Laparoscopic Dor Fundoplication

Indications

Laparoscopic Dor Fundoplication is indicated for:

• Gastroesophageal Reflux Disease (GERD):
  • Patients with symptomatic GERD who have not responded adequately to medical therapy (e.g., proton pump inhibitors – PPIs) or who wish to avoid long-term medication.
  • As an anti-reflux measure following laparoscopic Heller myotomy for esophageal achalasia. This is a very common indication for Dor fundoplication, as it helps prevent reflux after the esophageal sphincter is surgically weakened, without significantly increasing the risk of dysphagia.
  • Patients with GERD and documented impaired esophageal motility, where a partial fundoplication is preferred over a total (Nissen) wrap to reduce the risk of postoperative dysphagia.
  • Symptomatic hiatal hernias in conjunction with GERD.
• Specific Clinical Scenarios:
  • May be considered in patients where the risk of postoperative gas bloat and dysphagia needs to be minimized.

As with other anti-reflux surgeries, a thorough preoperative evaluation including endoscopy, esophageal manometry, and pH monitoring is crucial to confirm GERD, assess esophageal motility, and determine the suitability of an anterior wrap.

Preparation (Patient Preparation)

The preparation for a Laparoscopic Dor Fundoplication is similar to other laparoscopic anti-reflux surgeries:

• Medical Evaluation: A comprehensive medical history and physical examination to assess the patient’s overall health and surgical fitness.
• Diagnostic Studies:
  • Upper Endoscopy (Gastroscopy): To visualize the esophagus, stomach, and duodenum, assess for esophagitis, hiatal hernia, Barrett’s esophagus, and rule out malignancy. Biopsies may be taken.
  • Esophageal Manometry: Essential to evaluate esophageal peristalsis and lower esophageal sphincter (LES) function. This is particularly important when considering a Dor fundoplication, especially if not performed in conjunction with a Heller myotomy, to ensure it’s an appropriate choice for the patient’s motility pattern.
  • 24-hour pH Monitoring: To objectively document abnormal esophageal acid exposure and correlate symptoms with reflux episodes.
  • Barium Swallow/Upper GI Series: May be used to delineate anatomy, identify large hiatal hernias, and assess esophageal emptying.
• Lifestyle Modifications:
  • Smoking Cessation: Patients are strongly advised to stop smoking several weeks before surgery to reduce perioperative complications and improve healing.
  • Weight Management: If the patient is overweight, weight loss may be recommended to reduce surgical risks and improve long-term outcomes.
  • Dietary Adjustments: Some surgeons may recommend a specific diet (e.g., liquid or low-residue) for a period before surgery, particularly if a large hiatal hernia is present or to reduce liver size.
• Medication Management:
  • Discontinuation of blood-thinning medications (e.g., aspirin, NSAIDs, warfarin, clopidogrel) for a specified period before surgery, as directed by the physician, to minimize bleeding risk.
  • Review and optimization of all other regular medications.
• Fasting: Patients will be instructed to avoid eating or drinking for a set period (usually 6-8 hours) before the surgery to prevent aspiration during anesthesia.
• Preoperative Education: The surgical team will explain the procedure, potential risks and benefits, expected recovery course, and answer any questions the patient may have.
• Logistics: Arranging for transportation and post-discharge support.

Patient Positioning

For a Laparoscopic Dor Fundoplication, the patient is typically positioned as follows:

• Position: The patient is usually placed in a supine position, often in a modified lithotomy (Lloyd-Davies) position with the legs abducted and supported in stirrups, or a split-leg table. This allows the surgeon to stand between the patient’s legs.
• Table Tilt: The operating table is tilted into a steep reverse Trendelenburg position (head up, feet down, typically 15-30 degrees). This uses gravity to help displace the abdominal organs inferiorly, improving exposure of the upper abdomen and the esophageal hiatus.
• Straps: The patient is securely strapped to the table to prevent sliding, especially with the steep angulation.
• Surgeon and Assistant Positioning:
  • The primary surgeon typically stands between the patient’s legs.
  • The first assistant and camera operator are usually positioned on the patient’s sides (e.g., first assistant on the patient’s left).
• Monitors: Video monitors displaying the laparoscopic view are placed ergonomically for the entire surgical team.

Port Placement

The port placement for a Laparoscopic Dor Fundoplication is generally similar to other laparoscopic fundoplications. Typically, 4 to 5 ports are used:

• Camera Port: A 10 mm or 12 mm port is usually placed in the midline, supraumbilically (above the navel) or at the umbilicus, for the laparoscope.
• Working Ports (usually 5 mm, one may be 10/12 mm if needed for suturing devices or specimen retrieval):
  • Subxiphoid Port: A 5 mm port placed in the midline just below the xiphoid process is commonly used for a liver retractor to elevate the left lobe of the liver and expose the hiatus.
  • Right Upper Quadrant Port: A 5 mm port placed in the right mid-clavicular line or anterior axillary line, below the costal margin, used for dissecting and retracting instruments.
  • Left Upper Quadrant Port(s): One or two 5 mm ports in the left mid-clavicular line or anterior axillary line, below the costal margin. These are primary operating ports for the surgeon’s left and right hands.
• The precise location and number of ports can vary based on surgeon preference, patient anatomy, and whether the Dor fundoplication is performed in conjunction with another procedure like a Heller myotomy. The goal is to provide good triangulation and access to the operative field.

