Indications for surgery
Surgical treatment via Nissen fundoplication is used for strictly defined pathologies of the esophagogastric junction. The main indication is a sliding hiatal hernia.
Surgery is indicated not for any hernia, but only in cases where the disease is accompanied by severe clinical complications, such as:
- Stenosing reflux esophagitis (inflammation of the esophageal mucosa with the development of cicatricial stricture).
- Recurrent esophageal or gastric bleeding.
Note: this technique should not be confused with the treatment of other diaphragmatic defects (e.g., paraesophageal hernia, Bochdalek hernia, or Larrey–Morgagni hernia).
Surgical approach and organ mobilization
The intervention begins with securing adequate access to the cardial part of the stomach and the esophageal hiatus of the diaphragm.
- Approach: An upper midline laparotomy is performed, providing a wide overview of the upper abdomen.
- Liver mobilization: To visualize the esophageal hiatus, the left lobe of the liver must be retracted to the right. To achieve this, the surgeon transects the left triangular ligament of the liver.
- Diaphragmatic region work:
- The peritoneum covering the esophageal hiatus is incised.
- A sparing sagittal diaphragmatotomy is performed. At this stage, it is extremely vital to visualize and ligate the inferior phrenic vein to avoid bleeding.
- To widen the surgical gateway and improve access, the medial part of one of the crura of the diaphragm is transected.
Creation of the antireflux cuff
The main stage of the surgery is the creation of a circular muscular wrap that will prevent the reflux of gastric contents.
- After the esophagus is exposed, it is gently encircled with a rubber tape, which facilitates manipulation and traction (pulling) of the organ downward.
- The gastrophrenic ligament is transected. This is necessary for the complete mobilization of the gastric fundus, from which the cuff will be formed.
- The mobilized gastric fundus is brought behind the posterior wall of the esophagus from left to right.
- The walls of the stomach and esophagus are sutured together with two rows of stitches. Thus, a complete (360-degree) cuff is formed around the abdominal esophagus.
Prevention of complications and completion of the surgery
A key error during fundoplication is creating too tight or too short a cuff, which leads to persistent dysphagia (stenosis).
For the prevention of stenosis, a thick gastric tube must be inserted into the esophageal lumen before tightening the forming sutures. The circumference of the tube must be strictly 5.0–5.5 cm. Only with such a stent inside the esophagus can the tissues be safely secured. The length of the formed cuff along the esophageal axis must be at least 2–3 cm.
Final stage: The formed cuff is carefully positioned into the mediastinum. To prevent hernia recurrence, the stomach is additionally sutured to the edges of the esophageal hiatus using interrupted stitches.
Briefly: answers to topical questions
Which nerves must be visualized and preserved during mobilization of the abdominal esophagus?
- Anterior trunk (truncus vagalis anterior) — the trunk of the left vagus nerve, located in the loose connective tissue at the base of the phrenoesophageal ligament.
- Vagus nerves (nn. vagi) — pass through the esophageal hiatus of the diaphragm accompanied by the esophagus.
Tube inside — cuff outside! (Tying sutures on the esophagus without a thick tube inserted is strictly prohibited).
Class and exam questions
Which liver ligament is transected for access to the esophagus?
The left triangular ligament of the liver is transected, allowing the left lobe of the organ to be retracted to the right and exposing the operative field.
For what purpose is the diaphragmatic crus transected?
The medial part of one of the diaphragmatic crura is transected. This is done to widen the surgical gateway and facilitate manipulations on the esophagus.
In which direction is the gastric fundus brought when creating the cuff?
The fundus of the mobilized stomach is always brought behind the esophagus from left to right.
How to prevent postoperative esophageal stricture?
Before final tightening of the sutures, a thick tube with a circumference of 5.0–5.5 cm must be inserted into the esophageal lumen, and the length of the created cuff must be at least 2–3 cm.
What else to study on this topic
- Clinical presentation and pathogenesis of sliding hiatal hernia
- Anatomical structure of the diaphragmatic crura and their blood supply (inferior phrenic vein)
- Gastric ligamentous apparatus: gastrophrenic ligament
- Differential diagnosis with Bochdalek and Larrey–Morgagni diaphragmatic hernias
- Complications of hiatal hernia: stenosing reflux esophagitis and occult bleeding
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