R. Nissen's description of fundoplication has proven seminal in our understanding of anti-GERD surgeries. But making some minor changes early could bring major alterations in the long term. So, we attempted to draw a more organized and revised image of the Nissen fundoplication, not without criticism, and with a better understanding of various aspects of anti-GERD coming into sharper focus in recent years.
According to his original description in 1956, R. Nissen opted to construct a Witzel tube from the gastric fundus around the abdominal esophagus, which he called a gastroplication. The phrenoesophageal ligament was divided and the esophagus was mobilized, meanwhile the short gastric vessels were always preserved. Through a window created in the gastrohepatic ligament, a fundoplication was created, which involved wrapping the stomach's posterior wall around the lower 6 cm of the esophagus and suturing it to the anterior wall. He used four or five interrupted silk sutures immediately in front of the lower esophagus, one or more of which incorporated part of the anterior wall of the esophagus. The diaphragmatic crura were untouched in his description [2, 11].
To mitigate related complications such as dysphagia, gas bloat, wrap slippage or dislocation, and paraesophageal hernia occurrence/recurrence, several improvements to the initial Nissen protocol have been suggested. Aside from the evolution of non-complete wraps, the key changes to Nissen fundoplication over time can be summarized as follows: use of the anterior aspect of the stomach for the wrap [7, 12], thorough dissection of the gastric fundus [13], fixation of the wrap to prevent dislocation, short floppy wrap [14,15,16], and cruroplasty [15,16,17].
According to the results of the conducted survey, most respondents thought the initial Nissen's wrap was wrapping a completely mobilized gastric fundus around the abdominal esophagus, with suture bites placed at the fundus's curve and suturing was either ventral to esophagus or tilted to the right to some degrees.
Meanwhile improvements made to the Nissen wrap in the literature and among respondents to this survey were aimed at creating a tension-free wrap to avoid the complications of dysphagia and wrap dislocation, both still present as the most common problems. This might indicate that the technique's alterations are primarily the consequence of a lack of sharp awareness of the original approach and are merely a matter of surgeon perceptions.
Hence, the words "Nissen fundoplication – Modified Nissen fundoplication” are nomenclatures that entitled variably inconsistent contents - to a large degree depending on surgeon preference –with nevertheless unpleasant consequences. It looked that each component's arguments needed to be re-evaluated in order to construct the most acceptable set. In this context, several studies contrasted Nissen operations with and without fundus mobilization [18, 19]. This maneuver does not minimize the likelihood of wrap disruption or the occurrence of postoperative dysphagia, according to the findings. Luostarinen et al., on the other hand, found an abnormally prolonged gastric transit time in patients undergoing fundus mobilization, indicating the possibility of partial stomach denervation during dissection [18]. Moreover, due to a slipping up of the wrap, the telescope phenomenon, fundus mobilization increased the recurrence rate of hiatal hernia [18, 19].
Further, we have recently argued that the antiperistaltic waves generated within the grinding pyloric antrum are absorbed by the dome-shaped gastric fundus, which works as a natural anti-reflux barrier in terms of fundus receptive relaxation as well as harboring a substantially compressible fundus air bubble. As a result, the sided gastroesophageal junction is mostly immune to the splashes of antiperistaltic waves. When the gastrosplenic ligament is surgically divided to wrap a completely mobilized fundus around the abdominal esophagus, the antireflux mechanism is eventually sacrificed, rendering the new anatomical alignment exposed to stress with every antiperistaltic wave being propagated; this is motility generated dynamic tension (Fig. 2). Accordingly, we proposed that the gastric fundus should, preferably, not be mobilized when making a surgical wrap. Moreover, the natural inclination angle between the axis of the lower esophagus and the organoaxial ‘‘pyloro-dome" axis of the stomach should never be set to zero [20].
Cruroplasty is another contentious topic that puts component rationale versus surgeon choices. Since the crura's function as an antireflux mechanism has been sufficiently demonstrated [21, 22], surgeons frequently advocate for its closure [23]. It should be noted, however, that even in case of a normal hiatus, reflux can occur [24]. Furthermore, authors who did not perform any crural repair reported excellent results with no rise in the incidence of paraesophageal hernias [17, 25].
Other factors that may have influenced the outcome of laparoscopic fundoplication include the surgeon's number of years of experience as well as the annual volume per surgeon and per centre [26]. The fact that experienced practise improves outcomes emphasises that surgical training with intensive supervision ensures patient safety, whereas reducing supervision based on raising trainee autonomy may have unfavourable effects on surgical outcomes [26, 27].
Based on the facts presented, it seemed reasonable to re-define the tension free Nissen wrap in order to perhaps unify the technique based on components’ justifications rather than surgeons’ preferences.
