Fig. 11.1
Selection of the correct piece of anterior fundus for anterior 180° partial fundoplication. The assistant pulls the gastro-esophageal junction downwards. The correct piece of fundus is usually closer to the gastro-esophageal junction than the greater curve aspect of the fundus
Worldwide, the Dor fundoplication, a variant of the anterior partial fundoplication, is often added following cardiomyotomy for achalasia, in an attempt to minimize the risk of reflux following this procedure. With cardiomyotomy the lower esophageal sphincter is fully divided, and the body of the esophagus in patients with achalasia also lacks peristalsis. This is a highly refluxogenic situation. It is widely agreed that the use of an anterior partial fundoplication is appropriate in these patients, and the reported clinical outcomes are generally good, with good antireflux efficacy. If an anterior fundoplication is effective in this difficult situation, it seems like it would make sense to consider wider application in the context of surgery for reflux, as an alternative to a Nissen fundoplication for example, which can minimize side effects but still achieve reflux control, would be desirable. Examples of high-risk situations where a partial fundoplication is already more widely used include patients with reflux and an aperistaltic esophagus, as well as difficult clinical situations such as reflux with atypical throat symptoms, and scenarios where the surgeon wants to control reflux but avoid adding any new post-fundoplication problems (emotionally “challenging” patients). Using an anterior partial fundoplication as a form gastropexy in patients undergoing repair of a large hiatus hernia, in whom the presenting symptoms are due to mechanical problems from the hernia, rather than gastro-esophageal reflux, also makes sense.
In the past, the absence of good long-term outcome studies led many surgeons to apply a selective approach to the use of partial fundoplications for the surgical treatment of gastro-esophageal reflux, with the Nissen fundoplication widely accepted as the “gold standard” and the expectation that partial wraps would have a compromised success rate. However, long-term outcome data at 10 or more years follow-up is now available, and this suggests overall success rates for partial wraps which are equivalent to Nissen fundoplication [3, 4]. This late follow-up data shows similar patient satisfaction with the overall outcome, but with a tradeoff between the risk of recurrent reflux versus the risk of side effects. For anterior partial fundoplication, the supporting data is more robust for anterior 180° partial fundoplication [3, 5], than for anterior 90° partial fundoplication with some studies suggesting a higher rate of recurrent reflux following the latter approach [6, 7].
Hence, in clinical practice, there is now sufficient data to support the application of an anterior 180° partial fundoplication in most patients presenting for antireflux surgery. In patients with reflux and normal or relatively normal esophageal motility a discussion about the risks of side effects versus the risk of recurrent reflux following anterior 180° partial versus Nissen fundoplication is appropriate, and in my practice patients are encouraged to choose the type of fundoplication which best fits their expectations. Approximately 60 % choose an anterior 180° partial fundoplication. In addition, an anterior 180° partial fundoplication is always used for patients in whom the side effect profile needs to be minimized (scenarios described above). In patients with a large hiatus hernia, but no reflux symptoms, repair of the hernia rather than controlling reflux becomes the aim of surgery, I construct an anterior 90° partial fundoplication primarily to improve anchorage of the stomach within the abdomen, as minimization of the risk of side effects is particularly important in these patients.
Surgical Technique
When constructing an anterior partial fundoplication, the key steps are to reduce and repair any hiatal hernia, stabilize and maintain an adequate length of intra-abdominal esophagus, and create a stable flap valve by folding and anchoring the anterior fundus loosely across the front of the esophagus. Stabilization of the partial fundoplication requires anchorage to the more rigid diaphragmatic hiatus, and this new anatomical relationship needs to be stable for the long-term. To ensure this, adequately large bites of tissue must be taken with each suture—stomach, esophagus and hiatal rim. As the laparoscope magnifies the view, the tendency to be cautious and take superficial bites of all structures must be resisted. Full thickness sutures of the esophageal and gastric walls are rarely a problem, and adequate sutures ensure adequate anchorage of the fundoplication.
