Left Side First Approach in Nissen Procedure for Gastroesophageal Reflux Disease; How We Do It

Abstract

Introduction Gastroesophageal reflux disease (GERD) is a major public health problem. The "gold standard" in the surgical treatment of this condition is the laparoscopic technique called Nissen fundoplication. Aim This paper presents a safer alternative of the laparoscopic Nissen fundoplication, with special focus on the most difficult moment of the intervention, the creation of a retroesophageal passage. Material and method (presentation of the surgical technique) The conventional Nissen technique consists of the dissection of the esogastric junction in a clockwise direction, right to left: right pillar, hiatus, left pillar, retroesophageal passage, skeletonization of the fornix and reconstruction of the valve. We decided to perform a technique inspired from laparoscopic sleeve gastrectomy, which starts in anticlockwise direction, with the skeletonization of the upper third of the greater curvature of the stomach, then continues with the complete dissection of the left diaphragmatic pillar ("left side first") and finally with the dissection of the right pillar and the creation of the retroesophageal passage, thus, the procedure becoming less complicated. A complete decollement of the area nuda is performed, this way avoiding possible complications at this stage, like: bleeding from the area nuda or short vessels, ruptures of the stomach, esophagus, spleen, penetrating the thoracic cavity with a retroesophageal clamp, etc. Results Introduced in 2011, this technique was applied with success in all 20 consecutive cases of hiatus hernia operated in our clinic. There were neither intraoperative accidents and conversions nor early or late postoperative complications. 19 cases were primary Nissen while one case was a recurrent hiatal hernia after an insufficient cruroplasty made in another center. There were three cases in which we had to use Parietene Composite type mesh to strengthen the cruroplasty. Conclusion The applied modification has improved the original laparoscopic Nissen fundoplication technique, thus this has become a less complicated procedure at the same time providing more security to the patient.