The laparoscopic partial anterior fundoplications (LAF) have been described as 90°, 180° (Dor Fundoplication) [18], or 120° (Watson Fundoplication) [19]. Anterior wraps have three main components: mobilize sufficient abdominal esophagus, secure distal esophagus to crural repair, and close the angle of His via a partial fundoplication. The 90° fundoplication detailed by Krysztopik et al. [20] is described here. The patient positioning and port placement are the same as that described for the laparoscopic Nissen [5]. Briefly, the patient is placed in a modified Lloyd Davies position in reverse Trendelenburg with the operating surgeon standing between the patient’s legs and the assistant at the patient’s left side. A five-port technique is utilized for the operation (Fig. 6.4). The camera port is placed cephalad of the umbilicus and to the left of midline to provide for visualization of the structures within the hiatus. One must be able to extend the laparoscope all the way to the hiatus in order to visualize mediastinal mobilization of the esophagus. Next, 5 mm trocars are placed bilaterally in the anterior axillary lines for retraction of the liver and the surgeon’s assistant. A 12 mm trocar is beneath the costal margin in the left mid-clavicular line. It is important to place this port lateral so as to maintain appropriate triangulation at the hiatus. Lastly, with the liver retracted through the right lateral port, the final 5 mm trocar is placed in the right midclavicular line. Placement of this port prior to liver retraction can result in obstructed access to the hiatus.

The operation is begun with dissection and isolation of the esophagus from the surrounding structures. This is started by transection of the pars flaccida, moving cephalad so as to identify the right crus. The phrenoesophageal ligament is transected moving anteriorly from right to left. This dissection is carried laterally and posteriorly as far as possible until visualization is limited by the gastric fundus. Next, the short gastric vessels are divided moving cephalad until the left crus can be completely identified and all posterior short gastric vessels are sacrificed. A Penrose drain is then passed posterior to the esophagus to facilitate retraction. The hiatus is restored posteriorly with nonabsorbable suture. The fundoplication begins with an esophagopexy between the right posterolateral side of the esophagus (proximal to the gastroesophageal (GE) junction) to either the right or both crura. Next, the fat pad overlying the cardia is retracted inferiorly to reconstruct the angle of His, and an additional suture is placed between the left lateral esophagus and the neighboring gastric fundus. Another suture is placed more cranially to close the angle of His. This suture brings the left portion of the intra-abdominal esophagus to the gastric body in juxtaposition to the left crura. The left crura can be included in this suture to gain additional length of the intraabdominal esophagus. Next, the gastric fundus is directed midline to sit loosely over the anterior portion of the esophagus. An apical suture, the highest extent of the fundoplication, is placed from the fundus to the anterior esophagus including the apex of the hiatus. The inferior portion of the fundal fold is secured midline to the anterior esophagus at the EG junction. In this 90° wrap, the short gastric vessels are left intact and no bougie is needed [20]. The Watson fundoplication is similar to the above yet the fundus is brought over as a 120° wrap. In the Dor fundoplication the short gastric vessels are ligated and the fundus is secured in place as a 180° wrap.

The laparoscopic posterior partial fundoplication (LPF) that has been described for the treatment of GERD is the Toupet (270° wrap) [21] although according to Nissen, a 360° fundoplication is a type of posterior fundoplication [7]. The laparoscopic Toupet fundoplication described by Wenck is discussed here. Somewhat similar to the LAF, the posterior consists of three main steps: mobilizing the abdominal esophagus, mobilizing the posterior portion of the fundus, and esophogastroplasty with phrenogastroplasty. The patient positioning and port placement mirrors that of the aforementioned LAF. Essential operative steps including esophageal isolation and mobilization as well as the crural repair are also the same. To complete the fundoplication, a portion of the superior fundus is drawn posterior to the esophagus to the right side. Following this, a shoeshine maneuver is performed to verify that the fundus is appropriately oriented and that there is not undue tension due to persistent caudal or posterior short gastric vessels. The right portion of the fundus is secured to right lateral aspect of the esophagus with three distinct stitches. The most cephalad stitch also incorporates the right crura to anchor the wrap within the abdomen. This is then completed on the left side in a mirror image of the right. Finally, the posterior wrap is affixed to the crural closure with two interrupted stitches to deter from cephalad migration of the wrap post-operatively [22].

As stated previously, the 360° fundoplication is a type of a posterior fundoplication [7] and is briefly narrated herein. Much like the partial wraps, there are three essential steps to the 360° fundoplication including mobilization of the esophagus in order to achieve appropriate abdominal length, transection of the short gastric vessels to afford for a tension-free wrap, and esophogastroplasty with phrenogastroplasty. The patient positioning and port placement mirrors that of the aforementioned procedures. Essential operative steps including esophageal isolation and mobilization as well as the crural repair are also the same. To complete the fundoplication, a portion of the superior fundus is drawn posterior to the esophagus towards the right. A shoeshine maneuver is performed to verify that the fundus is appropriately oriented and that there is not undue tension. A 2.0–2.5 cm complete fundoplication is then created with permanent stitches. The most cephalad stitch often incorporates the muscular esophagus to help prevent slippage of the wrap down onto the stomach. Further, many will anchor the wrap to the crura pillars bilaterally to deter cephalad herniation into the thoracic cavity. Finally, the posterior wrap is affixed to the crural closure with two interrupted stitches to complete intra-abdominal fixation [22].

