World J. Surg.
1,439-444, 1977
Fundoplication for the Treatment
of Gastroesophageal Reflux in Hiatai Hernia
M. ROSSETTI, M.D. and K. HELL, M.D.
Department of Surgery, (University of Basel), Kantonsspital, Liestal, Switzerland
Fundoplication, using an abdominal approach, is advo-
cated to create an adequate substitute for the insufficient
sphincter in gastroesophageal reflux associated with hiatus
hernia. To achieve success, correct indications for surgical
treatment are important. Based on experience with approxi-
mately 1,400 patients over the past 20 years, these include:
(a) a retrosternal burning sensation (in 90% of our cases); (b)
objective confirmation of reflux by means of x-ray and endos-
copic examination, together with biopsy examination of the
esophageal mucosa and gastric acid evaluation; and (c) evi-
dence of organic complications such as endobrachyesophagus
with ulcerostenotic changes at the junction between the esoph-
ageal and gastric mucosa. Long-term follow-up of 590 pa-
tients with simple reflux esophagitis who underwent fundopli-
cation showed that 87.5% were symptom free. In 44 patients
with complicated gastroesophageal reflux disease, fundopli-
cation produced clinical healing in 84.1%.
Since 1956, when Nissen [1] described "a simple
operation to influence reflux esophagitis" and re-
ported for the first time the procedure called "fundo-
plication," our understanding of how this operation
prevents reflux has increased greatly. The original
concept was that of a mechanical valve formation
which prevented reflux by purely mechanical forces.
The stability of the cardia and especially of the angle
of His is considered essential for such valve function;
increases of pressure and volume in the upper part of
the stomach result in reflux if the cardia is unstable
and slides into the thoracic cavity. If the cardia is
stable, these same mechanisms tend to occlude the
orifice of the esophagus, thus eliminating the poten-
tially hazardous reflux of gastric contents. This is
even more pronounced in the prone position where
Reprint requests: M. Rossetti, M.D., Kantonsspital,
CH-4410 Liestal, Switzerland.
439
9 1977 by the Soci6t~
lmernationale de Chirurgie
gravity favors reflux and its sequelae in cases with
sphincteric insufficiency; here fundoplication coun-
teracts reflux by hindering funnel formation, a condi-
tion well known to facilitate reflux.
At the present time we favor fundoplication in or-
der to create an adequate substitute for the in-
sui~icient sphincter. The fundoplication remains in-
fluenced by neurohormones and, therefore, behaves
normally. This has been demonstrated by the experi-
ments of Siewert [2], which showed that the gastric
muscle layers close to the cardia react to natural stim-
uli and blood gastrin levels in the same way as the
sphincter. These properties are highly specific for the
gastric wall in the vicinity of the cardia and cannot be
reproduced in the remaining gastric musculature.
Furthermore, the studies of Liebermann [3] showed
the anatomical position of the muscle fibers in the
fundusicuff, thus explaining the function of the newly
created muscle sling.
Operative Technique
There are two available techniques for creating a
fundoplication, both of which function in the manner
described above when performed correctly. In the
original method [1, 4] portions of the anterior and
posterior walls of the fundus are united in front of the
esophagus, usually incorporating layers of the esopha-
geal wall into the suture line in order to prevent slid-
ing back of the periesophageal cuff and recurrence of
reflux due to funnel formation above the plication.
