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Ann Thorac Surg 1996;61:1062-1065
© 1996 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Laparoscopic Fundoplication: A Natural Extension for the Thoracic Surgeon

Departments of Surgery, Saint Louis University Health Sciences Center, St Louis, Missouri, and The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Thoracic surgeons have historically played a significant role in surgical treatment of benign esophageal disorders. With the advent of video-assisted thoracic surgical techniques, chest surgeons have also become adept at minimally invasive procedures. Thus, it seems appropriate that thoracic surgeons participate in minimally invasive antireflux operations, such as laparoscopic Nissen fundoplication.

Methods. From February 1993 to May 1995, 66 patients (32 male, 34 female) with a mean age of 45.5 years (range, 15 to 82 years) underwent a laparoscopic fundoplication. Gastroesophageal reflux disease was diagnosed on the basis of history and endoscopically documented esophagitis or abnormal esophageal pH testing or both. There were 45 type I, 3 type II, and 7 type III hiatal hernias. Eleven patients had gastroesophageal reflux disease with no hernia.

Results. Conversion to laparotomy occurred in 6 patients (9%) due to bleeding in 2 patients, inability to expose the gastroesophageal junction in 3, and gastric laceration in 1 patient. All but 1 patient underwent a Nissen fundoplication performed over a 50F to 60F dilator. The remaining patient (type II hernia without gastroesophageal reflux disease) underwent a reduction, closure, and anterior gastropexy. There was no operative mortality. Immediate postoperative morbidity included moderate dysphagia in 7 patients (11%), ileus in 2 patients (3%), and deep venous thrombosis and atrial arrhythmia in 1 each (1.5%). Excluding 1 patient hospitalized for 42 days due to severe psychosis, the mean postoperative stay was 4.0 ± 2.5 days (median, 3 days). Three patients (5%) required dilation for dysphagia, and 1 (1.5%) has noted recurrent reflux during follow-up (mean, 14.4 months; range, 6 to 30 months). A single patient has undergone reoperation for persistent dysphagia (1.5%).

Conclusions. A laparoscopic Nissen procedure is safe, effective treatment for refractory gastroesophageal reflux disease when performed by thoracic surgeons experienced in minimally invasive surgical procedures.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Surgical intervention for uncomplicated gastroesophageal reflux disease (GERD) can be accomplished using a thoracic or abdominal approach, and thoracic surgeons performing esophageal operations have long been involved with both routes for the treatment of reflux. With the introduction and evolution of laparoscopy, a substantial number of antireflux procedures are being performed using a minimally invasive abdominal approach. The recent introduction and dissemination of thoracoscopic techniques have allowed thoracic surgeons to become facile with minimally invasive surgical techniques. It seems only natural for chest surgeons experienced in esophageal surgery and trained in minimally invasive technique to undertake laparoscopic antireflux procedures. The purpose of this article is to present the early experience of thoracic surgeons in the performance of such procedures.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients referred to Saint Louis University Health Sciences Center or University of Pittsburgh Medical Center for antireflux operations from February 1993 to May 1995 were considered for a laparoscopic Nissen fundoplication. All patients underwent general anesthesia and were operated on in the dorsal lithotomy position. Five 10- to 12-mm trocars were placed either after insufflation with CO₂ using a Veress needle (early experience) or using a Hassan cutdown technique. The remaining trocars were placed under laparoscopic visualization. The initial trocar was usually placed in the linea alba approximately one third of the way between the umbilicus and the xiphoid in the cephalad direction. The remaining trocars were placed in the subcostal position on the left and right halfway between the midline and subcostal trocar. A 30-degree Olympus rigid laparoscope (Olympus America Inc, Melville, NY) was used for visualization of the gastroesophageal junction. The gastroesophageal junction dissection was started on the right lateral border of the hiatus and continued until a circumferential dissection of the esophagus was obtained. An umbilical tape was passed around the esophagus and used for subsequent manipulation. Downward traction was placed on the esophagus, and a periesophageal dissection was carried into the mediastinum until 3 to 4 cm of esophagus lay free within the abdomen without tension. The body of the stomach was then grasped and retracted to the right. Lateral to the greater curvature of the stomach, the greater omental sac was entered by blunt dissection, and mobilization of the greater curvature was begun. The highest three to five short gastric arteries were divided using an Endo GIA stapling instrument with a vascular cartridge. Sharp and cautery dissection was used to divide the gastrophrenic and phrenoesophageal ligaments on the left lateral aspect of the gastroesophageal junction. Once the entire distal esophagus and cardia were mobilized the crura were thoroughly cleaned of fatty tissue, and the hiatal orifice was inspected. The crura were closed in the majority of patients with one or two simple 2-0 Ethibond sutures (Ethicon, Somerville, NJ) using extracorporeal tying techniques. The fundus of the stomach was drawn posterior to the gastroesophageal junction and allowed to rest without tension. If the fundus spontaneously retracted back to its anatomic position, then more short gastric vessels were divided. A Maloney or Savary dilator was then passed into the stomach. Initially we used a 50F dilator, but gradually this was increased to a 54F dilator in smaller male and female patients and a 60F dilator in larger individuals. With the dilator in place, an anterior fundoplication was performed using 2-0 Ethibond sutures. Three sutures were placed in the same fashion as would be accomplished in a laparotomy. The stitches were passed through the gastric fundus lying to the left (anterior wall) and right (posterior wall) of the esophagus, as well as through the esophagus with care taken to avoid the vagus nerve. The total length of wrap varied from 2 to 3 cm. The dilator was then removed and a nasogastric tube was placed. Each trocar site was closed with a 0 Vicryl (Ethicon) figure-of-8 suture, and the patient was awakened, extubated, and taken to the recovery room.

