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314 Gastro-oesophageal Reflux Disease
Table 49.2: Surgical steps in treating GORD.

Mechanism preventing reflux Surgical steps in treating GORD
Oesophageal clearance Secondary effect from treating oesophagitis;
however, a tight wrap can delay and cause
dysphagia.
Length of intraabdominal Mobilisation of oesophagus and achieving an
oesophagus intraabdominal length of at least 2–3 cm.
Physiological lower Repairing hiatus hernia. Reinforcing the HPZ
oesophageal sphincter with a wrap of stomach around the abdominal
oesophagus.
Diaphragmatic pinch-cock Tightening of hiatus with sutures. Repairing
effect of crura hiatus hernia.
Angle of His Reinforcing acute angle between stomach
and oesophagus (e.g., in Boix-Ochoa
fundoplication).
Gastric emptying Increased due to a decrease in stomach size. Figure 49.2: Incision in zona pellicuda over caudate lobe of liver. The incision is
extended towards the crura, seen just superior to the incision.
± Pyloroplasty increases emptying

depending on the body habitus and size of the patient as well as the
surgeon’s preference.)
2. The upper portion of the gastrohepatic ligament above the left
gastric vessels over the caudate lobe of the liver (zona pellucida of the
lesser omentum) is incised (Figure 49.2) and extended cranially and
medially towards the oesophageal hiatus.
3. The crura of the diaphragm are then identified and dissected free
while mobilising the oesophagus (incising the phreno-oesophageal
ligament) to ensure an adequate intraabdominal length (usually 2–3
cm, depending on the size of the child).
4. If present, the sac of any hiatal hernia is excised, taking care not to
enter the pleural cavity.
5. A window posterior to the oesophagus is created by dissection Figure 49.3: Second suture about to be placed to narrow the oesophageal
between it and the crura. The posterior vagus (and anterior, if possible) hiatus. The anterior vagus is visible above the oesophagus.
are identified during the dissection and kept with the oesophagus. The
fundus of the stomach should be visible through this window.
6. The fundus of the stomach is freed from adhesions to the abdominal
wall and spleen. Small peritoneal adhesions to the spleen are relatively
common and need to be divided. Formal division of the short gastric
vessels are not mandatory, but should be undertaken if needed to
ensure a “floppy” wrap.
7. The oesophageal hiatus is then narrowed by using nonabsorbable
sutures to approximate the crura posterior to the oesophagus (Figure
49.3). Usually, two sutures are needed, but this can vary. The crura
are approximated enough to leave a small space between them and the
oesophagus; this should be just enough for a fingertip.
8. The proximal oesophagus is sutured to the diaphragm by using a
nonabsorbable suture to anchor it in place. This is optional, but adds
stability to the oesophagus in the abdomen.
9. The fundus is then guided behind the oesophagus, ensuring that it is
not under tension when wrapped around the lower oesophagus and that Figure 49.4: Completed floppy Nissen fundoplication.
it is not twisted.
10. A floppy wrap is then constructed by using the fundus of the stomach,
using three rows of nonabsorbable sutures placed widely on the fundus
(Figure 49.4). These sutures can also be passed superficially through the
oesophagus between the stomach ends (stomach-oesophagus-stomach).
11. The looseness of the wrap is tested by gently lifting the wrap off
the oesophagus (or a gentle shoe-shining manoeuvre).
12. If required, a gastrostomy can be constructed in a Stamm fashion at
the junction of the body and antrum.
13. A pyloroplasty is not routinely performed by this author, even in