This method requires extensive preparation of the
area surrounding the cardia. The upper part of the
gastrohepatic ligament has to be divided in order to
provide access to the omental bursa and permit for-
mation of the posterior fold of gastric fundus. As a
result, most of the vagal innervation to the liver, an-
trum, and duodenum are traumatized. Furthermore,
the stitches through the esophageal wall may damage
440
Fig. 1. Technique of fundoplication. The peritoneum over-
lying the cardia is incised, the phrenoesophageal membrane
is stripped offand a 4 to 5 cm segment of distal esophagus is
isolated and surrounded with a rubber tube for downward
traction. A large bare esophageal probe, inserted by the
anesthetist, facilitates identification of the cardia and pre-
vents creating too tight a fundoplication.
branches of the anterior vagus nerve, either directly
or indirectly by scar tissue formation from peri-
esophagitis,
To correct these shortcomings of the original
method, and particularly to preserve the vagal nerves,
the technique was modified to one in which the plica-
tion is confined to the anterior wall of the fundus
[5-8], To facilitate identification of the esophagus the
anesthetist inserts a thick esophageal probe, 8-10 mm
in diameter, After detachment of the phrenoesopha-
geal membrane, the distal esophagus is freed by fin-
ger dissection creating a plane between esophagus
and aorta without disturbing important anatomical
structures. Interference with the various branches of
the vagus nerve is avoided. Through the "window"
created in this manner a mobile anterior fold of fun-
dus is brought around posterior to the esophagus (to
encircle ~he esophagus anteriorly) and is reattached
to the anterior aspect of the fundus by a few sero-
muscular sutures. The esophageal wall is not included
in this suture. We stress the point that the fundoplica-
tion has to be loose and without tension; there should
be no attempt to form a permanent one-way valve. A
clamp with a small swab should pass easily between
World J. Surg. Vol. 1, No. 4, July, 1977
the cuff and the esophagus. Muscular contraction
will lead to the valvelike action whenever needed
and will counteract any tendency to funnel forma-
tion. This precaution is essential to avoid the post-
fundoplication syndrome, with overdistension of the
stomach due to inability to belch or vomit. In experi-
enced hands, this complication is rarely encountered
because the loose plication functions only in response
to neurohumoral impulses.
Technical Details
Preoperative investigation includes full assessment
of gastroduodenal function by radiological and en-
doscopic examinations. The patient is placed in the
supine position with slight elevation of the left side.
After intubation, the anesthetist inserts a thick esoph-
ageal probe which serves the purposes of facilitating
identification of the subdiaphragmatic esophagus,
and of splinting the esophagus to prevent undue nar-
rowing by the fundoplication. Usually an upper mid-
line abdominal incision is used to permit simultane-
ous treatment of accompanying conditions such as
gallstones or gastroduodenal ulcers. Self-retaining
Rochard retractors facilitate exposure of the cardia.
After routine exploration of the abdominal organs
the cardia and esophageal hiatus are palpated. The
width of the hiatus, the presence of a hernia sac, and
the mobility of the cardia are determined. Evaluation
of the gastroesophageal junction may be complicated
by periesophagitis. The stomach is drawn down to ex-
pose the peritoneal reflection near the hiatus, and the
reflection is incised (Fig. 1). The extraperitoneal fat
pad and the yellowish phrenoesophageal membrane
are gently removed with a soft swab until the longitu-
dinal muscle fibers of the esophagus are exposed. In
cases of endobrachyesophagus or Barrett's esopha-
Fig. 2. Technique of fundoplication. The anterior fundic
wall is gently brought around the esophagus and grasped
with an atraumatic clamp.
M. Rossetti: Fundoplication as Treatment of Gastroesophageal Reflux 441

addition to performing the fundoplication. The oper-

ation requires about 30 minutes. Peroral alimentation
is started on the first postoperative day. Following an
uncomplicated fundoplication the average period of
hospitalization is one week.

Fig. 3. Technique of fundoplication. Seromuscular non-
absorbable interrupted sutures are placed across the esoph-
agus from fundic wall to fundic wall. The wall of the esoph-
agus is not included in the sutures.
