Principles of Surgical Therapy in the Management of Gastroesophageal Reflux Disease

Surgery aims to achieve the following:

Reduction of a hiatal hernia and resection of the sac if present

Fixation of the lower esophageal sphincter in the abdomen, allowing it to function under positive intra-abdominal pressure

Closure of the crura behind the esophagus to keep the wrap in the abdomen

Ensuring an adequate length of the intra-abdominal sphincter

Correcting the defective sphincter pressure while still allowing the sphincter to relax on swallowing.

Obtaining a fine balance of the sphincter pressure is critical to avoid postoperative complications such as dysphagia or gas bloating.

The technical goals are closure of the diaphragmatic crura behind the esophagus and fundoplication creating a short floppy wrap of 15–20 mm in length. Mobilization of the wrap is achieved by division of the short gastric vessels, and calibration of the wrap is performed around a 60 Fr bougie (Fig. 5.1).

Patient Positioning

The patient is placed in lithotomy position. The surgeon stands between the patient’s legs with the monitor directly ahead. The first assistant stands to the surgeon’s right and the camera assistant to the surgeon’s left. The patient’s arms are tucked (Fig. 5.2).

Nissen

Fundoplication