the stomach to the diaphragm are taken down.

Creation of the Fundoplication. A short, loose fundoplication is fashioned with particular attention to

the geometry of the wrap (Fig. 42-44). The midposterior fundus is grasped and passed left to right

behind the esophagus rather than pulling right to left. This ensures that the posterior fundus is used for

the posterior aspect of the fundoplication. This is accomplished by placing a Babcock clamp through the

left lower port and grasping the midportion of the posterior fundus (Fig. 42-45). One should gently

bring the posterior fundus behind the esophagus to the right side with an upward, rightward, and

clockwise twisting motion. This maneuver can be difficult, particularly for the novice. If so, placement

of a 0-silk suture in the midposterior fundus 6 cm down from the GEJ and grasping it from the right

side facilitates bringing the posterior fundus around to create the fundoplication. The anterior wall of

the fundus is then folded over the esophagus to meet the posterior at about the 9 o’clock position such

that the esophagus is imbricated within the fundus rather than having the fundus twisted or spiraled

around the esophagus.

Figure 42-44. Schematic representations of the various possibilities of orientation of a Nissen fundoplication. The top set of figures

represents the preferred approach, whereas the bottom two sets can be seen to result in twisting of the fundoplication.

The posterior and anterior fundic lips should be maneuvered (as in a “shoe shine”) to allow the fundus

to envelope the esophagus without twisting. Laparoscopic visualization has a tendency to exaggerate the

size of the posterior opening that has been dissected. Consequently, the space for the passage of the

fundus behind the esophagus may be tighter than thought and the fundus relatively ischemic when

brought around. If the right lip of the fundoplication has a bluish discoloration, the stomach should be

returned to its original position and the posterior dissection enlarged. A 60-French bougie is passed to

properly size the fundoplication, and the “lips” of the fundoplication sutured utilizing a single U-stitch of

2-0 Prolene buttressed with absorbable pledgets. The most common error is an attempt to grasp the

anterior portion of the stomach to construct the right lip of the fundoplication rather than the posterior

fundus. The esophagus should comfortably lie in the untwisted fundus prior to suturing. If the posterior

fundus tries to pull away back under the esophagus there is tension likely from inadequate mobilization

of the fundus, particularly posteriorly along the pancreas. This should be addressed to release the

tension and reduce the risk of disruption of the fundoplication postoperatively. Finally, two anchoring

sutures of 2-0 silk or Ethibond are placed above and below the U-stitch to complete the fundoplication.

When finished, the suture line of the fundoplication should be facing in a right anterior direction (Fig.

42-46). The abdomen is then irrigated, hemostasis checked, and the Penrose drain and any sponges

placed into the abdomen removed.

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Figure 42-45. Placement of Babcock on the posterior fundus in preparation for passing it behind the esophagus to create the

posterior or right lip of the fundoplication. Inset: To achieve the proper angle for passage, the Babcock is placed through the left

lower trocar. The posterior fundus is passed left to right and grasped from the right via a Babcock through the right upper trocar.

A: Location of posterior fundus for passage to the right side. B: The posterior fundus passed underneath the esophagus and grasped

on the right.

Figure 42-46. Fixation of the fundoplication. The fundoplication is sutured in place with a single U-stitch of 2-0 Prolene pledgeted

on the outside. A 60-French mercury-weighted bougie is passed through the gastroesophageal junction prior to fixation of the wrap

to ensure a floppy fundoplication. Inset illustrates the proper orientation of the fundic wrap.

Transthoracic Nissen Fundoplication. The indications for performing an antireflux procedure by a

transthoracic approach are given in Table 42-9.

In the thoracic approach the hiatus is exposed through a left posterior lateral thoracotomy incision in

the sixth intercostal space (i.e., over the upper border of the seventh rib). When necessary, the

diaphragm is incised circumferentially 2 to 3 cm from the lateral chest wall for a distance of

approximately 10 to 15 cm. The esophagus is mobilized from the level of the diaphragm to underneath

the aortic arch. Mobilization up to the aortic arch is usually necessary to place the repair in a patient

with a shortened esophagus into the abdomen without undue tension. Failure to do this is one of the

major causes for subsequent breakdown of a repair and return of symptoms. The cardia is then freed

from the diaphragm. When all the attachments between the cardia and diaphragmatic hiatus are

divided, the fundus and part of the body of the stomach are drawn up through the hiatus into the chest.

The vascular fat pad that lies at the GE junction is excised. Crural sutures are then placed to close the

hiatus though are not tightened until later. The fundoplication is constructed by enveloping the fundus

around the distal esophagus in a manner similar to that described for the abdominal approach. When

complete, the fundoplication is placed into the abdomen by compressing the fundic ball with the hand

and manually maneuvering it through the hiatus. The previously placed crural stitches are then

tightened and knotted.

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