Reproducible “Wrap” in Laparoscopic Fundoplication

BACKGROUND

Laparoscopic Nissen (LN) and laparoscopic Toupet’s (LT) fundoplication are the two most common antireflux surgery (ARS) performed for gastroesophageal reflux disease (GERD) and Hiatus hernias (HH). The three principles of fundoplication are achieving adequate intraabdominal length of the esophagus, floppy wrap, and snug hiatal closure.¹

Ideal wrap length in LN should be between 1.5 and 2 cm and it should be over the esophagogastric junction (EGJ) and lower esophagus.² One of the bites is taken on the esophagus to prevent the wrap migration. In LT, the wrap is fixed to either side of the esophagus using three bites from the wrap to the esophagus.

There have been various techniques described in the creation of the wrap to prevent wrap-related complications leading to recurrent GERD/HH. The anatomical causes of wrap failure are tight wrap, long wrap, slipped wrap, disrupted warp, migrated wrap, twisted wrap, and wrap on the stomach causing hourglass contraction.³

We herein describe a simple, reliable, reproducible technique of floppy and correct wrap creation during LN and LT.

TECHNIQUE

Currently, we have used this technique of wrap creation during LN and LT performed in cases of GERD/HH. Four ports were used in 12 cases and 5 ports in 8 cases. In these 12 cases, liver retraction is facilitated by liver hammock stitch using No. 0 V-lock.⁴ In the other eight cases, liver was retracted using Nathanson’s retractor fixed to a stand.

After adequate intraabdominal length of esophagus was achieved (5 cm with traction and 3 cm without traction by umbilical tape) and division of short gastric vessels, the EGJ pad of fat was cleared using harmonic shears. We have not used esophageal bougie during wrap creation or for assessment of the floppiness of the wrap.

The assistant now grasps the fundus of the stomach and traction was given in such a way that EGJ and angle of His are seen. A point is marked on the anterior wall of the fundus of the stomach 3 cm from the EGJ (Figs 1A and 2A). Another point is marked 2 cm from the superior most point of the fundus of the stomach meeting the previous point (Figs 1A and 2B). These are done by means of a sterile measuring scale. This point on the anterior wall of the fundus is marked by 2–0 silk sutures (Fig. 2C).

The assistant now flips the stomach to expose the posterior wall of the fundus (Fig. 2D). Similar marking is made 3 cm from EGJ (Figs 1B and 2E) and 2 cm from the fundus of the stomach (Figs 1B and 2F) and this point is again marked with 2–0 silk sutures (Fig. 2G). The cut silk sutures on the posterior wall of the fundus are left close to the left crus.

The hiatal closure is then performed using interrupted 2–0 polyester. The silk suture from the posterior wall of the fundus is taken anteriorly from the retroesophageal tunnel created and shoe–shine maneuver is performed.⁵ This ensures a floppy wrap. The silk thread on the posterior wall and the anterior wall is now held and examined for symmetry on both sides of the wrap (Fig. 2H). The silk sutures on the anterior wall (left side) and posterior wall (right side) form the lower end of the 360-degree Nissen wrap. The wrap is approximated using 2–0 polyester at the EGJ (Fig. 2I). Then the upper end of the wrap is created taking a bite from the anterior wall of the esophagus taking care of the vagus (Fig. 2J). This suture is taken 2 cm from the lower end of the wrap (Fig. 2K). This suture bite on the esophagus is said to protect against wrap migration. Then a suture is taken exactly in between the upper and lower end to create a 2 cm, floppy, 360-degree wrap over the EGJ and esophagus (Fig. 2L).

In the case of LT, similarly, a 5 cm distance is taken from EGJ and 5 cm from the fundus of the stomach (Figs 3A, 4A and 4B). This is first taken on the anterior wall and then on the posterior wall (Figs 3B, 4C to 4G). The same procedure is followed and the wrap is fixed to both sides of the esophagus using three interrupted sutures taken 1 cm apart using 2–0 polyester forming a 3 cm long 270-degree wrap (Figs 4H to 4J). It is proved that a 3 cm Toupet wrap will result in better control of reflux symptoms than a 1.5 cm wrap.²

With the above technique of geometry of the wrap, we were able to achieve a wrap length of 2 cm for LN and 3 cm for LT. Long-term results of ARS depends also on wrap length.²

In both, the wraps were not fixed to the crus or the diaphragm. We believe that the wrap and the diaphragm ordinarily move in different planes and with violent motion of the diaphragm several times a day, such a point of attachment could conceivably contribute to disruption, although some surgeons routinely advocate it.

