The ideal therapy for gastroesophageal reflux disease (GERD) is a tailored approach with a short, floppy Nissen total fundoplication. This is the current “gold standard” for patients with GERD and normal esophageal motility. However, total fundoplication may result in unacceptable rates of postoperative dysphagia in the subset of patients with GERD and disorders of esophageal motility, a spectrum of benign disorders associated with delayed esophageal clearance. Most surgeons prefer a Toupet 270-degree partial posterior fundoplication for patients in this group.1 Some surgeons advocate partial fundoplication for all patients to minimize the undesirable side effects of a 360-degree wrap.2,3
The operation is performed with the standard laparoscopic equipment using a 5- or 10-mm, 0- or 30-degree laparoscope. With the patient in the lithotomy reverse Trendelenburg position, the surgeon stands between the patient's legs. The two assistants are on the patient's left and right sides. Five trocars for proper port placement are required (Fig. 40-1).
After the left lobe of the liver has been retracted and the hiatal hernia reduced by pulling at the anterior part of the stomach, the surgeon gains access to the hiatal region and the right crus by opening the lesser omentum. Attention is paid to an accessory left hepatic artery, which is spared if present. The hepatic branches of the anterior vagus are preserved to avoid impaired gallbladder motility and to reduce the risk of wrapping the gastric fundus around the stomach instead of the esophagus (Fig. 40-2).
Exposure for performing the Toupet fundoplication.
The phrenoesophageal membrane is detached from both pillars of the right crus circumferentially. Care should be taken to avoid stripping the peritoneal covering of the pillars because this will compromise subsequent suture repair. The gastrophrenic ligament is incised. Working from the right side, a retroesophageal window is created, and the esophagus is encircled with a Penrose drain. The mediastinal esophagus is freed circumferentially for a length of about 10 cm with blunt and sharp dissection to obtain a 3 to 4cm length of tension-free intra-abdominal distal esophagus.
Both the anterior and posterior vagal nerves are identified but not isolated to avoid the risk of delayed gastric emptying with gas bloat syndrome. Although not described in the original Toupet fundoplication, the medial part of the upper short gastric vessels is divided to create a fundoplication without undue circumferential tension around the distal esophagus. Temporarily, a 30-degree scope is used. This maneuver also permits direct access to the retrogastric attachments, which are divided.
Upward traction on the sling provides good access to the V-shaped junction of the pillars (Fig. 40-2). A loose, nonobstructing hiatal closure is performed, leaving a 2-cm retroesophageal space. Unlike the originally described Toupet repair, in which the posterior wrap was sutured to the right and left pillars, the approximation of the pillars is performed with one to three big-bite 0 nonabsorbable sutures tied snugly with an extracorporeal knot. Some surgeons advocate using a 54 to 58F bougie to calibrate the degree of closure. We do not recommend the Maloney bougie in this situation for fear of causing a perforation.
The gastric fundus is passed behind the esophagus. Three to four interrupted 0 nonabsorbable sutures are placed from the esophagus to the left and right anterior edges of the fundus at the 2 o'clock and 10 o'clock positions, respectively to create a posterior wrap over a 3 to 4 cm length. Two or three additional sutures are placed from the right side of the wrap to the corresponding pillar. The final result should be a tension-free 270-degree posterior fundoplication securely fixed to the diaphragm and leaving the anterior part of the esophagus free (Fig. 40-3). The abdomen is deinsufflated and all 10-mm fascial defects are closed.
Toupet fundoplication. A. Right-side wrap fixation. B. Left wrap fixation.
The 270-degree laparoscopic Toupet fundoplication is associated with good early results. In one study it produced a good result in 80% to 90% of patients at 2 years follow-up.4 Temporary dysphagia, abdominal discomfort, and gas bloat syndrome were infrequent. However, despite achieving adequate fundoplication for most patients, the late results are not as satisfactory, with signs of weakness reported with this repair on follow-up manometry and pH monitoring testing. Particularly for patients with normal esophageal motility, the repair seems to afford a generally less competent antireflux mechanism, with a failure rate of up to 50% on 24-hour pH testing, yet half of such patients remain asymptomatic.4,5 While these signs of deterioration are concerning, heuristic end points such as symptom resolution, duration of convalescence, satisfaction, well-being, and quality of life bear more weight clinically than outcomes measured with manometry and pH monitoring.6 Support for this procedure stems from experience in the subset of patients who have delayed esophageal clearance secondary to esophageal motility disorder. Although the results have not been documented independently, many surgeons are of the opinion that the 360-degree total fundoplication creates an unacceptable rate of postoperative dysphagia for this patient group, and they are willing to accept the possibility of a higher rate of postoperative reflux long term.7,8 This view persists, despite reports that both approaches to fundoplication maintain good reflux control over time and that with time the reported differences in mechanical side effects disappear.3 Some surgeons prefer this approach for all patients.