Technically correct fundoplication
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Technically Correct Fundoplication. David W Rattner,MD. Patient Selection. Body Habitus Size of Hiatal Hernia Type of symptom Reoperation? Motility disorder. Principles of Antireflux Surgery. Restoration of intra-abdominal esophagus Reconstruction of the diaphragmatic hiatus

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Patient selection
Patient Selection

  • Body Habitus

  • Size of Hiatal Hernia

  • Type of symptom

  • Reoperation?

  • Motility disorder


Principles of antireflux surgery
Principles of Antireflux Surgery

  • Restoration of intra-abdominal esophagus

  • Reconstruction of the diaphragmatic hiatus

  • Creation of the fundoplication


Technical points
Technical Points

  • Use 5 mm ports

  • Know where the vagi are

  • Routine:

    • crural closure

    • short gastric division

    • secure wrap to esophagus

  • Dilator decreases post op dysphagia rate

  • LOOSE FUNDOPLICATION!


Know where the Vagi are!

Posterior Window



Re herniation is the most common cause of failure
Re-herniation is the most common cause of failure!

  • Reconstruction of the diaphragmatic hiatus

    • Failure to reconstruct

    • Reinforcement with prosthetic material






When is a nissen the wrong choice for fundoplication
When is a Nissen the wrong choice for fundoplication?

  • Need for fixation to diaphragm-PEH

  • Severely disordered peristalsis

  • Pt who will need to vomit

  • Adjunct to myotomy


Toupet procedure indications
Toupet Procedure indications

  • Best reserved for special circumstances

    • Adjunct to myotomy

    • Patient will need to vomit

    • Very poor esophageal peristalsis

  • Ideal for Paraesophageal Hernia Repair

    • Multiple points of fixation



Intraoperative challenges
IntraOperative Challenges

  • Unsuspected Hepatomegaly

  • Portal Hypertension

  • “Short Esophagus”

  • Too much fat!

  • ? Chronic Pancreatitis



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