Indications

  • Gastroesophageal reflux (see Chap. 13), generally in patients in whom laparoscopic Nissen fundoplication is not applicable

Preoperative Preparation

  • Esophagogastroduodenoscopy with brushing and biopsies of any abnormal mucosa

  • Esophageal manometry or pH studies in selected patients

Pitfalls and Danger Points

  • Inadequate mobilization of gastric fundus and abdominal esophagus

  • Injury to spleen or to vagus nerves

  • Fundoplication wrap too tight or too long

  • Inadequate fundoplication suturing

  • Undiagnosed esophageal motility disorders, such as achalasia, diffuse spasm, aperistalsis, or scleroderma

  • Hiatal closure too tight, causing esophageal obstruction

  • Hiatal closure too loose, permitting postoperative paraesophageal herniation

  • Injury to left hepatic vein or vena cava when incising triangular ligament to liberate left lobe of liver

Operative Strategy

Mobilizing the Gastric Fundus

To perform a hiatus hernia repair efficiently, the lower 5–7 cm of the esophagus and the entire gastric fundus from the gastroesophageal junction down to the upper short gastric vessel must be completely mobilized from all attachments to the diaphragm and the posterior abdominal wall. Identify the gastrophrenic ligament by passing the left hand behind the stomach so the fingertips can identify this avascular ligament, which attaches the greater curvature to the diaphragm. The ligament extends from the gastroesophageal junction down to the first short gastric vessel. It is simple to divide once it has been stretched by the surgeon’s left hand behind the stomach. Although in a few cases no short gastric vessels must be divided, there should be no hesitation to divide one to three proximal short gastric vessels to create a loose fundoplication.

On the lesser curvature aspect of the gastroesophageal junction, it is necessary to divide the proximal portion of the gastrohepatic ligament. This ligament often contains an accessory left hepatic artery arising from the left gastric artery and going to the left lobe of the liver and the hepatic branch of the left vagus nerve. Division of the accessory left hepatic artery has, in our experience, not proved harmful. Do not divide the left gastric artery itself. Preserving the left gastric artery and the hepatic branch of the vagus nerve helps prevent the fundoplication from slipping in a caudal direction. The lower esophagus is freed by incising the overlying peritoneum and phrenoesophageal ligaments; continue this incision in a semicircular fashion so the muscular margins of the diaphragmatic crura are exposed down to the median arcuate ligament. During all of this mobilization, look for the major branches of the anterior and posterior vagus nerves and preserve them.

Preventing Splenic Injury

Splenic trauma is a common but preventable complication of the Nissen operation. With use of the Thompson or upper hand retractor, there is no reason for any retractor to come into contact with the spleen. The mechanism of splenic injury is usually traction on the body of the stomach toward the patient’s right, which avulses that portion of the splenic capsule attached to the omentum or to the gastrosplenic ligament. Early during the operation, make it a point to look at the anterior surface of the spleen. Note where the omentum may be adherent to the splenic capsule. If necessary, divide these attachments under direct vision. Otherwise, simply apply a moist gauze pad over the spleen and avoid lateral traction on the stomach. Traction on the gastroesophageal junction in a caudal direction along the lesser curve of the stomach generally does not cause injury to the spleen.

If a portion of the splenic capsule has been avulsed, it can almost always be managed by applying topical hemostatic agents followed by 10 min of pressure. Other splenic injuries can be repaired by suturing with 2-0 chromic catgut (see Chap. 97). Extensive disruption of the spleen at its hilus may necessitate splenectomy.

Avoiding Postoperative Dysphagia

Probably secondary to local edema, transient mild dysphagia is common during the first 2–3 weeks following operation, although some patients have difficulty swallowing for many months after a hiatus hernia operation. There are several possible causes for this dysphagia. First, it is possible to make the fundoplication wrap so tight or so wide that permanent dysphagia ensues (see below). Second, the defect in the hiatus may be sutured so tightly the hiatus impinges on the lumen of the esophagus and prevents passage of food. With an 18 F nasogastric tube in place, after the crural sutures have been tied to repair the defect in the hiatus, it should still be possible to insert an index finger without difficulty between the esophagus and the margins of the hiatus. There is no virtue in closing the hiatus snugly around the esophagus. A final cause of dysphagia in patients who have experienced this symptom as a preoperative complaint is the presence of an esophageal motility disorder such as achalasia or aperistalsis. Patients who present to the surgeon with reflux esophagitis and who also complain of dysphagia should undergo preoperative esophageal manometry to rule out motility disorders that may require surgery in addition to the antireflux procedure or instead of it.

How Tight Should the Fundoplication Be?