Technical Errors
Traumatizing the distal esophagus may lead to
bleeding and perforation. This complication may be
fatal, if it is not recognized immediately. The per-
foration is dealt with by oversewing and in-
corporation into the fundoplication, together with
adequate drainage. Laceration of the spleen is not in-
frequent and may call for splenectomy. In spite of
careful handling and gentle manipulation we have en-
countered this complication about 10 times. We
strongly advise against intentional splenectomy in or-
der to free the greater curve, because it is usually un-
necessary and, furthermore, may increase the risk to
the patient. The most frequent surgical error is creat-
ing a tight fundoplication which interfers with the es-
sential active muscular function of the gastric fundus
and may lead to permanent postoperative dysphagia.
Dilatation may not be helpful in this situation and

/
gus, in contrast to the acquired secondary esophageal
shortening, these muscle fibers continue into the wall
of the stomach and the angle of His is readily recog-
nizable; furthermore, the fundus is quite normal so
that no difficulty is encountered in performing a fun-
doplication. The subdiaphragmatic esophagus is
gently freed by passing a finger around the esopha-
gus, creating a window that will admit 2 or 3 fingers
easily. The cardia is encircled with a soft rubber tube
and retracted forward. A fold of the anterior fundal
wall is brought around posteriorly until the serosa
emerges on the right side of the esophagus where it is
kept in place with a long Allis or Babcock clamp (Fig.
2). The fundal fold is sutured to the remainder of the ,///
fundus by 3 or 4 seromuscular sutures of non-
absorbable 3-0 suture material (Fig. 3). The esopha-
r

gus is not included in these sutures. The fundic cuff

loosely surrounds the esophagus and its indwelling
probe. The rubber tube is removed and the thick
esophageal probe is replaced by a conventional gas-
tric tube which is left indwelling for 24 hours. A few
interrupted sero-serous sutures at the inferior border
of the fundoplication provide adequate stability and
prevent upward migration of the fundal fold and
periesophageal cuff (Fig. 4).
Manipulation" of the hiatus itself is not a part of
this procedure. Only in the case of a mixed hernia Fig. 4. Technique of fundoplication. The sutures are tied to
with a paraesophageal component and considerable unite the gastric wall in front of the esophagus. The cuff of
dilatation of the hiatus do we narrow the hiatal gap in stomach should be loose, easily admitting one finger.
442
reoperation may prove necessary. Finally, an uneven
cuff may cause pseudodiverticula formation and give
rise to complaints similar to those seen in para-
esophageal hernias. The surgical correction of this
complication may prove technically difficult.
Reasons for the Abdominal Approach
The abdominal approach is less traumatic for the
patient and less time-consuming. About one-third of
our patients are over 60 years of age and are not
suited to the thoracic approach. In our view, thoracic
and thoracoabdominal procedures are not justified
by the clinical implications of the disease. The fundo-
plication can be performed more correctly from below
even if access and visibility are more limited in obese
patients. Furthermore, the abdominal approach facil-
itates evaluation of the entire morphological and
functional unit (distal esophagus, cardia, stomach,
duodenum) and allows correction of concomitant
abdominal lesions. For example, surgical disorders of
the biliary tract have been encountered in 25% of our
patients suffering from gastroesophageal reflux.
Addition of Measures to Reduce Gastric
A cid Secretion
Fundoplication should be combined with proximal
selectiv~e vagotomy under 3 circumstances: (1) pres-
ence of duodenal ulcer; (2) proven hyperacidity (PAO
> 30 mEq/1 per hour); and (3) presence of an endo-
brachyesophagus with ulcerostenotic complications.
In obese or high risk patients we use a truncal va-
gatomy with mini-pyloroplasty (anterior elliptoid
partial hemipylorectomy) instead of the time-con-
suming proximal selective vagotomy. In cases of in-
trathoracic esophageal stenosis, usually associated
with endobrachyesophagus, the antireflux and anti-
peptic procedures are combined with perioperative
dilatation.