Initially, the nasogastric tube was left in place for 48 hours, and the patient progressed to soft solids by postoperative day 5. More recently, the nasogastric tube has been removed on the first postoperative day and patients have advanced to soft solids by postoperative day 2, at which time they are discharged. Postoperative analgesia is managed using parenteral narcotics for the first 24 hours, but this is changed to oral medication (acetaminophen with codeine or acetaminophen with propoxyphene) when enteral feeding is tolerated.

The patients have been followed up from the time of operation, and follow-up has been obtained in all but 2 patients through September 1995.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From March 1993 through May 1995, 66 patients underwent laparoscopic approach for repair of hiatal hernia, treatment of GERD, or both. There were 32 male and 34 female patients ranging in age from 15 to 82 years (mean, 45.5 years). Forty-five patients (68%) had a type I hiatal hernia, 10 (15%) had a type II or III (paraesophageal) hernia, and in 11 patients (16%) no hernia could be demonstrated. All but 1 patient were symptomatic with complaints of substernal burning, waterbrash, or postprandial epigastric discomfort. The remaining patient was a profoundly retarded adolescent with multiple episodes of recurrent pneumonia and radiographically demonstrated spontaneous gastroesophageal reflux. All patients had failed conservative medical management including the use of omeprazole in all but 2 patients.

Twenty-four–hour esophageal pH testing and manometry were performed in 46 patients, and an additional 2 patients underwent only esophageal manometry. The average total time of esophageal acid exposure (pH < 4) was 12.0% ± 12.1% (range, 0% to 68%). The mean lower esophageal sphincter pressure was 9.3 ± 6.2 mm Hg (range, 1 to 25 mm Hg). No patient was noted to have severe abnormalities in esophageal peristalsis, although 9 of 48 (19%) were noted to have mild nonspecific esophageal motor disorders. These included nonpropagated waves in 4, simultaneous or spontaneous contractions in 3 patients, and low-amplitude waves and tertiary contractions in 1 each. Those patients not undergoing 24-hour pH testing had either typical reflux symptoms with endoscopically documented esophagitis or a radiographically documented paraesophageal hernia. The operation performed was a Nissen fundoplication in all but 1 patient who had a type II paraesophageal hernia with normal 24-hour pH study. This patient was treated with hernia reduction, crural closure, and anterior gastropexy.

