Heartburn or reflux is probably one of the most common symptoms in USA. Patients are treated mostly with drugs that will decrease or abolish the acid production by the stomach. While this is a valid alternative that avoids the risks of surgery, the cost and side effects of these drugs have been minimized by the pharmacologic industry. The operation can be carried out in 120 minutes. It mainly creates a new high-pressure zone around the stomach inlet preventing the reflux of acid. Patients stay on a soft diet for approximately 3 weeks.
Hospital Stay: 24 Hours
Type of Anesthesia: General
Operative Time: 90 minutes
Possible Complications: Bleeding, Infection, Swallowing Difficulties (dysphagia if too tight), Gas Bloat Syndrome, Recurrence
Pictures of the Operative Technique
Figure 1. Positioning of the patient and team. Patient in lithotomy position. ANS, Anesthetist; S, surgeon; A1, A2, assistants; N, nurse; M, monitor
Figure 2. Surgeon's position.
Figure 3. Trocar sites and instrumentation
Figure 4. Traction and countertraction to initiate the dissection of the gastroesophageal junction
Figure 5a.
Figure 5b., 5c. Dissection of the diaphragmatic crura. The right and left crura are dissected first anteriorly and then posteriorly with manipulation of the esophagus via the Babcock clamp on the gastroesophageal fat pad
Figure 6 a, b. Initial retraction for exposure of the esophageal hiatus. A fan retractor is placed below the left lateral segment of the liver to retract it anteriorly. A Babcock clamp is placed on the esophageal fat pad and retracted toward the patient’s feet to expose the phrenoesophageal membrane.
Figure 7. Closure of the diaphragmatic crura. The esophagus is displaced anteriorly and to the left and three to four sutures of 2 - 0 silk are placed to approximate the crura
Figure 8. The GE-Junction is being retracted with a Penrose drain showing the sutured hiatus
Figure 9. Division of short gastric vessels
Figure 10 a, b. Creation of the fundoplication. A Babcock clamp is placed behind the esophagus, and the posterior fundus of the stomach is grasped and brought to the right. Careful attention must be paid to grasping the posterior portion of the stomach and not the anterior wall to avoid twisting of the stomach
Figure 11 a - c. 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-F mercury-weighted bougie is passed through the gastroesophageal junction prior to fixation of the wrap to assure a floppy fundoplication.