Medical management remains the first line treatment for GERD. Recent publications have identified associations between PPI usage and dementia [23], chronic kidney disease [24], and even risk of infections [25, 26]. These findings have produced consternation amongst millions of chronic PPI users and have led to uncertainty as to the superiority of medical management of GERD. It is with this ambiguity in mind that investigators have assessed the efficacy of the two treatment options. A randomized study by Mahon et al. noted that anti-reflux surgery objectively improved the acid exposure within the esophagus while also significantly benefiting patient gastrointestinal and general well-being [27]. In another randomized controlled study by Goeree et al., surgery produced fewer heartburn days and improved overall quality of life when compared with medical management alone [28]. Perhaps more importantly, the long-term cost-effectiveness of surgery has been validated in two distinct trials out to at least 5 years post-operatively [2, 28]. While these studies have lacked standardized patient-oriented outcomes and are limited in length of follow-up, there is compelling evidence that the surgical management of GERD is successful and with an acceptable side effect profile.

Many reviews have been published with over 10 years of follow up data for the LPF versus LAF. These studies demonstrate that the posterior partial fundoplication is a durable surgical treatment for GERD with better reflux control than an anterior wrap at the expense of mild increase in dysphagia [8–10, 29]. Patients with anterior fundoplication have been found to need significantly more antisecretory drugs postoperatively and reoperative surgery for their recurrent GERD. This is evidence that an anterior fundoplication is overall less durable than a posterior wrap [30]. Of note, the anterior partial fundoplication is technically simpler its counterpart [30] which may continue to make it a popular procedure despite the evidence suggesting it to be an inferior operation in the long-term.

The incidence of post-operative dysphagia is up to 70% following a 360° fundoplication [31]. The vast majority of these cases are transient and related to post-operative edema. Advocates for a Toupet fundoplication assert that reflux control is comparable, but the incidence of post-operative dysphagia is lower than that of the LNF [32]. Specifically, those patients with preoperative esophageal dysmotility are thought to be better served with the looser partial fundoplication [33]. To date, the literature has been inconsistent its support of this assertion. Zornig et al. noted that, while the Toupet was a superior operation for prevention of dysphagia, the outcome was independent of preoperative motility. Conversely, others have noted that the presence of dysphagia is similar between the two operations [29]. Perhaps most importantly, a meta-analysis of over 400 patients found that the LNF was significantly more likely to require dilation for persistent dysphagia [34]. Few have investigated the differences between LAF and the LNF. While limited by a follow-up of only 6 months, one group noted fewer side effects following the LAF [35]. Another paper reported improved outcomes following LAF out to 10 years. It is notable that their investigations into improved reflux control and side effect profiles were based strictly on subjective evaluation by the patient.

The issue of post-operative dysphagia has also been investigated for the LAF and LPF. A randomized, controlled trial of 95 patients noted no difference in the compliant of dysphagia post-operatively based on type of fundoplication [36]. Others have observed a higher incidence of early dysphagia with the LPF, but that this resolved by 6 months post procedure [37]. Of note, the LPF performed in setting of a Heller myotomy for achalasia has been found to be associated with improved postoperative dysphagia with nearly identical reflux control in comparison to partial anterior fundoplication [38]. While it is not as intensely debated when considering the anterior versus partial wrap, there is evidence to support that neither is superior in prevention of post-operative dysphagia .

For many prospective patients one of the principal deterrents to anti-reflux surgery is anxiety at the prospects of an inability to belch or vomit, excess flatulence and abdominal bloating. These so called wind-related side effects can be identified in up to 60% of patients depending on the complaint [8, 39]. When compared to the Nissen, the LAF has been shown to have less flatus, abdominal bloating, inability to belch and vomit, and other gas-related symptoms [7]. Those with a LPF also noted less flatulence and postprandial fullness compared to those undergoing a 360° fundoplication [29]. When comparing the LAF and LPF, the results have been less uniform. Well-designed studies with a follow-up up to 5 years found no difference in the complaints of flatulence or inability to belch between the LAF and LPF cohorts. Conversely, other investigations have noted that those who underwent LAF were significantly more likely to be able to vomit [28, 32]. Hagedorn et al. observed an improved ability to vomit as well as fewer complaints of flatulence in those undergoing an LAF [36]. While the literature is more conclusive when comparing a partial to a full wrap, there is more ambiguity with the LAF and LPF. Perhaps the only area where there is a more explicit difference is the improved ability to vomit following LAF.

There have been several comparisons via randomized controlled trials and meta-analyses of the Nissen to both the LAF and LPF [7, 8, 10, 29, 30, 36, 37, 40–43]. While thoughtfully designed, many of these investigations have been limited by short-term follow-up. For instance, using 24-h pH testing Zornig et al. identified no difference in reflux control up to 4 months post-operatively [32]. This result was replicated in a randomized study with 1 year follow-up using impedance pH testing [33]. A meta-analysis of the available studies showed that the ability to heal esophagitis was not significantly different between the two operations (LNF vs. LPF was 6.28% vs. 8.63% respectively, P = 0.42). Certainly the durability of a partial wrap remains a concern in that any degree of unwrapping would negatively affect the increased LES pressures. With that said, the available data speaks to the equivalence of the LPF to the LNF for reflux control.