Nissen fundoplication: three causes of failure (video).

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure for gastroesophageal reflux disease. The rate of failure following fundoplication varies from 2% to 30%, and revision is required in many of the patients who have recurrent or new foregut symptoms. Common causes of failure include hiatal hernia, wrap disruption, slipped wrap, and misplaced wrap.

METHODS

This video depicts three different causes of failure of LNF, each demonstrated while performing a redo fundoplication. The first case shows a common cause of failure, a misplaced wrap. Less common causes of failure are seen in the second and third cases: a retained foreign body and fundus herniation through the retroesophageal space. In the first two cases, following the dissection of the original wrap, the proper construction of a Nissen fundoplication is shown.

RESULTS

The first patient developed recurrent reflux symptoms that can be explained by the misplaced wrap. In case two, the patient's dysphagia was a result of a retained foreign body from the initial procedure creating a fibrotic reaction and esophageal stricture. The final case shows how chronic failure can sometimes have an acute presentation. We see the patient's gastric fundus has herniated through the retroesophageal space and it has become incarcerated and volvulized, creating a closed loop obstruction and acute distention.

CONCLUSIONS

The surgeon watching this video can appreciate the identification of various causes of LNF failure, the approach to dissection of the old wraps, and the important steps in the creation of a Nissen fundoplication.