Geometry and reproducibility in 360° fundoplication

Abstract

Background: In this study, we set out to precisely define two symmetrical points—a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or “floppy”) 360° fundoplication (FP).

Methods: For the terms of this study, circumference=c; diameter=d; c/d=π; π=3.14; and d(cm)=Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n=5) and intraoperatively (n=16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c. Results: The smallest measured value for c was 7.5 cm (d=2.39 cm); the largest value for c was 10.0 cm (d=3.18 cm). The mean value was 8.35 cm (d=2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d=2.66 cm. This technique creates a correctly oriented, symmetrical, “floppy,” true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible.

Conclusions: Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a “floppy” 360° fundoplication.