Indications, Principles of Procedure Selection, and Technique of Laparoscopic Nissen Fundoplication

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Abstract
The successful performance of antireflux surgery is a significant therapeutic challenge. Simple reliance on patient symptomatology is inadequate to establish a diagnosis of gastroesophageal reflux and select patients for surgical therapy. Foregut symptoms are common and nonspecific. Not infrequently, gastroesophageal reflux disease can give rise to atypical symptoms, including asthma, chest pain, chronic cough, wheezing, and hoarseness. Objective documentation of gastroesophageal reflux via 24-hour pH monitoring is required. Additionally, the performance of antireflux surgery that successfully relieves symptoms in over 90% of patients without undue morbidity or the creation of new symptoms is more difficult than readily apparent. This is particularly true for the surgeon undertaking occasional antireflux surgery. At the time the patient is referred for surgery, the disease has often progressed to include functional and anatomic foregut alterations. Abnormalities of esophageal motility, shortening of esophageal length, and the presence of a stricture or Barrett's metaplasia are common. Antireflux surgery in this setting is particularly challenging, and when the abnormalities are not adjusted for, the results can be less than ideal. These facts are particularly important in the era of laparoscopic fundoplication. The desire to perform a minimally invasive procedure must not foster disregard for objective confirmation of the diagnosis, careful performance of the appropriate antireflux procedure, and detection of abnormalities associated with advanced disease.

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