Laparoscopic Nissen fundoplication

A technique for laparoscopic Nissen fundoplication is described and a series of 11 cases is presented. The technique secures the patient to the operating table with three safety straps and the patient is then placed in a reverse Trendelenburg position with the hips flexed. The surgeon operates from the patient's right side using two midline trocar sites as the main operating ports. Other ports provide retraction and laparoscope access. The liver retractor is held by a mechanical arm. Once the esophageal peritoneum has been opened, the esophagus and diaphragmatic crura are dissected out and elevated by a Penrose drain sling. The short gastrics are divided and the fundus is brought posterior to the esophagus passing from left to right. A large Maloney dilator is placed in the esophagus and the fundal wrap is sutured to the anterior aspect of the stomach by three sutures; the inferior--most of which incorporates the anterior wall of the esophagus. Once the fundoplication is completed, the dilator is replaced by a nasogastric tube. Postoperatively, patients are given clear liquids and when these are tolerated the nasogastric tube is removed. Most patients are discharged on the second or third postoperative day. Operating time averaged 147 min, and all patients returned to unrestricted activity within 2 to 3 weeks. All patients reported complete relief of gastroesophageal reflux. Average follow up was 120 days with a median of 148 days. Long-term follow up is in progress.