The classical indications for Nissen fundoplication are;

Outcomes of Nissen have been described as being better if patients are not morbidly obese [15] have typical symptoms have good response to medical therapy [16] and who have not had previous anti-reflux surgery [17, 18].

Upper endoscopies performed in chronic GERD, as part of the workup for possible surgery, have shown that at most only half of the patients will have erosive reflux disease. The majority of reflux patients today have no visibly active esophagitis [19, 20]. Ambulatory 24-h pH monitoring with symptom association analysis is therefore a gold standard test to diagnosed GERD in absence of esophageal erosions. Patients can be divided into isolated upright, isolated supine, and bi-positional reflux based on the body position in which pathological reflux occurs during pH monitoring. Traditionally those with isolated supine and bi-positional reflux are considered the best candidates for reflux surgery, as this finding indirectly indicates a mechanical defect of the LES and is associated with more severe disease. Isolated upright reflux disease is often associated with less typical manifestations of reflux disease and sometimes indicative of maladaptive behaviors. Therefore fundoplication tends to be withheld from these patients. However, well-controlled studies comparing upright refluxers with those having reflux in supine and bi-positional body positions have revealed that patients with all three reflux patterns responded equally well to Nissen fundoplication over the long-term [21, 22]. Another important predictor of outcomes is the presence of both a pathological acid exposure time and a positive symptom reflux correlation during pH monitoring. Patients with clearly pathological esophageal acid exposure benefit from a total fundoplication, irrespective whether they have a negative or a positive symptom reflux correlation [23]. There remains a question as to whether the 10–15 % of patients with GERD who have a positive symptom association in spite of normal acid exposure (so called “sensitive esophagus”) are good candidates for a reflux surgery. Relatively few short-term studies have been published that would support that patients with esophageal acid hypersensitivity alone would benefit from a Nissen fundoplication to the same degree as those with abnormal clearly pathological acid reflux [24]. This patient group clearly has to be better researched.

Endoscopy negative reflux disease has traditionally been regarded as a mild form of GERD and sometimes considered to represent a relative contraindication for a total fundoplication. However, during the latest two decades studies have demonstrated that the impairment of quality of life and severity of symptoms are similar in the endoscopy negative GERD group (non-erosive reflux disease, NERD) compared with the endoscopy positive one (erosive reflux disease, ERD). Studies have carefully evaluated the effect of Nissen fundoplication on NERD and ERD patients [25]. When doing so, subjective and objective outcome measures, after total fundoplication and reoperation rates, were very comparable [26]. Therefore, at present it can be concluded that the absence of erosions on endoscopy in patients with chronic GERD symptoms and with pathological acid reflux variables on testing is not a reason to refrain from an anti-reflux operation.

It is important to define predictors of less favorable outcomes after total fundoplication. It has been assumed that patients with esophageal dysmotility, as diagnosed with esophageal manometry, are more likely to develop post-operative dysphagia. Many centers have therefore advocated a tailoring concept, meaning that a partial wrap should be done in similar situations to minimize the risk for obstructive symptoms postoperatively [27, 28]. However, randomized clinical trials have failed to demonstrate that the outcome after total fundoplication is worse in patients with poor motility compared to those with normal esophageal function [29–32]. The majority of practitioners who use Nissen may slightly modify it (e.g., use a larger dilator or make it shorter in length) but would not avoid it in mild and moderate dysmotility. The complete absence of motility on the other hand is widely considered a “red flag” and often an indication for a partial wrap.

It is well known that the proper creation of a full 360-degree fundoplication is paramount to its success and poorly performed fundoplications can lead to disastrous outcomes. Despite attempts to standardize the technique, there are numerous minor variations to the “Nissen” added by practitioners based on their own experience. Some of these variations are evidence based and some are not. The Nissen–Rossetti variation is one of the oldest alternatives. While it still includes mobilization of the distal esophagus and posterior crural repair, it differs significantly in that the short gastric vessels are not divided and the fundoplication is created using the anterior wall of the stomach only. [33] (Fig. 9.4). Several studies seem to indicate that in the hands of experts, there are no differences in the short- or the long-term outcomes between the original Nissen and the Nissen–Rossetti modified fundoplications [34, 35].

In the early days of laparoscopic fundoplication, many surgeons avoided the division of the short gastric vessels, as it was tedious to clip or tie them individually. After early reports describing increased problems not dividing them, [36] and with the availability of new energy devices that made division quick and reliable, [37] routine division became the norm as it was for the open procedure. Still, there is little to objectively support the need to divide them. Two randomized studies have shown no significant difference in outcomes between Nissens with fundic mobilization and without [38]. Whereas in the open era of fundoplication, closure of the hiatus was considered optional, and in fact was seldom done for all but the largest hiatal hernias, it was rapidly found that reduction of any resident hiatal hernia sac and a secure hiatal closure is mandatory for laparoscopic repairs [39]. This may be because of the relative lack of adhesions resulting from laparoscopic approaches that result in a more mobile stomach that is able to easily migrate into the mediastinum. Other elements of hiatal closure remain highly controversial and include type of suture used (heavy woven permanent suture being the preferred choice), pattern of closure (simple sutures, figure of 8, pledgeted, etc.), use or avoidance of mesh, and posterior versus anterior closure. Regarding the latter, while common practice is to close the hiatus posteriorly, there is level-one evidence that supports anterior closure as equivalent [40].

Another hallmark of the open Nissen was the mandatory use of a large esophageal dilator. After incidences of bougie perforations during laparoscopic fundoplication (incidence of 0.8 % in meta-analysis) many advocated against its routine use [41, 42]. There is some evidence that wrapping over a large dilator may decrease dysphagia rates but there is no doubt that it adds time and some risk to the procedure. The only randomized study would seem to indicate a lower short- and long-term dysphagia rate with bougie use [43]. Use of a bougie therefore varies widely from center to center, with perhaps slightly more favoring not using one over its routine use [44].