Laparoscopic Nissen fundoplication

Surgical history
Rudolf Nissen. German
First performed 1937 for bleeding chronic ulcer in sliding HH. Created to protect anastomosis
DeMeester introduced pH monitoring and bile reflux studies
Laparoscopic technique 1991

Modern principles
Long intra-abdominal segment
Posterior crural repair
Accentuation of angle of His
Fixation of intra-abdominal oesophagus to right crus
Loose, floppy wrap over large bougie (50Fr)

Types
Traditional Nissen: 360 deg post wrap
Partial
Besley Mark IV 270
Toupet 180 degree

Lithotomy
Hasson at mid point b/w umbilicus and xiphisternum
Nathanson retractor under left lobe liver
3 x 5mm ports (2 on Right side)
Harmonic scalpel
Reduce hiatal hernia
crural repair important
Division of short gastrics controversial: may lead to more gas bloat. Literature equivocal
Penrose drain around oesophagus for traction, held by assistant
Suture oesophageal hiatus over 50 Fr bougie (extracorporeal)
?temporary mesh over hiatus
Wrap fundus

Little role for Collis gastroplasty for shortened oesophagus as this is rare