Relative Advantages of Different Fundoplications

Nissen fundoplication. This is the most commonly performed fundoplication worldwide. It requires at least 3 cm of intraabdominal esophagus for its creation. It creates a symmetric nipple effect of the cardia. This serves to both augment the intrinsic function of the LES (both increasing resting pressure and decreasing transient relaxation) and recreate the angle of His. Closure of the hiatus by approximating the crura is essential to prevent a recurrent hernia, which can change these anatomic relationships. The Nissen fundoplication is the most commonly performed procedure because it is the easiest to reproduce and adheres to all the principles of an effective anti-reflux procedure.

Collis-Nissen fundoplication. This procedure is used primarily for patients in whom an adequate length of intraabdominal esophagus cannot be obtained. In this case, a neoesopha-gus is created from the cardia by stapling from the angle of His parallel to the lesser gastric cur-vature,making a tubular extension of the esophagus along the lesser curve of the stomach. A Nissen is then created around the neoesopha-gus. In theory, this attempts to adhere to all the principles of a Nissen fundoplication. In practice, the staple line and neoesophagus do not allow for the creation of symmetric valve and nipple effect. This, and presence of acid-secreting cells above the fundoplication, cause it to be inferior to a standard Nissen anti-reflux procedure. However, when a short esophagus exists, it may be the best way to preserve the esophagus and still permit an intraabdominal fundoplication.

Toupet fundoplication. This is the most common "partial" fundoplication performed currently. It is a posterior, approximately 270°, fundoplication. Some surgeons use this procedure routinely, but most use it for patients with

PRINCIPLES OF SUCCESSFUL SURGICAL ANTI-REFLUX PROCEDURES

impaired esophageal motility. Because it is less than a 360° fundoplication, it does not augment the LES to the degree that a Nissen does, and as a result it generally has less control of reflux than a Nissen. We have abandoned this procedure for most patients, because we found in patients with impaired peristalsis, a Nissen provided better control of GERD without increasing the incidence of dysphagia.13

Dor fundoplication. This is an anterior 180° fundoplication. It does not require as much esophageal length, nor does it augment the LES or accentuate the angle of His as much the other fundoplications described. As such, it is rarely used as a primary anti-reflux procedure, and is most often used after a myotomy for achalasia.

Hill fundoplication. This operation is usually referred to as a "cardioplasty," rather than a fundoplication. The operation secures the gastroesophageal junction intraabdominally and tightens the collar sling mechanism. It is a difficult operation to reproduce consistently, thus has few proponents apart from those trained by Lucius Hill, its developer.

We believe that the Nissen fundoplication is the most reproducible fundoplication procedure, has a long track record with exceptional results, and, as we have discussed, can be used for almost all patients. Therefore, we will describe our technique of performing a Nissen fundoplication as an example of how a fundo-plication operation adheres to the principles outlined earlier.

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