in hepatic necrosis. Circumferential mobilization of the esophagus is achieved by careful dissection of the anterior and posterior soft tissues within the hiatus. The anterior and posterior vagus nerves are identified, and the posterior vagus is dissected off the back of the esophagus. This is easy to do laparoscopically.
A large window is created below the left crus between the back wall of the esophagus, the posterior vagus nerve and the stomach wall. The next step is to close the crura with one to three nonabsorbable sutures, depending on the size of the hernia. The reason to close the crura in front of the nerve is to trap the nerve and to thereby decrease the probability of slippage of the stomach through the fundoplication into the chest.
As the wrap should be made without tension to prevent postoperative dysphagia or disruption of the fundoplication it is very important to mobilize the fundus. The short gastric vessels are clipped and divided or transected using the Harmonic scalpel to mobilize the greater curvature of the stomach beginning approximately 10 cm distal to the angle of His. The well mobilized fundus can be easily pulled by a Babcock clamp passed behind the esophagus.
The left limb of the fundoplication should be carefully selected by using a part of the proximal fundus of the stomach close to the divided short gastric vessels to avoid rotational torsion at the cardia. A loose 360° wrap around the abdominal esophagus is held in place by using a U-stitch passed through the stomach and esophagus.

2-0 Prolene and two Teflon pledgets are our preference. To control the tightness of the wrap a 58 to 60 Fr Maloney bougie may be passed into the stomach but has the risk of esophageal or gastric perforation in 1%. It has been shown that a wrap of only 2 cm in length is adequate to prevent reflux and results in a low rate of dysphagia.
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