Hiatal Dissection and Repair
Laparoscopic port placement is as for any other laparoscopic antireflux procedure. Four ports and a Nathanson liver retractor are used for surgical access. Two 11 mm ports are placed, one supra-umbilically for the laparoscope, and the other just below the left costal margin in the mid-clavicular line as the main working port. Two 5 mm ports are also placed, one just below the right costal margin in the mid-clavicular line, and the other in the left flank. A separate 5 mm subxiphoid incision is used for the Nathanson liver retractor.
Fig. 11.2
The correct piece of anterior fundus is selected when it sits loosely across the anterior esophagus and hiatus
The hiatus is dissected to expose the hiatal rim and the intra-abdominal esophagus, and any associated hiatal hernia is fully reduced. My preference is to use a blunt dissection technique, supplemented by diathermy hook dissection as required. If dissection is maintained in the correct plane and the fascial coverings over the hiatal rim are preserved so that muscle fibers are not exposed, then dissection is virtually bloodless. Troublesome bleeding indicates dissection in the wrong plane. If a very large hiatus hernia is present, the hiatal rim must be dissected first and the hernia sac removed fully from the chest before progressing to esophageal dissection.
The next step is dissection of the esophagus and the posterior hiatus. Care must be taken when dissecting behind the esophagus, as blind dissection or enthusiastic use of energy sources in this area can lead to perforation of the esophagus. The esophagus is encircled with a tape and retracted anteriorly and to the left, and dissection continues until both hiatal pillars are well displayed with the left pillar visible from behind the esophagus. The hiatus is then repaired posterior to the esophagus with interrupted non-absorbable sutures. Usually 1-3 sutures are sufficient. Care should be taken to avoid excessively narrowing the hiatus as this can cause post-operative dysphagia.
Fig. 11.3
The first suture includes the postero-lateral wall of the distal esophagus at least 2 cm proximal to the gastro-esophageal junction. To stabilize the anatomy a generous depth of tissue is included in this suture
Construction of an Anterior 180° Partial Fundoplication
When constructing an anterior 180° partial fundoplication, the aim is to create a stable flap valve, and anchor the distal esophagus within the abdomen. This is done by suturing the gastric fundus to the distal esophagus and the right side of the hiatal rim. The short gastric blood vessels do not need to be divided. Before suturing, the correct piece of stomach for the construction of the partial wrap must be carefully selected (Figs. 11.1 and 11.2). When doing this, the assistant uses a grasper to retract the pericardial fat pad downwards into abdomen. This ensures that the gastro-esophageal junction and at least 4–5 cm of distal esophagus are fully reduced into the abdomen. Next, the upper part of the anterior gastric fundus is folded across the esophagus and manipulated until it sits loosely across the front of the esophagus and hiatus. This entails using the fundus approximately 1/4 to 1/3 of the way from the gastro-esophageal junction to the greater curve of the fundus, rather than the more lateral fundus, which is adjacent to insertion of the short gastric vessels.
Fig. 11.4
The first suture also includes a generous bite of the right hiatal pillar at the level of the most anterior hiatal repair suture
Fig. 11.5
The completed first suture anchors the anterior fundus to the right postero-lateral esophagus and the right hiatal pillar. When correctly placed this suture sets and guides the placement of the remaining sutures
The first fundoplication suture is critical as correct placement sets up the rest of the operation and ensures the anterior partial fundoplication is correctly constructed. This suture is placed through the gastric fundus, then the postero-lateral wall (7–8 o’clock position) of the distal esophagus at least 2 cm proximal to the gastro-esophageal junction (Fig. 11.3), and finally through the right hiatal pillar at approximately the same level as the most anterior hiatal repair suture (Figs. 11.4 and 11.5). Generous bites of the gastric and esophageal walls and the hiatal rim are included to ensure a stable fundoplication, and near full thickness bites (and perhaps occasionally actual full thickness bites) stabilize the anatomy long-term.
