Nissen Fundoplication or Toupet or Dor fundoplication with or without absorbable mesh (hiatal)

When it comes to addressing gastroesophageal reflux disease (GERD) and hiatal hernias, surgery is often the best solution for patients who have not responded to conservative treatments such as lifestyle changes or proton-pump inhibitor therapy. Among the surgical options, fundoplication techniques like Nissen fundoplication, Toupet fundoplication, and Dor fundoplication are widely used. These procedures aim to restore the natural barrier function of the lower esophageal sphincter (LES), preventing the backward flow of acid and stomach contents into the esophagus. Each approach differs in the way the stomach is wrapped around the esophagus, offering varying levels of reflux control and minimizing postoperative complications like dysphagia.

The decision to perform one of these procedures often depends on findings from diagnostic tools such as endoscopy, esophageal motility studies, and upper gastrointestinal series. These evaluations help identify the disease severity, the presence of a hiatal hernia, and the overall condition of the gastrointestinal tract. For patients undergoing hiatal hernia repair, the use of surgical mesh—either absorbable or permanent—remains a topic of significant discussion. While mesh can reinforce the repair and reduce short term recurrence rates, it is not without risks, including stenosis.

With advancements in laparoscopy and minimally invasive techniques, fundoplication surgeries now offer shorter recovery times, improved outcomes, and reduced risks of complications. However, the success of these procedures also relies heavily on the surgeon’s expertise, meticulous preoperative planning, and individualized care for each patient. This article explores the different types of fundoplication, their benefits and drawbacks, and the evolving role of mesh in surgical practice, supported by insights from randomized controlled trials, meta-analysis, and systematic reviews. Whether addressing GERD, a hiatal hernia, or associated complications like Barrett’s esophagus or esophagitis, these surgeries continue to play a pivotal role in modern gastroenterology.

Fundoplication Techniques

Fundoplication surgeries aim to strengthen the barrier between the esophagus and the stomach, reducing gastroesophageal reflux by wrapping the stomach partially or completely around the esophagus. the wrap essentially functions as a valve mechanism to reduce reflux. The choice of technique is tailored to the patient based on the severity of GERD, the presence of a hiatal hernia, and findings from diagnostic studies such as esophageal motility studies, endoscopy, and upper gastrointestinal series. Each technique offers distinct benefits and potential challenges.

Nissen Fundoplication

The Nissen fundoplication is the most commonly performed and well-established surgical option for GERD and hiatal hernia repair. In this technique, the surgeon creates a 360° posterior wrap of the stomach around the esophagus, fully encircling the lower esophageal sphincter (LES). This approach effectively increases pressure at the LES, preventing acid reflux and regurgitation.

Key Benefits:

• Superior control of reflux symptoms.
• High success rates in patients with severe GERD or large hiatal hernias.
• Long-term durability

However, the Nissen fundoplication is associated with higher rates of postoperative dysphagia, particularly in patients with pre-existing esophageal motility disorders. Careful preoperative assessment using an esophageal motility study can help identify patients at higher risk of complications.

Toupet Fundoplication

The Toupet fundoplication involves a 270° posterior partial wrap, which partially encircles the esophagus but leaves a portion of it uncovered. This technique is less restrictive than the Nissen and is particularly suitable for patients with weak esophageal motility or those at higher risk of postoperative complications such as dysphagia.

Key Benefits:

• Lower incidence of postoperative dysphagia, as it places less tension on the esophagus.
• Effective reflux control for most patients, comparable to the Nissen in many cases.
• Reduced bloating and difficulty belching compared to the Nissen.

Research studies, including randomized controlled trials, have demonstrated that the Toupet fundoplication provides good long-term outcomes in symptom control, patient satisfaction, and reduced complications.

Dor Fundoplication

The Dor fundoplication involves a 180° anterior partial wrap, where the stomach is wrapped around the front of the esophagus. This technique is often performed in conjunction with a Heller myotomy for patients with achalasia, as it helps prevent reflux after the myotomy while preserving the posterior gastroesophageal anatomy.

