Belsey Fundoplication Technique

Belsey Fundoplication 360

The total Nissen fundoplication is a 360-degree wrap of gastric fundus around the distal esophagus. After complete distal esophageal and proximal gastric mobilization including division of the proximal short gastric vessels left panel , the crura are approximated to close the hiatus to a normal caliber center panel . The proximal fundus is wrapped posteriorly around the esophagus and a portion of the fundus is brought anterior to the esophagus.The two edges are sutured together to...

Considerations for Esophageal Lengthening Procedures

Foreshortened Esophagus

It is essential that the gastroesophageal junction lie tension free in the abdomen before creating a fundic wrap. The length of tension-free intraabdominal esophagus should be measured after closing the crural defect. When the crura are closed from the caudal condensation of the crural fibers toward the anterior margin of the hiatus, the hiatal orifice is effectively displaced cephalad. This transposition of the hiatal orifice lengthens the intraabdominal segment of esophagus because the...

Potential Causes of Failure

Floppy Fundoplication

Regardless of the surgical nuances, failed antireflux operations can be analyzed and subdivided into three distinct anatomic regions. Failure can occur at the esophageal, wrap, or crural level, although there may be overlapping or concurrent issues. Before the wide adoption of laparoscopic techniques,wrap disruption was the most common mode of failure. In the laparoscopic era, the most common cause of failure is herniation of the wrap through the diaphragmatic hiatus. The construction of a...

Methods of Evaluation

Nissen Fundoplication Barium Swallow

Given the poor correlation between symptoms and anatomic failure, a careful and thorough evaluation is warranted. A complete history and physical should be performed with particular attention to the patient's current symptoms. Are the symptoms similar to those experienced before the original surgery Do symptoms of reflux or dysphagia predominate Was there a precipitating event Do antacid medications ameliorate the symptoms The patient's original operative report should be obtained to clarify...

Persistent Postoperative Dysphagia

Slipped Fundoplication

In contrast to the patient with recurrent GERD symptoms, the patient with persistent postoperative dysphagia represents a different problem. The management of the patient with early postoperative dysphagia was discussed above. In the patient with dysphagia persistent for gt 3 months, we first confirm an anatomic abnormality exists by performing a video barium swallow with a 12.5-mm barium tablet. If the pill passes the gastroesophageal junction readily, there is little that one can do to fix...

Functional Constituents of the EGJ

Hill Grade Iii Esophagus

Conceptualized as an impediment to reflux, the EGJ is generally viewed as a high-pressure zone at the distal end of the esophagus that isolates the esophagus from the stomach. The anatomy of the EGJ is complex. The tubular esophagus traverses the diaphragmatic hiatus and joins the stomach in a nearly tangential fashion. Thus, there are several potential contributors to EGJ competence, each with unique considerations the intrinsic lower esophageal sphincter LES , the influence of the...

Flatulence Diarrhea and Irritable Bowel Syndrome

Anti Reflux Surgery

Problems related to flatulence, diarrhea, and irritable bowel syndrome IBS are very common among adult patients with or without GERD.38 It is therefore to be expected that many patients will have these symptoms both before and after anti-reflux surgery. In a study from our institution, diarrhea was present in 14 of patients before surgery and 29 after. Other symptoms included bloating 3 preoperative, 19 postoperative , constipation 15 and 18 , respectively , and abdominal pain 2 and 8 ,...