Six procedures (9%) were converted to an open laparotomy due to bleeding (no transfusion requirement) in 2 (3%), severe obesity with fat obscuring the gastroesophageal junction in 2 (3%), a gastric laceration in 1 (1.5%), and a large left lobe of the liver that prevented adequate exposure in 1 (1.5%).

There was no operative mortality. Operative morbidity was as follows:

Although mild transient dysphagia was noted in the majority of patients, only 7 complained of persistent moderate dysphagia. One of these also complained of intermittent epigastric fullness consistent with gas bloat syndrome. In all but 3 patients, the dysphagia resolved within 2 to 4 weeks. In 3 patients, moderate dysphagia persisted, and all 3 were treated initially with endoscopic dilation of the wrap. The dysphagia resolved in 2 patients with one and three dilations, respectively. The last patient underwent four dilations over a period of 6 months, after which time he could take a regular diet except for beef and bread. He was unhappy not being able to eat regularly, although his reflux symptomatology and asthma had been absent during the 6 months of follow-up. He insisted on further therapy and underwent laparotomy with takedown of his Nissen fundoplication. At the time of operation, the cephalad-most crural closure suture was seen to be tight around the esophagus. This was confirmed by passage of a 56F dilator, which revealed the crural opening to be constrictive. This suture was removed, and the Nissen fundoplication reconstructed over a 60F dilator. Subsequently, the patient has noted return of some asthma symptomatology, but no significant reflux symptomatology. His dysphagia has resolved.

The mean hospital stay for all 66 patients was 4.5 ± 5.5 days, and ranged from 1 to 42 days with a median of 3 days. One patient hospitalized for 6 weeks was a known schizophrenic who suffered an episode of severe psychosis before planned discharge on postoperative day 5. She was transferred to the psychiatric ward and stayed there for the ensuing 5 weeks. If this patient's prolonged hospitalization is excluded, the mean hospital stay is 4.0 ± 2.5 days. If one includes only those patients in whom the procedure was completed laparoscopically, the mean hospital stay is 3.7 ± 2.4 days (median, 3.0 days). There did appear to be a significant learning curve. When the mean hospital stay for the first 30 laparoscopic fundoplication patients is compared with that of patients in the second half (n = 29) of the experience, there is a significant (p < 0.001) difference in the length of postoperative hospitalization (4.7 ± 2.8 versus 2.7 ± 1.1 days), with median stays of 4 days (first half) and 2 days (second half).

The mean follow-up has been 14.4 months (range 6, to 30 months). Two other patients have symptoms that have persisted since the operation. One has complained of excess flatulence since discharge, and a second patient noted the return of reflux symptomatology approximately 11 months after the laparoscopic procedure. The patient is now being satisfactorily managed on antireflux medication. No other patient has been restarted on antireflux medication.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The field of laparoscopic surgery has evolved rapidly since the first article reporting laparoscopic cholecystectomy in 1989 [1]. As early as 1991, laparoscopic antireflux procedures were performed, and these procedures are now commonly done by laparoscopic surgeons throughout the country [2]. In the past, thoracic surgeons have been leaders in the field of treatment for benign esophageal disorders including gastroesophageal reflux disease. With the advent of video-assisted thoracic surgery, many chest surgeons have become quite adept at performing minimally invasive intrathoracic procedures using thoracoscopic techniques. It would seem quite natural for surgeons experienced in these techniques and with expertise in esophageal surgery to combine these two skills and undertake laparoscopic Nissen fundoplication. As Kaver and colleagues [3] have emphasized, the skilled esophageal surgeon must be ready to tailor both the approach and the procedure to the individual patient's needs. Adding laparoscopic fundoplication to the surgeon's armamentarium will allow the thoracic surgeon to do just that.

