A simplified approach to laparoscopic fundoplication.
BACKGROUND
There is a certain amount of controversy regarding the need to divide the short gastric vessels (SGV) in laparoscopic fundoplication for treatment of gastroesophageal reflux disease (GERD). In addition, there is often difficulty in identifying the crural fibers when encircling the lower esophagus.


METHODS
We determine whether it is necessary to divide the SGV by trying to appose the gastric fundus to the anterior abdominal wall intraoperatively. If this could be done easily, the SGV are preserved. When their division is required, a posterior gastric approach is employed. We have also found that the injection of methylene blue into the left crural fibers anterior to the esophagus is helpful in identifying the left side when dissection posterior to the gastroesophageal junction is difficult.


RESULTS
Between 1992 and 1995 we performed 20 laparoscopic fundoplications for GERD. All patients had at least grade 3 esophagitis (Savary-Miller scale), increased esophageal exposure to acid (median DeMeester score of 195), and decreased lower esophageal sphincter (LES) pressure. The median operative time was 175 min. There were no conversions to open surgery, and there was no mortality. Three patients developed transient postoperative dysphagia and one patient had pneumonia. The median hospital stay was 3 days; all patients were free of reflux symptoms at follow-up ranging from 7 to 42 months.


CONCLUSIONS
We conclude that the techniques described by us aid in intraoperative decision making and allow laparoscopic fundoplication to be both simple and effective.
Ferzli
G S
GS
Department of Laparoendoscopic Surgery, Staten Island University Hospital, 78 Cromwell Ave., Staten Island, NY 10304, USA.
Hurwitz
J B
JB
Hallak
A
A
Fiorillo
M A
MA
Kiel
T
T
D000328:Adult; D000368:Aged; D004935:Esophageal Diseases / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D020706:Laparoscopes; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D013536:Suture Techniques