The Nissen operation produces a high pressure zone in the lower esophagus by transmitted gastric pressure in the wrap, rather than by the tightness of the wrap itself. An excessively tight wrap causes dysphagia and the gas bloat syndrome. Therefore the fundoplication should be made loose, rather than tight enough to constrict the esophagus. Many surgeons use an indwelling esophageal bougie to avoid creating a wrap that is too tight. Regardless of whether the indwelling bougie is used, it is possible to judge the tightness of the wrap by applying Babcock clamps to each side of the gastric fundus and tentatively bringing them together in front of the esophagus. This mimics the effect of the sutures. The surgeon should be able to pass one or two fingers between the wrap and the esophagus without difficulty with an 18 F nasogastric tube in place. Otherwise readjust the fundoplication so it is loose enough for this maneuver to be accomplished.

How Long Should the Fundoplication Be?

Another cause of postoperative dysphagia is making the fundoplication wrap too long. For the usual Nissen operation, do not wrap more than 2–3 cm of esophagus. A shorter wrap may be appropriate when esophageal dysmotility and gastroesophageal reflux coexist (e.g., when a fundoplication is added to a myotomy).

Avoiding Fundoplication Suture Line Disruption

Polk and others have noted that an important cause of failure after Nissen fundoplication has been disruption of the plication because the sutures broke. For this reason, use 2-0 sutures. Generally, the sutures that were found to have broken were silk. We have used 2-0 Tevdek because it retains its tensile strength for many years, whereas silk gradually degenerates in the tissues. It is also important not to pass the suture into the lumen of the stomach or esophagus. If this error is committed, tying the suture too tight causes strangulation and possibly leakage. Some insurance against the latter complication is to turn in the major fundoplication sutures with a layer of continuous 4-0 Prolene seromuscular Lembert sutures.

Failure to Bring the Esophagogastric Junction into the Abdomen

If it is not possible to mobilize the esophagogastric junction from the mediastinum and bring it into the abdomen while performing transabdominal repair of a hiatus hernia, it is likely that esophageal fibrosis has produced shortening. Such a situation can generally be suspected prior to operation when the lower esophagus is strictured. In our opinion, these patients require a transthoracic Collis-Nissen operation (see Chap. 22). Although it is possible to perform a Collis-Nissen procedure in the abdomen, it is difficult. If it cannot be accomplished transabdominally, it is necessary to open the chest through a separate incision or through a thoracoabdominal extension to perform the Collis-Nissen operation.

Keeping the Fundoplication from Slipping

Various methods have been advocated to keep the fundoplication from sliding in a caudal direction, where it constricts the middle of the stomach instead of the esophagus and produces an “hourglass” stomach with partial obstruction. The most important means of preventing this caudal displacement of the wrap is to include the wall of the esophagus in each of the fundoplication sutures. Also, catch the wall of the stomach just below the gastroesophageal junction within the lowermost suture. This suture anchors the lower portion of the wrap (see Fig. 19.10 below).

Documentation Basic

  • Findings

  • Placement of wrap relative to vagus nerves

  • Closure of hiatus?

Operative Technique

Incision

Elevate the head of the operating table 10–15°. Make a midline incision beginning at the xiphoid and continue about 2–3 cm beyond the umbilicus (Fig. 19.1). Explore the abdomen. Insert a Thompson or Upper Hand retractor to elevate the lower portion of the sternum. Reduce the hiatus hernia by traction along the anterior wall of the stomach. Look at the anterior surface of the spleen to determine whether there are omental adhesions to the capsule that may result in the capsule avulsing later during the operation. Place a moist gauze pad over the spleen. In most cases it is not necessary to free the left lobe of the liver; simply elevate the left lobe with a Weinberg retractor to expose the diaphragmatic hiatus.

figure 1

Fig. 19.1

Mobilizing the Esophagus and Gastric Fundus

Make a transverse incision in the peritoneum overlying the abdominal esophagus (Fig. 19.2) and continue this incision into the peritoneum overlying the right margin of the crus. Then divide the peritoneum overlying the left margin of the diaphragmatic hiatus. Separate the hiatal musculature from the esophagus using a peanut dissector until most of the circumference of the esophagus has been exposed. Then pass the index finger gently behind the esophagus and encircle it with a latex drain (Fig. 19.3). Enclose both the right and left vagus nerves in the latex drain and divide all the phrenoesophageal attachments behind the esophagus. If the right (posterior) vagus trunk courses at a distance from the esophagus, it is easier to dissect the nerve away from the upper stomach and to exclude the right vagus from the fundoplication wrap. Some exclude both vagus trunks from the wrap, but we prefer to include them inside the loose wrap. Before the complete circumference of the hiatus can be visualized, it is necessary to divide not only the phrenoesophageal ligaments but also the cephalad portion of the gastrohepatic ligament, which often contains an accessory left hepatic artery that may be divided (Fig. 19.4). The exposure at the conclusion of this maneuver is seen in Fig. 19.5. Now pass the left hand behind the esophagus and behind the gastric fundus to identify the gastrophrenic ligament and divide it carefully down to the proximal short gastric vessel (Fig. 19.6).

