BASIC INFORMATION:

Date & Time: 11 April 2026, 14:24 IST

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY:

This consolidated lecture outlines contemporary principles and practice of laparoscopic fundoplication for gastroesophageal reflux disease (GERD) and hiatal hernia, emphasizing disciplined patient selection, objective diagnostic confirmation, standardized operative steps, and safety-focused technique. A floppy Nissen fundoplication is reaffirmed as the gold standard when esophageal motility and length are adequate, while partial wraps are reserved for poor motility. The workup centers on endoscopy (Los Angeles classification), barium swallow, manometry, and 24-hour dual-probe pH monitoring. Key operative elements include precise exposure with liver retraction, atraumatic anterior and posterior esophageal mobilization (with sling-assisted traction), liberal short gastric division to achieve a floppy fundus, and careful crural approximation while respecting critical vascular and neural structures. Short esophagus management is addressed with Collis gastroplasty when safe intra-abdominal length cannot be achieved. Device-based options (LINX) and endoscopic alternatives (TIF) are briefly described with practical constraints. Complications, intraoperative hazards (including risk of IVC injury and pleural breach), and postoperative dysphagia are discussed with prevention and management strategies. Surgical pearls, medicolegal documentation, and standardized decision-making aim to enhance safe, reproducible outcomes for postgraduate surgeons and gynecologists.

KEY KNOWLEDGE POINTS:

• Endoscopy with Los Angeles (LA) classification is central to grading esophagitis; barium swallow complements structural assessment.

• Objective testing (manometry, 24-hour pH monitoring) guides candidacy; nonresponders to medical therapy often do poorly without objective acid reflux confirmation.

• Nissen fundoplication (floppy 360° wrap) is the preferred operation when motility and esophageal length are adequate; partial wraps (Toupet/Dor) suit poor motility but have higher recurrence.

• Achieve 3–5 cm intra-abdominal esophageal length; address short esophagus with Collis gastroplasty when needed.

• Liberal short gastric division (10–12 cm) facilitates a floppy fundus and the shoe-shine maneuver.

• Crural approximation requires non-absorbable sutures and curved needles; avoid deep bites near the caudate lobe to prevent IVC injury.

• Immediate conversion to open surgery is mandated for IVC puncture to prevent CO2 embolism.

• LINX augmentation and TIF are alternatives with specific technical and practical constraints; LINX demands minimal dissection and device sizing.

INTRODUCTION:

GERD is a prevalent condition characterized by pathologic reflux of gastric contents, leading to mucosal injury and potential complications. Fundoplication restores the antireflux barrier through mechanical augmentation of the lower esophageal sphincter and hiatal repair. Historically performed for hiatal hernia, fundoplication is now predominantly indicated for GERD in carefully selected patients. Outcomes depend on rigorous preoperative evaluation, anatomic understanding, and meticulous operative technique that prioritizes safety, reproducibility, and functional preservation.

LEARNING OBJECTIVES:

• Identify indications, contraindications, and objective diagnostic criteria for laparoscopic fundoplication in GERD and hiatal hernia.

• Describe operative anatomy, standardized steps, and safety principles for a floppy Nissen fundoplication, including crural repair and fundal mobilization.

• Recognize intraoperative and postoperative complications, with emphasis on prevention, early detection, and appropriate management.

CORE CONTENT:

1. Epidemiology, Clinical Features, and Indications

   • Background and Symptomatology

     • GERD affects a substantial fraction of the population; typical symptoms include heartburn and regurgitation.

     • Alarm features: retrosternal chest pain and nocturnal respiratory symptoms from aspiration.

   • Indications for Surgery

     • Refractory GERD with relapse after cessation of medical therapy.

     • Presence of associated hiatal hernia.

     • Intolerance to PPIs/H2 blockers.

   • Cautionary Notes

     • Patients reporting nonresponse to medical therapy often have poor surgical outcomes unless objective acid reflux is documented.

2. Diagnostic Workup

   • Step 1: Endoscopy and Barium Swallow

     • Endoscopy: LA classification for esophagitis grading.

       • LA A: <5 mm mucosal break confined between folds.

       • LA B: >5 mm break confined between folds.

       • LA C: breaks extend between folds with <75% circumferential involvement.

       • LA D: ≥75% circumferential involvement.

     • Barium swallow: delineates morphology, strictures, and extrinsic compression.

