Recurrence rates following successful surgery varies from different centres but can account for as high as 30% of all Nissen Fundoplications over time. Despite the fact that nowhere in surgery the pre-operative patient is more thoroughly evaluated and surgeons strictly adhere to the indications for surgery, as well as following all mandatory surgical steps, an increase in re-do hiatus hernia repairs has been documented in almost every major high volume centre where surgery of the upper G.I.T. has been performed. A successful approach to anti-reflux surgery requires that the surgeon must have a clear understanding of the pathophysiology of gastro-esophageal reflux disease and of the complex, contributing anatomical factors, anomalies and their mechanical sequels. A critical analysis of the reasons for recurrence of hernias demonstrates the fact that the majority of failures can be attributed to crural disruption. This prompted me to compile a video in which I will highlight the reasons why anti-reflux surgery fails, and how failures can be avoided. Meticulous surgical technique is the surest way to prevent recurrence and this will be highlighted in the compilation video that follows a presentation on the pathophysiology, anatomy, anomalies, patient selection, choice of suture material and mandatory surgical steps. The video will begin with the O R setup, and emphasis will be placed on the importance of the positioning of the patient on the O R table, the direction of the trochar placements, and the positioning of the surgical team and the scrub assistant. The surgery will be completed with the assistance of only one surgical assistant -camera operator, focusing on the relevant anatomy and anatomical variations and will illustrate how to effectively perform a Nissen Fundoplication, using a chronologically ordered approach, minimising unnecessary movements. All mandatory technical steps, including the three crucial steps, will be demonstrated, namely:
Clinical Background
The return of the intra-abdominal esophagus, and ensuring that it remains intra-abdominally.
The reconstruction of the crural support
The reproduction of a competent L.E.S, proximal to the gastro-esophageal junction. This Fundoplication, or new sphincter must provide a competent barrier to gastro-esophageal reflux whilst allowing effective esophageal clearance and remain intact and in place below the diaphragm.
Technique Description
Although only Type I and type III hernias are seen in this video it is important to understand that the techniques and principles are relevant to all four types of hernias. The take-away messages are: The surgeon must realise that:
An in depth knowledge of the pathophysiology, anatomy and anomalies is imperative.
They must be well trained in laparoscopic surgical techniques.
They must adhere strictly to all indications for surgery and follow all surgical principles.
Not all patients who qualify for surgery should be offered a surgical repair.
Re-do surgery should preferably be performed in high volume upper G.I.T. surgical units.
Despite the surgeon’s best efforts and compliance to all surgical principles –
UNFORTUNATELY RECURRENCES DO OCCUR!
Share it with your network and help spread clinical knowledge.
