Laparoscopic fundoplication: A natural extension for the thoracic surgeon

Background. Thoracic surgeons have historically played a significant role in surgical treatment of benign esophageal disorders. With the advent of video-assisted thoracic surgical techniques, chest surgeons have also become adept at minimally invasive procedures. Thus, it seems appropriate that thoracic surgeons participate in minimally invasive antireflux operations, such as laparoscopic Nissen fundoplication. Methods. From February 1993 to May 1995, 66 patients (32 male, 34 female) with a mean age of 45.5 years (range, 15 to 82 years) underwent a laparoscopic fundoplication. Gastroesophageal reflux disease was diagnosed on the basis of history and endoscopically documented esophagitis or abnormal esophageal pH testing or both. There were 45 type I, 3 type II, and 7 type III hiatal hernias. Eleven patients had gastroesophageal reflux disease with no hernia. Results. Conversion to laparotomy occurred in 6 patients (9%) due to bleeding in 2 patients, inability to laceration in 1 patient. All but 1 patient underwent a Nissen fundoplication performed over a 50F to 60F dilator. The remaining patient (type II hernia without gastroesophageal reflux disease) underwent a reduction, closure, and anterior gastropexy. There was no operative mortality. Immediate postoperative morbidity included moderate dysphagia in 7 patients (11%), ileus in 2 patients (3%), and deep venous thrombosis and atrial arrhythmia in 1 each (1.5%). Excluding 1 patient hospitalized for 42 days due to severe psychosis, the mean postoperative stay was 4.0 ± 2.5 days (median, 3 days). Three patients (5%) required dilation for dysphagia, and 1 (1.5%) has noted recurrent reflux during follow-up (mean, 14.4 months; range, 6 to 30 months). A single patient has undergone reoperation for persistent dysphagia (1.5%). Conclusions. A laparoscopic Nissen procedure is safe, effective treatment for refractory gastroesophageal reflux disease when performed by thoracic surgeons experienced in minimally invasive surgical procedures.