Laparoscopic Nissen Fundoplication Using a Left Posterior Approach Minimizes Esophageal Injury: Our Experience

Alicia J Mangram, MD, Francisco Rodriguez, MD, Olakunle F Oguntodu, James K Dzandu. Honor Health John C Lincoln North Mountain Hospital

Background: Laparascopic Nissen fundoplication (LNF) is now considered by most as the gold standard in surgical treatment of GERD with hiatal hernia. The most feared complication of LNF is esophageal perforation. There are different approaches to create the 360° wrap. However, little has been reported on modified posterior approaches resulting in improved patient outcomes.  We present our experience with modified Laparoscopic Nissen Fundoplication using the Left Posterior (mLNF-LP) approach to strategically minimize the risk of esophageal injury.

Methods: This retrospective review identified patients who underwent fundoplication from 2012 to 2014.  Data assessed were age, sex, body mass index (BMI). Indications for Nissen fundoplication repair were: persistent GERD, hiatal hernia type, Barrett’s esophagus, or recurrent GERD. Intra-operative and post-operative complications were assessed. Data were analyzed using descriptive statistics. Details of the procedure are described.

Results: 171 patients underwent mLNF-LP. The average age was 60±14 (range 17-86) years, males (29%) and the mean BMI was 29.8±6.2 kg/m2. Forty-seven percent of patients (80/171) were obese. Indications for fundoplication were: persistent GERD (88%), recurrent GERD (11%), recurrent hiatal hernia (8%), Barrett’s esophagus (4%).  Among the 171 patients, 158 patients underwent mLNF-LP and hiatal hernia repair, and 13 patients had mLNF-LP alone.  Intra-operatively, there were no esophageal perforations, splenic injuries, inadvertent vagotomies, or other organ injuries. The operation time was 100±20 minutes. Overall 98.5% of patients returned for follow-up (median time to visit 20 days). Postoperatively, 39 patients reported dysphagia. Thirty-one of whom improved by their second visit with only 21% (n=8) patients ultimately requiring endoscopic dilation. The following endpoints and complications were noted during follow-up visit: inability to belch (.6%), gas bloating (2%), diarrhea (11%), early transient recurrent reflux (11%), and epigastric pain (19%). There was no pleural effusion (0%), early satiety (0%) or mortality (0%). Seven percent of patients underwent revision surgery.

Conclusions: This mLNF-LP approach which strategically minimizes risk to the esophagus is a safe and effective surgical procedure for select patients presenting with symptomatic GERD and hiatal hernia. Moreover, this modified technique can potentially eliminate the high morbidity and mortality of esophageal injury.

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