Laparoscopic Nissen fundoplication.

Most patients with gastroesophageal reflux disease (GERD) can be treated effectively with medical therapy; however, in patients with severe GERD who are unresponsive to medical therapy, the lower esophageal sphincter (LES) is often found to be mechanically incompetent. Surgical therapy, which improves the LES antireflux barrier, may then be a good option. A very effective and popular antireflux procedure is the Nissen fundoplication, which can be safely done via the laparoscopic route. Preoperative evaluation should include contrast radiography, esophagoduodenoscopy (EGD) with biopsies, esophageal manometry, and 24-hour pH monitoring. Indications for surgery include failure or inability to continue on medical therapy, GERD-related respiratory symptoms, and severe complications of GERD, such as ulceration, stricture, and Barrett's esophagus. A short, loose Nissen fundoplication is ideal for patients with normal esophageal body motility. Operative complications are infrequent, and they include gastric perforation, bleeding, and pneumothorax. Following the laparoscopic approach, nearly all patients can leave the hospital on the first or second postoperative day. Follow-up esophageal manometry and 24-hour pH monitoring show the same good long-term results as seen after open Nissen fundoplication. Laparoscopic Nissen fundoplication can be performed safely and effectively with all of the advantages of a minimally invasive approach.