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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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Presentation Transcript
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!
slide5

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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