Intraoperative Steps

The Laparoscopic Dor Fundoplication involves the following key surgical steps, performed under general anesthesia:

1. Pneumoperitoneum: The abdomen is insufflated with carbon dioxide gas to create a working space.
2. Port Insertion: Trocars are inserted through small abdominal incisions.
3. Exposure and Hiatal Dissection:
   • The left lobe of the liver is retracted superiorly.
   • The gastrohepatic ligament (lesser omentum) is opened to expose the right crus of the diaphragm.
   • The phrenoesophageal membrane is incised, and the esophagus is circumferentially mobilized from the surrounding hiatal structures.
   • Care is taken to identify and preserve the anterior and posterior vagus nerves.
   • If a hiatal hernia is present, the hernia sac is dissected and reduced.
   • An adequate length of intra-abdominal esophagus (at least 3 cm) is ensured.
4. (If performed with Heller Myotomy): The Heller myotomy (division of the muscle fibers of the lower esophagus and proximal stomach) is performed prior to the fundoplication. The Dor wrap then covers this myotomy.
5. Crural Repair (Cruroplasty): The diaphragmatic crura are approximated posterior to the esophagus using non-absorbable sutures to narrow the hiatus. This is done carefully to avoid making the hiatus too tight, often calibrated over an esophageal bougie or endoscope.
6. Fundus Mobilization: The gastric fundus (the upper portion of the stomach to the left of the esophagus) is mobilized. This usually involves dividing a few of the short gastric vessels if necessary, although extensive mobilization as required for a Nissen or Toupet may not always be needed for an anterior wrap.
7. Creation of the Anterior (Dor) Fundoplication:
   • The mobilized anterior wall of the gastric fundus is brought over the anterior surface of the distal esophagus.
   • The fundus is typically wrapped for about 180 to 200 degrees around the anterior circumference of the esophagus.
   • The wrap is secured by suturing the edge of the fundus to the right and left sides of the esophagus and often to the corresponding diaphragmatic crura or the edges of the myotomy (if performed). Non-absorbable sutures are used.
   • The wrap should be “floppy” and tension-free.
8. Final Checks and Closure:
   • The integrity of the wrap and hemostasis are confirmed.
   • Instruments and trocars are removed.
   • The CO2 is evacuated.
   • The port site incisions are closed.

Possible Complications and Management

While generally considered to have a lower side-effect profile than total fundoplication, Laparoscopic Dor Fundoplication still carries potential risks:

General Surgical Complications:

• Bleeding: Intraoperative or postoperative.
• Infection: Surgical site infection or intra-abdominal infection.
• Injury to Adjacent Organs: Esophagus, stomach, spleen, liver, lungs (pneumothorax), or blood vessels.
• Blood Clots: Deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Hernia: At port sites.
• Anesthesia-related complications.

Specific Complications of Dor Fundoplication:

• Dysphagia (Difficulty Swallowing): Generally less common and less severe than with Nissen fundoplication. Temporary dysphagia due to edema is common. Persistent dysphagia may require investigation (e.g., barium swallow, endoscopy) and potentially endoscopic dilation.
• Gas Bloat Syndrome: Symptoms like bloating, inability to belch effectively, and increased flatulence. Usually less frequent than with total fundoplication.
• Recurrent Reflux/Heartburn: While the aim is to prevent reflux, it can recur. This may be due to wrap disruption, loosening, or an inadequate initial repair. Management can range from lifestyle changes and medication to revisional surgery in select cases. The rate of recurrent reflux might be slightly higher with partial fundoplications compared to total fundoplications over the long term, but this is often offset by fewer side effects.
• Wrap Migration or Slippage: The fundoplication can move from its intended position, potentially leading to recurrent symptoms or obstruction.
• Postoperative Pain: Usually managed with standard analgesics.
• Nausea and Vomiting: Can occur in the early postoperative period.
• Diarrhea: Occasionally reported after fundoplication procedures.

Management of Complications:

• Conservative Management: For mild symptoms like temporary dysphagia, dietary modifications (liquid to soft diet progression) are usually sufficient.
• Medical Therapy: Antacids or PPIs for recurrent reflux symptoms. Antiemetics for nausea.
• Endoscopic Procedures: Esophageal dilation for persistent dysphagia.
• Radiological Imaging: Barium swallow or CT scan can help diagnose structural problems like wrap migration or stenosis.
• Revisional Surgery: Required in a small percentage of patients for severe, persistent complications such as wrap failure with intractable reflux or severe dysphagia unresponsive to other treatments. Revisional surgery is generally more complex.

The Laparoscopic Dor Fundoplication is a valuable surgical option, especially effective as an anti-reflux procedure following Heller myotomy and for GERD patients where minimizing postoperative dysphagia and gas bloat is a priority. Long-term outcomes are generally good, with significant improvement in reflux symptoms for most patients.