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Symptomatic gastroesophageal reflux disease is the most common indication for laparoscopic fundoplication using the floppy 360-degree Nissen technique. The clinical presentation and diagnostic workup are described in detail with Plate 41, Fundoplication. Repeated episodes of aspiration pneumonia or asthma triggered by reflux are significant indications. Intolerance to medical management with proton pump inhibitors, noncompliance with recommended medication regimens, and the cost of lifelong medications may also be additional indications for this procedure.

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A full general medical evaluation is performed and the usual preanesthesia testing is obtained. Esophageal function studies such as manometry or video esophagography are necessary in order to plan for a 360-degree wrap or a partial fundoplication and to detect underlying dysmotility not related to reflux. Special emphasis is placed upon the pulmonary workup. Pulmonary function studies are needed in high-risk patients, especially if recurrent episodes of aspiration pneumonia or asthma have occurred. Antacids, acid blockers, and proton pump inhibitors are continued. Perioperative antibiotic coverage is optional.

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General anesthesia with endotracheal intubation is used. An orogastric (OG) tube is placed for gastric decompression.

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The patient is placed in the supine position with the arms out on arm boards for anesthesia access or with the arms containing the blood pressure cuff, pulse oximeter, and intravenous access tucked in at the sides. Many surgeons prefer the semilithotomy position using Allen stirrups to support the feet and legs (Figure 1). The legs are spread sufficiently for the surgeon to be positioned, but the thighs are only partially elevated. Elastic stockings or pneumatic sequential compression stockings are put on the lower legs. The patient is placed in a reverse Trendelenburg position, with about 30 degrees of elevation to the head of the table.

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The area from the nipples to the pubic symphysis is shaved. Routine skin preparation is performed.

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A combination of 5- and 10-mm ports are placed as shown if the patient is in the semilithotomy position (Figure 1). The size of each port is determined by the instruments used. In general, 10-mm ports are used for the Hasson with its videoscope and the endoscopic suturing instrument. The size of the grasping Babcock clamp and the ultrasonic dissector determines whether a 5- or 10-mm port is placed for these instruments. Larger ports may also be indicated ...

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