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Minimally Invasive Antireflux Surgery
Video
Introduction
Gastroesophageal reflux disease (GERD) remains one of the most common diseases for which patients seek medical treatment. Surgical intervention is offered after failure of maximal medical therapy and/or when an anatomic defect, such as a hiatal hernia, is detected, or if the patient is suffering a complication of reflux such as a stricture. Minimally invasive antireflux surgery serves to reestablish the original anatomic barriers to reflux and reinforce the closing function of the lower esophageal sphincter (LES) by wrapping the gastric fundus around the gastroesophageal junction (GEJ).
Surgical Principles
Successful antireflux surgery results in recreation of a functional LES complex. This begins with circumferential dissection of the diaphragmatic crura and identification of a possible hiatal defect. If herniated, the GEJ is reduced below the diaphragm with the goal of at least 4 cm of intraabdominal esophageal length. The crura are reapproximated with sutures to allow only the esophagus to fit through the hiatal opening. After closure of the crura, a “floppy” 360-degree Nissen fundoplication is formed around the distal esophagus as the most commonly performed procedure to augment the lower esophageal sphincter ( Figs. 6.1 to 6.3 ).
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