   • Step 2: Manometry and 24-hour pH Monitoring

     • Manometry: assesses LES pressure (normal ~18–25 mmHg) and motility; adequate LES function cautions against surgery to avoid dysphagia.

     • Dual-probe pH monitoring: confirms pathologic acid exposure; neutral pH suggests nonacid or psychosomatic etiologies.

3. Procedure Selection and Esophageal Physiology

   • Wrap Choice by Motility and Length

     • Normal motility and adequate length: floppy Nissen 360°.

     • Poor motility: partial wrap (Toupet/Dor) to reduce dysphagia risk.

   • Esophageal Length Targets

     • Aim for 3–5 cm intra-abdominal esophagus.

     • Mobilize additional mediastinal length cautiously when needed.

     • Short esophagus: consider Collis gastroplasty to create a neo-esophagus.

4. Operative Setup and Exposure

   • Patient Positioning and Port Placement

     • Reverse Trendelenburg (10–15° head-up); French position feasible.

     • Camera port ~5 cm supraumbilical; working ports in left/right hypochondrium (mid-clavicular) and left anterior axillary line.

   • Liver Retraction

     • Nathanson self-retaining retractor via epigastric entry provides stable exposure.

     • Fan retractors may be used with careful orientation to avoid parenchymal injury.

     • Safe removal of beaded retractors requires withdrawing through the incision, not the cannula.

5. Esophageal Mobilization and Posterior Sling Technique

   • Anterior and Crural Dissection

     • Consistent anterolateral traction on the stomach to open pars flaccida (thin, transparent, fat-free).

     • Sequential mobilization of anterior esophagus, right crus, and left crus.

   • Posterior Mobilization

     • Create a posterior buttonhole; pass a cotton/rubber/silicone sling for controlled traction.

     • Preserve posterior vagus; avoid routine division of the gastrohepatic ligament to protect the hepatic branch of the vagus.

     • Control even minor bleeding immediately to maintain visualization.

6. Fundal Mobilization and Short Gastric Division

   • Technique and Rationale

     • Divide 10–12 cm of short gastric vessels close to the gastric wall to achieve a floppy fundus.

     • Perform the shoe-shine maneuver to confirm wrap laxity.

     • “Lift the stomach like a bread” to protect pancreas and omental bursa during division.

7. Crural Approximation (Hiatal Repair)

   • Materials and Needle Choice

     • Non-absorbable sutures (e.g., Dacron or silk) preferred; avoid Prolene for crura due to slipperiness.

     • Curved two‑third circle needles improve directional control and reduce risk to IVC.

   • Technique and Safety

     • Place bites anterior to the plane of the caudate lobe to avoid IVC injury.

     • Tailor number of sutures to hernia size; aim for a residual ~5 mm gap between esophagus and crura to reduce dysphagia.

8. Nissen Fundoplication: Wrap Construction

   • Suture Strategy

     • First stitch: stomach-to-stomach (fundus positioning) without including esophagus.

     • Subsequent stitches: right stomach bite → include esophagus (shallow bites; no serosa) → left stomach bite, sandwiching the esophagus between gastric walls.

     • Confirm a full 360° wrap with floppy configuration; avoid constriction.

   • Adjunct Fixation

     • Gastropexy is optional in Nissen; mandatory diaphragm fixation for partial wraps.

9. Short Esophagus Management

   • Collis Gastroplasty

     • Create a neo-esophagus using linear staplers (triple staple lines on each side with division between) to achieve adequate intra-abdominal length when thoracic mobilization is unsafe.

   • Thoracic Alternatives

     • Belsey-Eason thoracoscopic approach is more complex and less commonly employed.

10. Alternative Procedures

    • LINX Magnetic Augmentation

      • Earth magnets encased in titanium beads; FDA-approved with supportive medium-term safety data.

      • Minimal dissection via pars flaccida; retrogastric tunnel creation; sizing with color-coded tool; device placement without crural suturing.

      • Practical constraints: high cost, lifelong MRI restrictions, device certification requirements.

    • Transoral Incisionless Fundoplication (TIF)

      • Endoscopic internal plication using a stapling mechanism to augment the gastroesophageal valve.

      • Evolving, costly, and limited local adoption.

11. Anatomic Safety and Critical Scenarios

    • IVC Injury

      • Avoid deep right crus bites below the caudate lobe.

      • If IVC puncture occurs: immediate conversion to open surgery to abolish pneumoperitoneum and prevent CO2 embolism; liver descent aids tamponade.