figure 2

Fig. 19.2

figure 3

Fig. 19.3

figure 4

Fig. 19.4

figure 5

Fig. 19.5

figure 6

Fig. 19.6

While the assistant is placing traction on the latex drain to draw the esophagus in a caudal direction, pass the right hand to deliver the gastric fundus behind the esophagus (Fig. 19.7). Apply Babcock clamps to the two points on the stomach where the first fundoplication suture will be inserted and bring these two Babcock clamps together tentatively to assess whether the fundus has been mobilized sufficiently to accomplish the fundoplication without tension. Figure 19.8, a cross-sectional view, demonstrates how the gastric fundus surrounds the lower esophagus and the vagus nerves.

figure 7

Fig. 19.7

figure 8

Fig. 19.8

Generally, there is inadequate mobility of the gastric fundus unless one divides the proximal one to three short gastric vessels. Ligate each with 2-0 silk.

On the greater curvature aspect of the esophagogastric junction, there is usually a small fat pad. Excising the fat pad improves adhesion of the gastric wrap to the esophagus.

Repairing the Hiatal Defect

Using 0 Tevdek sutures on a large atraumatic needle, begin at the posterior margin of the hiatal defect and take a bite (1.3–2.0 cm in width) of the crus and its overlying peritoneum on each side of the hiatus. Insert the next suture about 1.0–1.2 cm cephalad and continue this process until the index finger can just be inserted comfortably between the esophagus and the margin of the hiatus (Fig. 19.9).

figure 9

Fig. 19.9

Suturing the Fundoplication

Pass a 40 F Maloney dilator into the stomach. Insert the first fundoplication suture by taking a bite of the fundus on the patient’s left using 2-0 atraumatic Tevdek. Pass the needle through the seromuscular surface of the gastric lesser curve just distal to the esophagogastric junction; then take a final bite of the fundus on the patient’s right. Attach a hemostat to tag this stitch but do not tie it. Each bite should contain 5–6 mm of tissue including submucosa, but it should not penetrate the lumen. Do not pierce any of the vagus nerves with a stitch. To perform a fundoplication without tension, it is necessary to insert the gastric sutures a sufficient distance lateral to the esophagogastric junction. Place additional sutures, as illustrated in Fig. 19.10, at intervals of about 1 cm. Each suture should contain one bite of fundus, then esophagus, and then the opposite side of the fundus. No more than 2–3 cm of esophagus should be encircled by the fundoplication. Now tie all of these sutures (Fig. 19.11). It should be possible to insert one or two fingers between the esophagus and the Nissen wrap (Fig. 19.12). If this cannot be done, the wrap is too tight.

figure 10

Fig. 19.10

figure 11

Fig. 19.11

figure 12

Fig. 19.12

A number of surgeons place sutures fixing the upper margin of the Nissen wrap to the esophagus to prevent the entire wrap from sliding downward and constricting the stomach in the shape of an hourglass. DeMeester and Stein, after considerable experience, advocated a Nissen wrap measuring only 1 cm in length, claiming that longer wraps produce postoperative dysphagia in a number of patients. Even with a 60 F Maloney bougie in the esophagus, a 1 cm wrap has effectuated excellent control of reflux. They constructed this wrap employing one horizontal mattress suture of 2-0 Prolene buttressed with Teflon pledgets (Figs. 19.13 and 19.14).

figure 13

Fig. 19.13

figure 14

Fig. 19.14

Optionally, at this point one may invert the layer of fundoplication sutures by inserting a continuous seromuscular layer of 4-0 Prolene Lembert sutures (not illustrated). This layer provides protection against leakage if any of the fundoplication sutures were placed too deep.

Testing Antireflux Valve

Ask the anesthesiologist to inject 300–400 ml saline solution into the nasogastric tube and then withdraw the tube into the esophagus. Now try to expel the saline by compressing the stomach. If the saline cannot be forced into the esophagus by moderate manual compression of the stomach, the fundoplication has indeed created a competent antireflux valve.

Abdominal Closure

Close the abdomen without drainage in routine fashion.

Postoperative Care

Continue nasogastric suction for 1–2 days. Then initiate oral feeding. A barium esophagram is obtained before the patient is discharged. If a satisfactory repair has been accomplished, 3–4 cm of distal esophagus becomes progressively narrower, tapering to a point at the gastroesophageal junction. If this tapering effect is not noted, it suggests that the wrap may be too loose. Successful antireflux procedures, whether by the Nissen, Hill, Belsey, or Collis-Nissen technique, show similar narrowing of the distal esophagus on the postoperative esophagram. A typical postoperative barium esophagram is shown in Fig. 19.15.

figure 15

Fig. 19.15

Complications

  • Dysphagia, usually transient “gas bloat” (rare)

  • Disruption of fundoplication

  • Slipping downward of fundoplication with obstruction

  • Postoperative paraesophageal hernia if hiatal defect was not properly closed

  • Herniation of fundoplication into thorax

  • Esophageal or gastric perforation by deep necrosing sutures

  • Persistent gastroesophageal reflux