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After the left lobe of the liver has been retracted and the hiatal hernia reduced by pulling at the anterior part of the stomach, the surgeon gains access to the hiatal region and the right crus by opening the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). ...