    • Pleural Breach

      • Vigilance during left crural mobilization to prevent pneumothorax.

12. Postoperative Care and Follow-up

    • Early Dysphagia

      • Common and usually self-limited due to edema/inflammation.

    • Imaging and Diet

      • Day-2 gastrografin swallow under fluoroscopy to exclude esophageal injury following upper GI procedures.

      • Gradual diet progression from liquids to soft, well-chewed solids; small frequent meals.

    • Interventions

      • Endoscopic dilatation for persistent dysphagia; consider reversal in selected refractory cases.

SURGICAL PEARLS:

• Practical tips:

  • Confirm acid-mediated disease with pH studies and assess motility with manometry before offering surgery.

  • Achieve a truly floppy wrap using the shoe-shine maneuver; divide short gastrics liberally.

  • Use a sling for posterior mobilization; avoid direct hooking of the esophagus.

  • Preserve anterior and posterior vagus nerves; avoid routine division of the gastrohepatic ligament.

  • Maintain a ~5 mm hiatal gap; looser closure is safer than tight to prevent dysphagia.

• Common mistakes and avoidance:

  • Proceeding without objective testing in medical nonresponders leads to poor outcomes.

  • Misgrading esophagitis; apply LA criteria rigorously.

  • Deep right crus bites risking IVC injury; place sutures anterior to the caudate lobe with curved needles.

  • Overly tight wraps; ensure fundal floppiness and cautious esophageal bites.

ANESTHETIC AND PHYSIOLOGICAL CONSIDERATIONS:

• CO2 embolism risk in major venous injury during laparoscopy is amplified by pneumoperitoneum; immediate conversion and decompression are critical.

• Brief, careful use of energy for peritoneal opening; predominant blunt dissection reduces thermal injury risk.

COMPLICATIONS AND THEIR MANAGEMENT:

• Intraoperative:

  • IVC puncture: immediate conversion to open; remove liver retractor to allow caudate lobe tamponade.

  • Pleural breach with pneumothorax: recognize promptly; chest tube as indicated.

  • Esophageal injury from deep bites or direct hooking: avoid with sling technique and shallow esophageal bites.

  • Bleeding during posterior dissection: stop, coagulate gently, and restore visualization.

  • Liver injury from improper retractor orientation: correct device handling and placement.

  • Instrument failure (bead-wire breakage) with intra-abdominal foreign body: prevent by withdrawing beaded retractors through the wound, not the cannula.

• Early postoperative:

  • Dysphagia from tight wrap or edema: prevent with floppy wrap and adequate gap; manage expectantly; dilatation if persistent.

• Late postoperative:

  • Persistent reflux-like symptoms in non-acid etiologies: underscores importance of objective preoperative confirmation.

  • Wrap migration/strangulation if crural repair inadequate: prevent with strong non-absorbable sutures and appropriate closure.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS:

• Document endoscopy grading, pH monitoring, and manometry findings to substantiate indications.

• Match wrap type to motility and esophageal length; reserve partial wraps for poor motility and Collis for short esophagus.

• Record details of crural sutures (material, number, needle type) and confirmation of residual hiatal gap.

• For LINX, obtain informed consent regarding MRI restrictions, device certification, and cost implications.

• Provide thorough counseling on expected dysphagia course, diet progression, and potential need for dilatation.

SUMMARY AND TAKE-HOME MESSAGES:

• A floppy Nissen fundoplication remains the gold standard when selected and executed with objective confirmation and meticulous technique.

• Esophageal length (3–5 cm intra-abdominal) and fundal mobilization (10–12 cm short gastric division) are pivotal for durable, functional outcomes.

• Safety-first principles—sling-assisted mobilization, careful crural suturing anterior to the caudate lobe, and immediate conversion for IVC injury—prevent catastrophic complications.

