Laparoscopic Toupet Fundoplication

Indications

Laparoscopic Toupet Fundoplication is primarily indicated for patients with:

• Chronic Gastroesophageal Reflux Disease (GERD):
  • Failure of, or intolerance to, medical therapy (e.g., proton pump inhibitors – PPIs).
  • Desire to discontinue long-term medication.
  • Persistent symptoms like heartburn, regurgitation, or retrosternal pain despite medical management.
  • Massive reflux, especially when bending over, during sleep, or leading to aspiration.
  • Extraesophageal manifestations of GERD (e.g., reflux-induced coughing, pharyngitis, asthma) not fully controlled by PPIs or in cases of PPI intolerance.
• Hiatal Hernia: In conjunction with GERD.
• Patients with Esophageal Dysmotility: The Toupet fundoplication is often preferred over a Nissen fundoplication in patients with documented impaired esophageal peristalsis (weak esophageal muscle contractions) because a full wrap might exacerbate swallowing difficulties. Preoperative esophageal manometry is crucial in identifying these patients.
• Consideration after other esophageal surgeries: For example, after a Heller myotomy for achalasia, a partial fundoplication like the Toupet is often performed to prevent reflux.

Objective confirmation of GERD through investigations like endoscopy, 24-hour pH monitoring, and esophageal manometry is essential before considering surgery.

Preparation (Patient Preparation)

Similar to other anti-reflux surgeries, thorough preoperative evaluation and preparation are key:

• Medical History and Physical Examination: Comprehensive assessment of the patient’s overall health, GERD symptoms, and surgical risk factors.
• Diagnostic Tests:
  • Upper Endoscopy (Gastroscopy): To evaluate the severity of esophagitis, identify hiatal hernias, detect complications like strictures or Barrett’s esophagus, and rule out malignancy. Biopsies may be taken.
  • Esophageal Manometry: Crucial for assessing esophageal motility and lower esophageal sphincter (LES) function. This helps determine if a partial wrap (like Toupet) is more appropriate than a full wrap.
  • 24-hour Esophageal pH Monitoring: To objectively quantify reflux episodes and correlate them with symptoms, especially if the diagnosis is uncertain or if atypical symptoms are present.
  • Barium Swallow (Contrast X-rays): To visualize the anatomy, identify hiatal hernias, and assess esophageal emptying.
• Lifestyle Modifications:
  • Smoking Cessation: Advised for at least 4 weeks prior to surgery.
  • Weight Management: Achieving a healthy weight can improve outcomes.
  • Dietary Adjustments: Some surgeons may recommend a specific diet (e.g., liquid diet) before surgery to reduce liver size.
• Medication Adjustments:
  • Discontinuation of blood-thinning medications (e.g., aspirin, NSAIDs, warfarin, clopidogrel) for a specified period before surgery, under medical supervision.
  • Review of all current medications and supplements.
• Fasting: Patients will need to avoid eating or drinking for a certain period (typically 6-8 hours) before surgery.
• Bowel Preparation: Usually, no special bowel preparation is required beyond fasting.
• Preoperative Education: Detailed discussion about the procedure, expected outcomes, potential risks, and postoperative care.
• Logistics: Arranging for transportation home and support during the initial recovery period.

Patient Positioning

During Laparoscopic Toupet Fundoplication, the patient is typically positioned as follows:

• Position: Most commonly, a modified lithotomy position (supine with legs separated and supported in stirrups) or a supine split-leg position. Some surgeons may use a “beach chair” position with the upper body slightly elevated and legs spread.
• Table Tilt: The operating table is usually placed in a steep reverse Trendelenburg position (head up, feet down) to allow gravity to retract the abdominal organs inferiorly, providing better exposure of the esophageal hiatus.
• Surgeon and Assistant Positioning:
  • The primary surgeon often stands between the patient’s legs or on the patient’s right side.
  • Assistants are positioned on the opposite side or as needed to facilitate the procedure.
  • The camera operator stands in a position that provides the best view for the surgeon.
• Monitors: Video monitors are placed ergonomically for the surgical team to view the laparoscopic images.
• The patient is securely strapped to the operating table to prevent movement, especially with steep table tilts.

Port Placement

Laparoscopic Toupet Fundoplication utilizes several small incisions (ports) for the insertion of the laparoscope (camera) and surgical instruments. The placement can vary but generally follows a pattern similar to other laparoscopic foregut procedures:

• Camera Port: Often a 10 mm or 12 mm port, commonly placed in the midline, superior to the umbilicus, or slightly to the left of the umbilicus in the epigastrium.
• Working Ports (typically 5 mm, sometimes one 10/12 mm for sutures or specimen retrieval):
  • Subxiphoid Port: A 5 mm port placed just below the xiphoid process, frequently used for a liver retractor to elevate the left lobe of the liver.
  • Left Subcostal Port(s): One or two 5 mm ports in the left upper quadrant, below the costal margin, serving as main working ports for the surgeon.
  • Right Subcostal Port: A 5 mm port in the right upper quadrant, below the costal margin, also used as a working port or for retraction.
  • An additional port may be placed depending on the surgeon’s preference and the specific needs of the operation.

The exact number (usually 4-5 ports) and location are determined by the surgeon to ensure optimal access and visualization of the surgical field.