RESULTS

We have performed 20 cases of ARS using this technique of wrap creation between January 2022 and September 2022. All patients were evaluated preoperatively by upper gastrointestinal (GI) endoscopy. A 24-hour pH-metry and esophageal manometry were done in three patients who had atypical symptoms. Hiatus hernia was present in 12 patients and Barrett’s esophagus in 1 patient. The mean age of the patient was 42.5 years with 12 females and 8 males. Furthermore, LN was performed in 17 and LT in 3 patients. The mean operating time using this wrap creation technique for LN was 62 minutes and LT was 68 minutes. All the patients were discharged on the first postoperative day (POD). The patients were on liquid diet till fifth POD, then gradually stepped up to soft diet. Proton pump inhibitors were stopped 6 weeks following surgery. The follow-up period was from 6 weeks to 10 months. None of the patients had transient or persistent dysphagia requiring endoscopic dilatation or a redo surgery due to anatomical fundoplication failure in the mentioned follow-up period. There was no recurrence of reflux symptoms or development of new symptoms in the follow-up period. Gas bloat was complained of by two patients who underwent LN which gradually subsided in 2 months by lifestyle modifications.

DISCUSSION

Antireflux surgery is a technically demanding procedure and was first performed by Rudolph Nissen in 1955 and was published in the year 1956.^6,7 The first LN fundoplication was reported in 1991.⁸ It has seen a tremendous growth in popularity and is now commonly performed by surgeons with expertise in laparoscopic surgery. Not only does experience reduce time of surgery but also reduce the anatomic failure rates.

Proper patient selection, surgical technique, and postoperative management play an important role in good outcomes following ARS. The patients should be evaluated well before being considered for surgery and motility disorders of the esophagus have to be ruled out by manometry in patients presenting with atypical symptoms. In our study, young patients, volume refluxers, patients with HH, and normal esophageal length and motility are considered for LN.

Persistent GERD symptoms or the development of new symptoms is considered a failure of ARS. Failure of ARS can occur due to anatomic problems with the fundoplication or the hiatus. Incorrectly constructed fundoplication, slipped wrap, migrated wrap, tight wrap, long wrap more than 3.5 cm, lateral torsion with corkscrew if the wrap goes to the right, recurrent hiatal hernia, and weakened antireflux valve results in failure of the procedure.³ Most of these require redo ARS which is more challenging with an increased risk of esophageal and gastric injury.

Anatomically/geometrically correct wrap creation is very important for good outcomes.⁹ Persistent dysphagia following ARS indicates a tight wrap, long wrap, wrongly created wrap, tight hiatal closure, or wrong selection of patient.

We have not used mesh during any of our procedures as there is no strong evidence to support the routine use of mesh in hiatal closure except in cases with very wide hiatus, that is, above 5 cm.^10,11

Anatomical failure of fundoplication occurs due to disruption or displacement of the wrap.

Horgen classified the fundoplication failures into the following types:¹²

• Type I: Esophagogastric junction (OG) junction above the hiatus.

• Type I (A): Both wrap and OG junction above the hiatus.

• Type I (B): Wrap is below the diaphragm but OG junction has migrated above the diaphragm.

• Type II: A part of the stomach from the wrap itself has migrated above the hiatus.

• Type III: Wrap malformation. The body of the stomach has been used to form the wrap.

In types I and II failures, the crural component and in type III failures, incorrect creation of the wrap plays an important role.

Laparoscopic Nissen offers better reflux control than LT but with greater mechanical complications. The postoperative symptoms of gas bloat and dysphagia are more common with LN. The presence of esophageal motility disorders may affect surgical outcomes. In patients with esophageal dysmotility LN is contraindicated.¹³ Laparoscopic Toupet has been favored as being more physiological by allowing venting from the stomach without compromising the antireflux barrier.¹⁴

CONCLUSION

This technique of wrap creation is safe, feasible, reliable, and reproducible during Nissen fundoplication and Toupet fundoplication and can be standardized. This may also lead to less failures of ARS requiring redo surgery due to wrong wrap creation.

ORCID

Ganesh Shenoy https://orcid.org/0000-0001-5384-191X

Sanjay Natarajan https://orcid.org/0000-0002-5766-7805

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