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INDICATIONS

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Fundoplication may be considered in certain patients with symptomatic reflux gastritis associated with esophagitis or refractory to maximal medical therapy. Esophagitis with stricture and paraesophageal hernia are other common indications. A preliminary trial of repeated dilatations should be instituted when there is evidence of a stricture of the lower end of the esophagus prior to fundoplication.

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Substernal pain, especially in the recumbent position, difficulty in swallowing, and recurrent bouts of aspiration pneumonia are commonly associated with gastroesophageal reflux. Esophagoscopy should be performed to assess for presence of hiatal hernia, esophagitis, esophageal stricture or mass, and Barrett’s esophagus. Esophageal motility must be assessed by either manometry or video barium esophagram demonstrating normal motility. In the absence of erosive esophagitis, 24-hour pH monitoring should be performed to provide objective evidence of acid reflux.

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Surgical procedures are designed to prevent acid peptic reflux and to restore normal sphincteric function. When reflux esophagitis is associated with duodenal ulcer, either parietal cell vagotomy or truncal vagotomy and pyloroplasty should be considered.

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PREOPERATIVE PREPARATION

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Pulmonary function studies are indicated in patients with a history of aspiration pneumonia. Antacid therapy is maintained. Systemic antibiotics may be given. Nasogastric intubation should be instituted.

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ANESTHESIA

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General anesthesia with endotracheal intubation is employed.

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POSITION

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The patient is placed in a comfortable supine position on the table with the feet slightly lower than the head.

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OPERATIVE PREPARATION

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The area from the nipples downward to the symphysis is shaved. The skin over the sternum, lower chest wall, and the entire abdomen is cleaned with the appropriate antiseptic solutions.

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INCISION AND EXPOSURE

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A liberal incision starting over the xiphoid and extending down the midline to the umbilicus is made (figure 1). When the xiphoid is elongated, it is removed to enhance the exposure of the esophagogastric junction. Active arterial bleeding in either xiphocostal angle is controlled with a transfixing suture of 00 silk.

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DETAILS OF PROCEDURE

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The peritoneum is opened and the abdomen explored with special attention given to the gallbladder, duodenal bulb, and the size of the esophageal hiatus. A considerable portion of the stomach may be up in the chest as a result of the enlarged hiatus opening.

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It is important to develop good exposure of the margins of the esophageal hiatus. The exposure is improved by dividing the relatively avascular triangular ligament of the left lobe of the liver and rotating it toward the midline (figure 2). It is retracted medially by a large S retractor applied to a moist pad placed over the mobilized left lobe (figure 3).

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The peritoneum over the esophagus is incised and the esophagus mobilized with the ...

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