Intraoperative Steps

The Laparoscopic Toupet Fundoplication is performed under general anesthesia and involves the following key steps:

1. Establishment of Pneumoperitoneum: The abdominal cavity is insufflated with carbon dioxide gas to create a working space (pneumoperitoneum).
2. Trocar and Instrument Insertion: Small incisions are made for the trocars, through which the laparoscope and specialized surgical instruments are introduced.
3. Liver Retraction: The left lobe of the liver is gently retracted anteriorly and superiorly to expose the esophageal hiatus and the gastroesophageal junction.
4. Hiatal Dissection:
   • The surgeon dissects the peritoneum and phrenoesophageal membrane overlying the esophagus and diaphragmatic crura.
   • The esophagus is carefully mobilized circumferentially, ensuring adequate length (at least 2-3 cm, ideally more) is brought into the abdomen without tension. This may involve mediastinal dissection.
   • The vagus nerves (anterior and posterior trunks) are identified and preserved to avoid injury.
   • The hiatal hernia sac, if present, is dissected and reduced or excised.
5. Crural Repair (Hiatorrhaphy): The diaphragmatic crura are approximated posterior to the esophagus with non-absorbable sutures to narrow the hiatus and prevent re-herniation. This is done over an esophageal bougie (dilator) of appropriate size to avoid making the hiatus too tight.
6. Fundus Mobilization: The gastric fundus (the upper part of the stomach) is mobilized. For a Toupet fundoplication, extensive division of the short gastric vessels (blood vessels between the stomach and spleen) may not always be necessary as in a Nissen, but sufficient mobilization is required to bring the fundus posteriorly without tension.
7. Creation of the Posterior Partial Fundoplication (Toupet Wrap):
   • The mobilized gastric fundus is passed behind the esophagus from left to right.
   • The fundus is then wrapped partially around the posterior aspect of the esophagus, typically covering about 270 degrees (leaving the anterior aspect of the esophagus unwrapped).
   • The wrap is secured by suturing the edges of the fundus to the sides of the esophagus (right and left aspects) and often to the diaphragmatic crura. Non-absorbable sutures are used.
   • A bougie (e.g., 50-60 French) is typically kept in the esophagus during the creation of the wrap to ensure it is not too constricting.
   • Some surgeons perform a “fundophrenicopexy,” anchoring the wrap to the diaphragm to prevent slippage.
8. Final Inspection and Closure:
   • The surgical site is inspected for hemostasis and integrity of the wrap.
   • Instruments and the laparoscope are removed.
   • The CO2 gas is evacuated from the abdomen.
   • The port site incisions are closed with sutures or surgical tape and dressed.
   • A nasogastric tube, if used, is typically removed at the end of the procedure or shortly thereafter.

Possible Complications and Management

While the Toupet fundoplication is designed to reduce certain side effects compared to a Nissen, complications can still occur. They are generally similar to those of other laparoscopic anti-reflux surgeries:

General Surgical Risks:

• Bleeding: Intraoperative or postoperative. May require transfusion or re-intervention if severe.
• Infection: Wound infection or intra-abdominal abscess. Treated with antibiotics and/or drainage.
• Thromboembolism: Deep vein thrombosis (DVT) or pulmonary embolism (PE). Preventative measures are standard.
• Injury to Adjacent Organs: Spleen, liver, stomach, esophagus, lungs (pneumothorax if pleura is breached during hiatal dissection), or blood vessels. Management depends on the specific injury.
• Hernia at Port Sites: Can occur later and may require surgical repair.

Specific Complications of Toupet Fundoplication:

• Dysphagia (Difficulty Swallowing):
  • Temporary: Common in the early postoperative period due to swelling. Usually resolves with dietary modifications (liquids progressing to soft foods).
  • Persistent: Less common with Toupet than Nissen, but can still occur if the wrap is too tight or due to underlying dysmotility. Management may involve endoscopic dilation or, rarely, revisional surgery.
• Gas Bloat Syndrome: Symptoms include abdominal bloating, inability to belch effectively, and increased flatulence. Generally less frequent or severe than with Nissen fundoplication. Dietary management is often helpful.
• Recurrent Reflux: The primary goal is to control reflux, but recurrence can happen if the wrap loosens, slips, or if the hiatal repair fails. May require medication, further investigation, or revisional surgery. Toupet may have a slightly higher rate of long-term reflux recurrence compared to Nissen in some studies, but often with fewer side effects.
• Wrap Slippage or Migration: The fundoplication can move from its intended position. May lead to recurrent symptoms or obstruction. Reoperation might be needed.
• Pneumothorax: If the pleura is entered during hiatal dissection. Small ones may resolve spontaneously; larger ones may require a chest tube.
• Vagus Nerve Injury: Can lead to gastroparesis (delayed gastric emptying) or diarrhea. Careful dissection is crucial.
• Denervation Syndrome: Related to vagal injury, causing gastric emptying disorders or diarrhea.
• Chest Pain: Can occur postoperatively; workup should assess for recurrent GERD or esophageal motor disorders.
• Diarrhea: Can affect a percentage of patients; the mechanism is not fully understood but may involve vagal effects or accelerated gastric emptying.

Management of Complications:

• Observation and Conservative Measures: For mild, temporary issues like early dysphagia or mild gas bloat (dietary advice, reassurance).
• Medical Therapy: Antacids, PPIs for recurrent reflux; antiemetics or prokinetics if needed.
• Endoscopic Intervention: Esophageal dilation for persistent dysphagia.
• Radiological Studies: Barium swallow or CT scan to assess wrap integrity or identify herniation.
• Revisional Surgery: Considered for significant, persistent, or recurrent problems such as severe dysphagia unresponsive to dilation, wrap failure leading to severe recurrent reflux, or wrap migration. This is typically more complex than the primary surgery.

Postoperative care involves a gradual return to a normal diet, starting with liquids and progressing to soft then solid foods over several weeks. Patients are generally discharged within 1-3 days and can return to light activities, with a full return to normal activities in 2-4 weeks. The Toupet fundoplication offers a good balance between effective reflux control and a lower incidence of postoperative side effects, making it a valuable option for appropriately selected patients.