11.01.08
Nissen Fundoplication
I. Nissen
360˚ wrap (left crus approach) used when medical management for GERD
fails, severe esophageal injury (ulcer, stricture, or Barrett’s)
- Procedure of choice for patients with normal esophageal motility
- Advantage of direct and early view of short gastrics, spleen
II. Operative -Position: low lithotomy -Surgery: Dissect out left crus and greater curvature. Take down short gastrics
to mobilize fundus. Mobilize left crus and right crus. Open lesser omentum. Preserve anterior and posterior vagi (both contained by wrap). Reapproximate crura posteriorly. Heavy permanent sutures allow passage of 52F bougie. Wrap created length of 2.5-3cm and anchor to esophagus and bilateral crus at hiatus. Anchor anteriorly and posteriorly.
III. Complications -3 – 10% of patients
A. Operative
-Pneumothorax – most common: 5 – 8%. Violation of pleural space by CO2. No need to evacuate gas. Lung will usually expand without incident. Supplemental O2, repeat CXR 2h after operation.
-Gastric/Esophageal Injuries – less common: <1%. Result of overaggressive tissue manipulation or passage of bougie. May be repaired with suture or automatic stapler if identified at time of surgery. If injury not seen at operation, patient will likely need second operation to repair viscus unless the leak is small and contained.
- Liver/Spleen – reported rarely. Careful retraction of left lobe of liver will prevent significant laceration and subcapsular hematomas. Splenic injury usually results from dissection of fundus and greater curvature.
B. Post-operative
-Bloating – complaint of bloating in 30% of patients, <4% after 2 months. Difficulty belching secondary to wrap. Vagal trauma may lead to delayed gastric emptying. Patients have tendency to swallow saliva (unconscious effort to relieve symptoms of reflux) and with this a significant amount of air.
- Dysphagia – 20% of patients. Due to dissection of hiatus or suture placement and handling of esophagus will cause some edema. dysphagia is usually short-lived. If the wrap is too tight, unlikely to resolve without dilation.