MULTIPLE CHOICE QUESTIONS (MCQs):

1. The gold standard initial test for grading esophagitis in GERD is:

   • A. Barium swallow

   • B. Endoscopy

   • C. Manometry

   • D. MRI

   • Correct answer: B

2. LA Grade B esophagitis is defined by mucosal breaks:

   • A. <5 mm between folds

   • B. >5 mm yet confined between folds

   • C. Extending beyond folds with ≥75% circumference

   • D. No mucosal breaks

   • Correct answer: B

3. Normal lower esophageal sphincter pressure on manometry is approximately:

   • A. 5–10 mmHg

   • B. 10–15 mmHg

   • C. 18–25 mmHg

   • D. 30–40 mmHg

   • Correct answer: C

4. A key indication for fundoplication is:

   • A. Asymptomatic patient

   • B. Refractory GERD with recurrence after stopping medication

   • C. Normal pH monitoring

   • D. Nonacid regurgitation only

   • Correct answer: B

5. Patients who do not respond to medical therapy typically:

   • A. Do better with surgery

   • B. Have excellent surgical outcomes

   • C. Often do not respond to surgery

   • D. Should undergo immediate fundoplication

   • Correct answer: C

6. The preferred wrap in patients with poor esophageal motility is:

   • A. Nissen 360°

   • B. Toupet 270°

   • C. Dor 180°

   • D. Rossetti

   • Correct answer: B

7. Desired intra-abdominal esophageal length during fundoplication is:

   • A. 1–2 cm

   • B. 3–5 cm

   • C. 6–8 cm

   • D. 10 cm

   • Correct answer: B

8. Liberal short gastric division during fundoplication primarily facilitates:

   • A. Reduced bleeding

   • B. Floppy fundus mobilization

   • C. Strengthening the wrap

   • D. Vagal preservation

   • Correct answer: B

9. The shoe-shine maneuver confirms:

   • A. LES pressure normalization

   • B. Adequate fundus mobility and wrap laxity

   • C. Hiatal closure tightness

   • D. Hemostasis

   • Correct answer: B

10. During crural suturing, placing bites below the caudate lobe risks injury to the:

    • A. Aorta

    • B. Portal vein

    • C. Inferior vena cava

    • D. Superior mesenteric vein

    • Correct answer: C

11. Immediate management of IVC puncture during laparoscopy is:

    • A. Apply electrocautery laparoscopically

    • B. Apply topical hemostatic agents

    • C. Continue laparoscopy with pressure

    • D. Convert to open surgery immediately

    • Correct answer: D

12. The primary physiological risk associated with IVC injury under pneumoperitoneum is:

    • A. Hypothermia

    • B. CO2 embolism

    • C. Hyperkalemia

    • D. Pneumothorax

    • Correct answer: B

13. The first stitch in Nissen wrap construction should include:

    • A. Esophagus only

    • B. Stomach-to-stomach without esophagus

    • C. Esophagus and left stomach only

    • D. Esophagus and right stomach only

    • Correct answer: B

14. In subsequent stitches of Nissen, the esophagus is:

    • A. Excluded to prevent perforation

    • B. Sandwiched between right and left stomach bites

    • C. Sutured to the diaphragm

    • D. Stapled to the fundus

    • Correct answer: B

15. The esophagus lacks which layer, increasing the risk of deep suturing?

    • A. Mucosa

    • B. Submucosa

    • C. Serosa

    • D. Muscularis

    • Correct answer: C

16. Preferred suture material for crural approximation is:

    • A. Prolene

    • B. Dacron or silk

    • C. Chromic catgut

    • D. Absorbable Vicryl

    • Correct answer: B

17. The recommended residual gap after crural repair to reduce dysphagia is the passage of:

    • A. A 10 mm trocar

    • B. A 5 mm instrument between esophagus and crura

    • C. A nasogastric tube around the wrap twice

    • D. A vascular clamp behind the esophagus

    • Correct answer: B

18. Collis gastroplasty is indicated when:

    • A. Short gastric division is incomplete

    • B. Only ~1–2 cm intra-abdominal esophagus can be achieved and further thoracic mobilization is unsafe

    • C. LES pressure is normal

    • D. Gastric bougie is unavailable

    • Correct answer: B

19. LINX augmentation requires:

    • A. Extensive posterior dissection

    • B. Minimal dissection via pars flaccida and retrogastric tunnel with device sizing

    • C. Routine crural suturing

    • D. Gastropexy to the left crus

    • Correct answer: B

20. A routine postoperative investigation on day 2 after upper GI antireflux surgery to exclude esophageal injury is:

    • A. Plain abdominal radiograph

    • B. CT scan with contrast

    • C. Gastrografin swallow under fluoroscopy

    • D. MRI of the chest

    • Correct answer: C

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA:

“Every safe operation begins with disciplined thinking—let your judgment shape each step, and your technique serve the patient.”

Wishing you precision in practice and unwavering commitment to patient safety as you advance your surgical craft.