Operation for GERD Conventional Approach

Karim A. Gawad, Christoph Busch

Introduction

The laparoscopic approach to gastroesophageal reflux (GERD) has become the "gold standard" over the past decade. Nevertheless, an open approach may be preferable in patients who have undergone previous open upper abdominal surgery or in cases of recurrent or re-recurrent GERD when revisional laparoscopy may not seem sufficient to definitely treat the disease.

Indications and Contraindications

Indications

Significant gastroesophageal reflux

"When a laparoscopic approach is not indicated"

Recurrent disease following previous open or laparoscopic surgery

Status postconventional upper abdominal surgery with massive adhesions

Failure of conservative treatment

Contraindications

General contraindications for surgery under general anesthesia

Preoperative Investigations/Preparation for the Procedure

See chapter on "Operation for GERD: Laparoscopic Approach."

Procedures Access

Transverse upper abdominal incision, if required with additional upper midline incision; alternatively, left subcostal or upper midline incision

Division of the triangular ligament with ligation (cave: accessory bile duct) to expose the esophagogastric junction

Choice of Procedure

■ Simple reflux disease (esophagitis up to III):

- Fundoplication

- Ligamentum teres (round ligament) plasty

■ Complicated reflux disease (esophagitis IV):

- Fundoplication + dilatation (of florid esophagitis)

- Fundoplication + parietal cell vagotomy (in gastric hyperacidity) + if necessary dilatation (of florid esophagitis)

- Fundoplication + parietal cell vagotomy + stricturoplasty (of scarred strictures)

- Limited resection of the gastroesophageal junction

The distal esophagus is completely dissected and armed with a vessel loop. The gastric fundus is completely mobilized by division of the short gastric vessels in order to form a loose, "floppy" fundoplication.

If ligamentum teres plasty is planned, there is no need for fundic mobilization. Special attention has to be paid to thoroughly preserving the ligament at laparotomy.

In the presence of a hiatal hernia, a posterior hiatoplasty is performed using non-absorbable suture material.

STEP 1

Mobilization of the distal esophagus and fundus

Plastia Esofago

Total ("Nissen") Fundoplication

STEP 2 Passage of the fundus

The mobilized fundus is passed behind the esophagus to the right side so far that it can be easily united with the remaining fundic frontwall in front of the esophagus.

STEP 3 Formation of the wrap

The two cuff-folds are fixed with three, maximally four, non-absorbable sutures. One suture should partially grab the esophageal wall to prevent a telescope phenomenon.

Plastia Esofago

STEP 4 Anchoring of the wrap

Finally the fundic cuff is again tested. Two fingers should easily pass the loose wrap around the distal esophagus ("floppy Nissen").

One or two additional sutures can fix the left cuff-fold to the anterior gastric wall in order to prevent slippage (telescope phenomenon).

Ligamentum Teres (Round Ligament) Plasty

STEP 1

See above.

STEP 2 Dissection of the round ligament

The round ligament is carefully dissected from the abdominal wall and from the liver, respectively. The free end of the ligament is transposed dorsally around the esophagus coming from the right side.

Plastia Esofago

STEP 3

Fixation to the anterior gastric wall

The round ligament is then attached to the anterior gastric wall under relative tension using three or four non-absorbable sutures. Fixation to the anterior aspect of the gastric corpus is performed.

Standard Postoperative Investigations

See chapter "Operation for GERD: Laparoscopic Approach."

Postoperative Complications

- Esophageal perforation

- Dysphagia

- Dysphagia

- Gas-bloat

- Recurrent disease

Tricks of the Senior Surgeon

■ Perform Nissen fundoplication around a large gastric tube to facilitate formation of a loose "floppy," fundic wrap.

■ Use of a self-retaining retractor system will facilitate exposure of the esophagogastric junction.

■ Dissection of the short gastrics is not mandatory but will ensure a loose fundoplication, thus preventing postoperative dysphagia.

■ Do not dissect the round ligament at laparotomy.

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