Laparoscpic Nissen fundoplication

Indications include oesophageal pH <4, recorded 5cm above a manometrically defined LOS, present for >4%/24hrs,
Complicated - oesophagitis/stricture/Barretts on endoscopy,
Uncomplicated - failure to respond to conservative measures, desire to discontinue lifelong medication.

1.Position the patient in low Lloyd -Davies, reverse Trendelenberg
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.If the greater omentum is obstructing the view it can be picked up in a suture and brought out through one of the left sided ports.
5.Commence by identifying and dissecting the left crus with the assistant retracting the fundus downwards, extending the incision to the left over the fundus of the stomach. At this point it is also convenient to divide the short gastric vessels to enable a mobile fundus if required.
6.Divide and open gastro-hepatic omentum. The hepatic vagal branch in the lesser omentum may have to be sacrificed; however a smaller window prevents the wrap from slipping caudally.
7.Dissect the right crus, while retracting the oesophagus.
8.There should now be an adequate posterior window created in the retro-oesophageal space. Bring a grasper through to the left of the oesophagus staying close to the posterior wall of the oesophagus.
9.Place a Penrose drain in the abdomen and bring it through around the oesophagus to be used as a retractor.
10.Complete the definition of the left crus.
11.Perform the crural repair with 1-3 sutures (3/0 prolene). A bougie (56 or 58F) in the oesophagus can be used as a guide but I don’t normally use this.
12.Bring the fundus around the back of the oesophagus and get the assistant to hold the fundus at the site of intended wrap.
13.Fix the right side of the wrap to the right crus with 1-2 sutures to prevent the wrap from falling back around.
14.Complete the wrap by suturing the right and left sides of the fundus across the front of the oesophagus with three sutures (posterior partial or 270 degree wrap also known as Toupet).

Complications PPPPDBV
1.Paraoesophageal hiatus hernia upto 5% (routine hiatal repair dramatically reduces)
2.PE
3.Pneumothorax in up to 2%
4.Perforation up to 1%
5.Dysphagia in nearly all
6.Bilobed stomach by using to distal stomach for wrap
7.Vascular injury rare.