The results of laparoscopic Nissen fundoplication in our series are quite comparable with those reported by others (Table 1). There were no deaths and a low incidence of recurrent reflux and reoperation. The 4.5% incidence of postoperative dysphagia requiring dilation is similar to that reported by Hinder and associates [4] and Weerts and colleagues [5]. The relatively short follow-up makes direct comparison with open fundoplication procedures quite problematic. However, the short length of hospitalization coupled with the low operative morbidity is very encouraging. The real proof of the value of this procedure will be in the incidence of recurrence at 5 and 10 years.

There are caveats when undertaking laparoscopic fundoplication. First, the indications for undertaking operative intervention should not change just because the operation is ``minimally invasive.'' Medical management will still prove satisfactory for the majority of patients with mild to moderate GERD. It is only those patients with symptoms refractory to medical therapy, or those demonstrating complications of chronic GERD (anemia, stricture, ulceration), who should be offered operation. It is interesting to note, however, that in our experience the rate of referral for operative correction of GERD increased markedly when gastroenterologists realized the relatively noninvasive nature of the procedure. In most cases, the referred patients had been refractory to medical management for several years, but either the patient or the referring physician were reluctant to submit to operation. However, once the ``endoscopic'' procedure that was ``not really an operation'' became available, both patient and physician became more comfortable with the notion of fundoplication.

The second caveat is that contraindications to the abdominal approach for fundoplication are also relevant to laparoscopic fundoplication. Patients with prior gastric or esophageal operations or those with foreshortened esophagus (nonreducible hiatal hernia 5 cm in size) should be approached using thoracotomy combined with a diaphragmatic incision or an abdominal incision when indicated. Other contraindications that may warrant a nonlaparoscopic (either open abdominal or thoracic) approach include a ventriculoperitoneal shunt, peritoneovenous shunt, and concomitant intraabdominal pathology that requires laparotomy.

Finally, it is critical that surgeons and patients alike realize that this is truly an operation and not just a procedure. The potential complications are identical to those of the open procedure, and significant postoperative complications can and will occur. Also, it is incumbent on the surgeon that he or she make no compromises and cut no corners. It is possible and advisable to perform the same operation laparoscopically as one does with a laparotomy. We believe that it is important to stress that the same surgical principles must be followed when performing laparoscopic fundoplication, eg, circumferential dissection of the gastroesophageal junction, mobilization of 2 to 4 cm of intraabdominal esophagus, division of short gastric vessels, crural closure, and performance of a tension-free wrap over a large intraesophageal dilator. A ``shortcut'' or avoidance of any of these steps will greatly increase the risk of perioperative morbidity and jeopardize the long-term success of the procedure.

In summary, we believe that a laparoscopic Nissen fundoplication is a promising procedure, which in our experience can be undertaken with operative morbidity and early results similar to those associated with open abdominal or transthoracic fundoplication procedures. Postoperative stay appears shorter, and patients return to normal routine more quickly. We believe this operative approach should be in the armamentarium of the general thoracic surgeon with an interest in esophageal surgery.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Address reprint requests to Dr Naunheim, Department of Surgery, Saint Louis University Health Sciences Center, 3635 Vista Ave at Grand Blvd, St. Louis, MO 63110-0250.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Reddick EJ, Olsen D, Daniell J, et al. Laser Med Surg News Adv 1989;Feb:38–40.
2. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991;1:138–43.
3. Kaver WK, Peters JH, DeMeester TR, et al. A tailored approach to antireflux surgery. J Thorac Cardiovasc Surg 1995;100:141–6.
4. Hinder RA, Filipi CJ, Wetscher G, Neary P, DeMeester TR, Perdikis G. Laparoscopic Nissen fundoplication as an effective treatment for gastroesophageal reflux disease. Ann Surg 1994;220:472–81.
5. Weerts JM, Dallemagne B, Hamoir E, et al. Laparoscopic Nissen fundoplication: detailed analysis of 132 patients. Surg Laparosc Endosc 1993;3:359–64.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Keith S. Naunheim Rodney J. Landreneau Peter F. Ferson Robert J. Keenan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Naunheim, K. S. Articles by Keenan, R. J. Search for Related Content PubMed PubMed Citation Articles by Naunheim, K. S. Articles by Keenan, R. J.