Laparoscopic fundoplication is one of the most significant advances in gastrointestinal surgery, designed to treat gastroesophageal reflux disease (GERD) and related conditions. In his lectures, Dr. R. K. Mishra, a renowned laparoscopic surgeon and educator, emphasizes both the scientific rationale and the technical mastery required for this procedure. His teaching not only covers surgical details but also highlights the importance of patient selection, anatomy, and long-term outcomes.

Understanding GERD and the Role of Fundoplication

Dr. Mishra begins his lecture by explaining the pathophysiology of GERD. It occurs due to the incompetence of the lower esophageal sphincter (LES), which allows stomach acid to flow back into the esophagus. Over time, this reflux can cause esophagitis, strictures, Barrett’s esophagus, and a significantly reduced quality of life.

While lifestyle modifications and medications like proton pump inhibitors provide symptomatic relief, many patients experience incomplete resolution or prefer a more permanent solution. This is where fundoplication surgery becomes essential.

Principles of Fundoplication

Dr. Mishra explains that fundoplication involves wrapping the gastric fundus around the lower esophagus to reinforce the LES, thereby preventing reflux.

The main types include:

Nissen Fundoplication (360° wrap) – Complete encirclement of the esophagus, considered the gold standard for GERD.

Toupet Fundoplication (270° posterior wrap) – Partial wrap, often preferred for patients with impaired esophageal motility.

Dor Fundoplication (anterior 180–200° wrap) – Often performed alongside procedures like Heller’s myotomy.

He emphasizes that the choice of technique must be individualized based on esophageal manometry and patient-specific conditions.

Patient Selection and Preoperative Workup

In his teaching, Dr. Mishra highlights that not every GERD patient is a candidate for laparoscopic fundoplication. The ideal patient is one who:

Has proven GERD with abnormal 24-hour pH study or endoscopic findings.

Responds to acid-suppressive therapy but requires long-term relief.

Has no major contraindications like severe esophageal motility disorders (except in selective cases).

Preoperative evaluation includes:

Upper GI endoscopy – to assess mucosal damage and exclude malignancy.

Esophageal manometry – to measure LES pressure and peristalsis.

24-hour pH monitoring – to confirm reflux.

Barium swallow – to visualize anatomy and detect hiatal hernia.

Surgical Technique

Dr. Mishra’s lecture places strong emphasis on step-by-step laparoscopic technique, stressing the importance of precision and adherence to safety principles.

Positioning and Port Placement

The patient is placed in a supine, reverse Trendelenburg position with legs apart.

Typically, five ports are inserted for camera and instrument access.

Steps of the Procedure

Hiatal dissection – The esophagus is mobilized, ensuring at least 2–3 cm of intra-abdominal length.

Crural repair – The diaphragmatic crura are approximated with sutures to close the hiatal defect.

Fundic mobilization – The short gastric vessels are divided to allow a tension-free wrap.

Fundoplication – Depending on the chosen technique (Nissen, Toupet, or Dor), the gastric fundus is wrapped around the esophagus and sutured in place.

Final check – Adequate wrap length (2–3 cm) is ensured, avoiding excessive tightness that can cause dysphagia.

Dr. Mishra emphasizes the critical balance between creating an effective anti-reflux barrier and maintaining normal swallowing function.

Postoperative Care

In his lectures, Dr. Mishra highlights the importance of postoperative management:

Early mobilization to reduce thromboembolic risks.

Gradual reintroduction of diet, starting with liquids and progressing to soft solids.

Monitoring for complications such as dysphagia, gas-bloat syndrome, or wrap failure.

Most patients recover quickly and are discharged within 2–3 days after surgery.

Outcomes and Long-Term Results

According to Dr. Mishra’s experience and evidence-based literature, laparoscopic fundoplication offers excellent results:

Over 90% of patients experience complete symptom relief.

Long-term control of reflux is superior to medical therapy.

Complications are rare when performed by skilled laparoscopic surgeons.

Potential long-term issues include dysphagia, inability to belch, or recurrence of reflux, but these are minimized with correct technique and patient selection.

Educational Insights by Dr. R. K. Mishra

What sets Dr. Mishra’s lectures apart is his ability to blend theory with practical demonstrations. He often uses live surgical videos, animations, and anatomical models to simplify complex steps. He stresses the importance of:

Hand-eye coordination in laparoscopic surgery.

Respect for anatomical landmarks to prevent injury.

Continuous practice and simulation training to master suturing and dissection.

He also encourages young surgeons to pursue structured laparoscopic training programs to gain confidence before performing independent procedures.

Conclusion

In his lecture on laparoscopic fundoplication, Dr. R. K. Mishra provides a comprehensive overview of GERD management, surgical principles, and technical nuances. By combining scientific depth, practical wisdom, and a structured teaching style, he inspires surgeons to adopt minimally invasive techniques with precision and safety. Laparoscopic fundoplication, when performed correctly, remains one of the most effective operations in gastrointestinal surgery, offering patients lasting relief and improved quality of life.