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INDICATIONS

The complete encirclement of the lower esophageal sphincter with the fundus of the stomach is very effective in stopping gastroesophageal reflux. A greater understanding of the complex physiologic relationship that exists in normal swallowing, esophageal motility, and gastric reservoir function has suggested that a 360-degree fundoplication may not be optimal for all patients. Many different forms of partial fundoplication exist, differing in the technical details of wrap construction and the part of the esophagus covered. The Dor and Toupet fundoplications represent anterior and posterior versions of a partial fundoplication, respectively. Despite their differences, the overall goals of restoring intraabdominal esophageal length and reinforcing the lower esophageal sphincter remain constant.

The indications for partial fundoplication are no different from the indications for total fundoplication. The decision to perform partial fundoplication is based more on patient factors and esophageal physiology than on the severity of gastroesophageal reflux disease (GERD). The indications include: (1) GERD that is refractory to proton pump inhibition, (2) GERD that is incompletely responsive to proton pump inhibition, (3) GERD that is entirely responsive to proton pump inhibition, but patient choice or side effect profile merits consideration of antireflux surgery, (4) extraesophageal manifestations of GERD, and (5) complications of GERD (stricture, bleeding, aspiration, Barrett esophagus). Specific indications for the use of a partial fundoplication as opposed to a total fundoplication include: (1) patients with esophageal motility disorders in addition to GERD, (2) patients who have failed previous Nissen fundoplication due to significant postoperative dysphagia, (3) as an adjunct to laparoscopic Heller myotomy to prevent gross reflux, and (4) severe aerophagia and gas symptoms in a patient with well-documented GERD.

PREOPERATIVE PREPARATION, ANESTHESIA, AND PATIENT POSITIONING

All are identical to that performed in laparoscopic Nissen fundoplication described in chapter 18. The patient is placed in a split-leg position with both arms tucked (Figure 1).

INCISION AND EXPOSURE

The initial trocar setup and exposure for both Dor and Toupet partial fundoplication proceed in fashion identical to that for the Nissen fundoplication or Heller myotomy (Figure 2). Some surgeons do not mobilize the greater curvature of the stomach, dissect the posterior esophageal space, or take down the short gastric vessels with the performance of a Dor fundoplication. We believe that this dissection is imperative to perform a fundoplication without tension on the fundus of the stomach or fundic distortion. The detailed technique of esophageal mobilization and short gastric vessel division are found in chapter 18. Once the posterior window has been made behind the esophagus, a Penrose drain is passed as described in the Nissen fundoplication chapter (Figure 3).

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