We believe that pyloroplasty alone without va-
gotomy, in addition to the antireflux procedure, is
potentially dangerous. The sequelae of the biliary-
pancreatic duodenogastric reflux have not yet been
fully assessed but are not without hazards. Experi-
mental data show that bile may sensitize the gastric
mucous membrane to acid and peptic secretion. In
certain instances it may be necessary to divert the bile
and pancreatic secretion by means of a long Roux-en-
Y intestinal loop, usually combined with adequate
gastric resection. This procedure may also have to be
considered if mobilization of the cardia is judged to
be too hazardous as a result of excessive in-
flammatory adhesions and periesophagitis in the re-
gion of the cardia.
World J. Surg. Vol. 1, No. 4, July, 1977
Results and Indications
During the past 20 years, we have operated on
about 1,400 patients. In 1972, 590 patients with fun-
doplication were evaluated in our follow-up clinic.
An x-ray examination was performed if the patient
was not satisfied with the results or if the operation
had not completely relieved symptoms. The results
are shown in Table l. In the early stages of our at-
tempts to understand gastroesophageal reflux we en-
countered many errors in patient selection and surgi-
cal technique, which later proved to be avoidable. In
this respect our experience was similar to that of
other surgeons working in this field. New insight into
the disease followed the adoption of routine endos-
copic examinations and histological verification of
esophagitis. Endomanometric measurements, not rou-
tinely employed, also proved helpful in providing an
understanding of the abnormal pathology and phys-
iology of gastroesophageal reflux.
In achieving success in this field a mature apprecia-
tion of the correct indications for surgical treatment
is as important as the development of a satisfactory
surgical technique. Originally many unnecessary op-
erations were performed for the relief of reflux. As a
consequence, many patients were dissatisfied with the
results. Some physicians became disenchanted with
the results of surgical therapy and advised against op-
eration even when surgical treatment was mandatory.
Today the majority of patients are satisfied with the
operative results after many years of suffering under
ineffectual conservative treatment, and a satisfactory
understanding between patient, gastroenterologist,
and surgeon has been established. Our indications for
surgical treatment are based on the following:
1. Typical symptoms of retrosternal burning sen-
sation (90% of our patients) or reflux with tracheal ir-
ritation due to recurrent aspiration (10% of our pa-
tients).
2. Objective comfirmation of reflux by means of x-
ray and endoscopic examinations together with
biopsy of the esophageal mucosa and measurement
of gastric acid secretion. We do not routinely perform
endomanometry, esophageal pH determinations, or
the Bernstein test.
3. Evidence of organic complications such as en-
Table 1. Long-term results Of fundoplication in 590 pa-
tients with simple reflux esophagitis.
Patients Percent
Postfundoplication syndrome 62 10.5
Reoperation for gastric or
duodenal ulcer 7 1.2
Reoperation for recurrence 5 0.8
Symptom-free 516 87.5
M. Rossetti: Fundoplication as Treatment of Gastroesophageal Reflux
Table 2. Results of fundoplication in 44 patients with com-
plicated gastroesophageal reflux disease.
Patients* Percent
Clinical healing 37 84. l
Early postoperative deaths 4 9.1
Late deaths (within 3 years) 3 6.8
*Observation period: 5 years--5 patients; 4 years--8 pa-
tients; 1-3 years--25 patients.
dobrachyesophagus with ulcerostenotic changes at
the mucosal junction between the esophagus and
stomach. Secondary brachyesophagus is rarely seen.
It is highly significant that we have encountered 20 in-
stances of adenocarcinoma in patients with endo-
brachyesophagus during the past 10 years.
Of our surgical patients, 75% have had gastroeso-
phageal reflux secondary to a hiatal hernia, and in
25% the reflux was due to functional incompetence of
the lower esophageal sphincter without hernia forma-
tion. Persistence of typical symptoms with radio-
logical evidence of recurrent and easily stimulated
reflux are an indication for operation even if on en-
doscopic examination no pathological changes are
seen in the lower esophagus. Endobrachyesophagus
must be regarded as a potential cause of serious com-
plications and an indication for surgical treatment
even in the absence of alarming clinical symptoms.
