Key Points

• Routine preoperative testing for antireflux surgery includes contrast upper gastrointestinal radiography, flexible upper endoscopy, and esophageal manometry. Ambulatory esophageal pH monitoring (with or without impedance testing) should be utilized to document pathologic gastroesophageal reflux when other objective indications for fundoplication (such as the presence of Los Angeles Grade C or D erosive esophagitis or a large hiatal hernia) are lacking. A gastric emptying study may be indicated if gastroparesis is suspected.
• Patients with associated esophageal pathology such as Barrett’s esophagus, dysplasia, or a reflux-induced stricture must be treated and followed as needed, in addition to undergoing antireflux surgery.
• Basic tenets of a Nissen fundoplication, regardless of operative approach, include: Reduction of the hiatal hernia and hernia sac, adequate esophageal mobilization to create at least 2-3 cm of intra-abdominal esophagus, division of the short gastric vessels, crural repair, creation of a short (1-2 cm), floppy fundic wrap around a large esophageal dilator incorporating the esophagus, and avoidance of injury to the vagus nerves.
• Despite high satisfaction rates after Nissen fundoplication, postoperative side effects, including dysphagia and gas-bloat, as well as recurrent reflux are potential risks. Approximately 5-10% of patients require a reoperation within 10 years of surgery.