The influence of surgical technique on clinical outcome of laparoscopic Nissen fundoplication

Background: During laparoscopic Nissen fundoplication (LNF), it is unclear whether the short gastric vessels (SGV) should be divided, the crura reapproximated, or the wrap sutured to the crus. Methods: Since first performing LNF, we have consistently utilized a < 2.5-cm wrap performed over a > 50 Fr dilator. Other technical details have varied, and these are reviewed in terms of early clinical outcome. Of 105 consecutive patients undergoing LNF, two were converted to open operation (2%). In the remaining 103 patients with greater than or equal to 3-month follow-up (mean 17 months), the initial 46 (group 1; 45%, mean age +/- SEM = 47 +/- 2 years) had selective division of the SGV, crural closure, and wrap fixation. In this group, 32 patients (70%) underwent SGV division, 30 patients (65%) had crural closure (10 anteriorly/20 posteriorly), and 14 patients (30%) had the wrap sutured to the crus. During the subsequent 57 LNFs (group 2; 55%, 47 +/- 2 years), all patients underwent SGV division, posterior crural closure, and suture of the wrap to the crus. Results: Clinical outcome at greater than or equal to 3 months was compared between the two groups. The frequencies of mild reflux symptoms, meteorism, and persistent dysphagia were similar in the two groups. However, the incidences of slippage of the wrap into the chest and the need for secondary intervention (esophageal dilatation and/or laparoscopic reoperation) decreased significantly from 15% and 13% of patients in group 1, respectively, to no occurrences in group II. Chi-square analyses revealed that combinations of these technical variables were significantly related to the improved outcome in group II. Conclusion: Based on these data demonstrating improved clinical outcome, we recommend routine division of the SGV, posterior closure of the crura, and fixation of the wrap to the crus during LNF.