CHAPTER 4 Nissen fundoplication
♦ The antireflux barrier of the gastroesophageal (GE) junction depends on proper anatomic alignment of the distal esophagus, proximal stomach, and the diaphragm. The intrinsic muscle fibers of the distal esophagus coordinate with the sling fibers of the cardia and muscle fibers of the diaphragm to prevent reflux of gastric acid into the distal esophagus (Figure 4-1).
♦ Tonic contraction of the sling and claps fibers of the GE junction works to maintain the acute angle of His. This contributes to the gastroesophageal flap valve mechanism, which further prevents gastroesophageal reflux (GERD) (Figure 4-2).
♦ A ¼-inch, 5-cm long Penrose drain is used to facilitate retraction of the esophagus. The ends of the Penrose drain are anchored together anterior to the esophagus using a 0 chromic or Vicryl Endoloop (Covidien, Mansfield, Massachusetts).
♦ Permanent suture (0 silk or Ethibond, Ethicon, Somerville, New Jersey) with felt pledgets is used to close the crural defect. The fundoplication is performed with the same suture but without pledgets.