The results of fundoplication in 44 patients with com-
plicated gastroesophageal reflux disease are shown in
Table 2.
Management of Recurrence
Most patients with recurrent reflux seek help at an-
other clinic or consult surgeons other than those who
performed the original operation. If the original op-
eration was performed on the basis of inadequate in-
dications and improper surgical technique, then per-
sisting signs and symptoms are classified as due to a
"false" recurrence. Genuine recurrences may be due
to technical errors or, in late recurrences, to phys-
iological degenerative changes. Treatment of recur-
rences requires experience and technical skill together
with the necessary facilities for the performance of
thoracoabdominal operations. Reoperation com-
mences with a laparotomy, with the patient in the su-
pine position and the left side elevated to an angle of
45 ~ The first step involves mobilization of the cardia
and an attempt to achieve correct fundoplication. Oc-
casionally this is impossible to achieve by the abdom-
inal route and a thoracotomy may be needed to pro-
vide access to the esophagus and cardia. Any oper-
443
ation for recurrence is hazardous and should be
considered only when a long course of medical treat-
ment has failed to relieve the patient's symptoms. The
only definite indications for further surgical treat-
ment are mechanical stenosis due to chronic ulcera-
tive esophagitis, hemorrhage, persisting severe and
uncontrollable symptoms, and the suspicion of ma-
lignant degeneration.
R6sum6
La fundoplicature par voie abdominale est con-
seill6e en cas de reflux gastro-oesophagien associ6/~
une hernie hiatale, car cette op6ration pallie la fonc-
tion du sphincter d6ficient. Le succ6s d6pend des in-
dications op6ratoires. En nous basant sur pr6s de
1,400 cas vus au cours de 20 derni6res ann6es, nous
pouvons pr6ciser les 616ments importants de ces in-
dications: (a) sensation de brfilure r6trosternale (80%
des cas); (b) confirmation objective du reflux par ex-
amen radiologique et endoscopique, biopsie de la
muqueuse oesophagienne et 6tude de la s6cr6tion gas-
trique; (c) complications organiques telles que endo-
brachyoesophage avec st6nose et ulc6rations fi la jonc-
tion gastro-oesophagienne. Un follow-up de longue
dur6e de 590 malades avec simple oesophagite de ref-
lux, trait6s par fundoplicature, a montr6 que 87.5%
sont sans symptomes. Sur 44 malades avec reflux gas-
tro-oesophagien compliqu6, la fundoplicature a gu6ri
cliniquement 84.1% d'entre eux.
References
1. Nissen, R.: Eine einfache Operation zur Beeinflussung
der Refluxoesophagitis. Schweiz. reed. Wochenschr. 86:
590, 1956
2. Siewert, R., Jennewein, H.M., Waldeck, F , Peiper,
H.J.: Experimentelle und klinische Unterschungen zum
Wirkungsmeehanismus der Fundoplicatio. Arch. Kiln.
Chir. 333:5, 1973a
3. Liebermann-Meffert, D.: Architecture of the musculature
at the gastroesophageal junction and in the fundus.
Chir. Gastroenterol. 9:425, 1975.
4. Nissen, R., Rossetti, M.: Die B'ehandlung der Hiatus-
hernien und Refluxoesophagitis mit Gastropexie und
Fundoplicatio. Stuttgart, Thieme, 1959
5. Rossetti, M.: Die Refluxkrankheit des Oesophagus.
Stuttgart, Hippokrates-Verlag, 1966
6. Rossetti, M.: Zur Technik der Fundoplicatio. Actuelle
Chit. 3:229, 1968
7. Rossetti, M., Hell, K., Allg~Swer, M.: Surgical therapy of
reflux oesophagitis. Chir. Gastroenterol. 5:5, 1971
8. Rossetti, M., Allg6wer, M.: Fundoplication for treat-
ment of hiatal hernia. Prog. Surg. 12:1, 1973