Laparoscopic Nissen fundoplication at a teaching center: prospective analysis of 103 consecutive patients

The Nissen fundoplication is the most extensively studied and successfully employed surgical solution to gastroesophageal reflux disease (GERD). Early success with the application of minimally invasive techniques to this procedure has been reported by several authors. One hundred three consecutive patients were operated on for the symptoms and complications of GERD. Preoperative evaluation consisted of esophagogastroduodenoscopy and esophageal manometry. Twenty-four-hour esophageal pH was obtained selectively. All cases were performed in a traditional training environment, adhering to techniques previously described in the open literature. Clinical data consisted of operative time, postoperative hospital days, days to resumption of normal activities, and morbidity. Patients were followed clinically for the incidence of dysphagia, bloating, and recurrent reflux symptoms. These were graded using a modified Visick score prior to discharge, at 1, 3, and 6 months, and then annually. All patients underwent completion of their procedure; however, four required conversion to open technique and were excluded from analysis. Mean operative time for the 99 laparoscopic procedures was 180 min. Mean operative time was significantly longer for the first 50 cases (202.1 min) than the last 49 (164.2 min). Mean postoperative hospital stay was 2.3 days with 10 days to resumption of normal activities. Mean follow-up was 15 months (range 3-39 months). Three of the four treatment failures underwent open revision with good subsequent results. Patient satisfaction as reflected by the modified Visick score reveals 96% good to excellent results (Visick 1 or 2) with no persistent dysphagia. The Nissen fundoplication can be safely performed using minimally invasive techniques with the benefit of postoperative recovery typical of other laparoscopic procedures. By strictly adhering to the primary technical principles previously described in the open approach, early results are comparable. The procedure can be safely performed in a traditional training environment. The modified Visick system is a simple and effective method to quantify postoperative patient satisfaction.