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 in Chapter 37. 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 or complications associated with lifelong medication use represent additional indications for this procedure.
A full general medical evaluation is performed, and the usual preanesthesia testing is obtained. Esophageal function studies such as manometry and video esophagography are necessary to plan for a full or partial fundoplication and to detect underlying dysmotility not related to reflux. Special emphasis is placed on 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 should be used.
General anesthesia with endotracheal intubation is used. An orogastric tube is placed for gastric decompression.
The patient is placed in the supine split-legged or low lithotomy position with the arms out on arm boards or tucked in at the sides (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 at least 30 degrees of elevation to the head of the table.
The area from the nipples to the pubic symphysis is shaved. Routine skin preparation is performed. Then a time-out is performed.
Both 5- and 10-mm ports are placed as shown (FIGURE 1). Following Veress needle access and peritoneal insufflation, a 5- or 10-mm camera port is placed just to the left of the midline, 15 cm caudal to the xiphoid process, using a closed technique. Alternatively, an open Hasson technique may be used (see Chapter 13). All four quadrants of the abdomen are explored visually. Placement of each of the other selected port sites begins with skin infiltration using a local anesthetic. The local needle then can be passed perpendicularly through the abdominal wall and its entry site verified. A 10-mm port is placed in the left midsubcostal position. Then 5-mm ports are placed in the epigastrium just to the right of the midline and through the falciform ligament and in the far-left subcostal positions. In order to expose the esophageal hiatus, a self-retaining liver retractor may be placed in the subxiphoid position or, alternatively, via a right subcostal port (FIGURE 2).