Key Benefits:

• Preserving posterior structures, reducing the risk of esophageal injury or disruption.
• Effective in preventing reflux in select populations, such as those undergoing treatment for achalasia or those with mild GERD.
• Lower likelihood of postoperative complications like dysphagia or stenosis.

While it may not provide as strong reflux control as the Nissen or Toupet, the Dor fundoplication is a valuable option for patients with specific indications.

Tailoring the Technique to the Patient

Choosing the most appropriate fundoplication technique depends on multiple factors, including:

• Esophageal motility: Patients with weak motility often benefit from partial wraps like Toupet or Dor to minimize pressure on the LES.
• Hiatal hernia size: Large hernias may require additional techniques like mesh reinforcement.
• Patient-specific risks of postoperative complications like dysphagia, bloating, or regurgitation.

Surgeons rely on diagnostic tools such as endoscopy, barium swallow studies, and esophageal motility studies to guide their decision-making. Each procedure has demonstrated efficacy in improving patient outcomes when performed with appropriate indications and surgical expertise. By tailoring the technique to the patient’s unique anatomy and disease profile, the likelihood of achieving durable symptom relief increases significantly.

Comparison of Techniques

Nissen fundoplication, Toupet fundoplication, and Dor fundoplication are all effective surgical techniques for managing gastroesophageal reflux disease (GERD) and hiatal hernias, but each has distinct advantages and considerations. Studies, including randomized controlled clinical trials and systematic reviews, have shown that the Nissen fundoplication provides excellent long-term reflux control due to its complete 360° wrap around the esophagus. However, it is associated with a higher risk of postoperative dysphagia, particularly in patients with weak esophageal motility. In contrast, the Toupet fundoplication, which uses a 270° posterior partial wrap, offers comparable control of reflux symptoms while significantly reducing the incidence of dysphagia, making it a preferred option for patients with impaired esophageal motility or a history of swallowing difficulties.

The Dor fundoplication, a 180° anterior wrap, is often used in conjunction with procedures such as Heller myotomy for achalasia and is particularly effective in preventing reflux in these cases. While the Dor wrap may not provide the same level of reflux control as the Nissen or Toupet, it minimizes tension on the lower esophageal sphincter (LES) and preserves posterior anatomy, reducing the risk of complications such as stenosis or injury. Long-term studies and meta-analyses have shown that patient satisfaction, symptom relief, and overall efficacy are comparable across the three techniques when they are appropriately matched to the patient’s condition and anatomical considerations. These findings emphasize the importance of individualized treatment plans, informed by preoperative diagnostics like endoscopy, esophageal motility studies, and upper gastrointestinal series, to ensure optimal outcomes for each patient.

Use of Mesh in Hiatal Hernia Repair

The inclusion of mesh in hiatal hernia repair is a topic of active investigation, with both potential benefits and risks.

Potential Benefits

• Surgical mesh, namely absorbable mesh, has shown promise in reducing short-term recurrence rates when compared to primary surgical suture repairs. However, permanent mesh is not used around the esophagus due to risk of erosion and infection

Concerns

• Risks include mesh-related complications such as erosion, infection, and stenosis especially in the case of permanent mesh.
• Long-term outcomes, as noted in meta-analyses and studies indexed in PubMed, reveal no significant difference in recurrence rates between mesh and non-mesh repairs.

Current Trends

• Many surgeons prefer absorbable mesh to reduce long-term complications while maintaining the benefits of short-term reinforcement.
• The decision to use mesh is often based on factors like the size of the hiatal defect, tissue quality, and patient-specific risk factors.

Postoperative Outcomes and Risks

Fundoplication surgeries, whether Nissen, Toupet, or Dor, are generally effective in alleviating the signs and symptoms of gastroesophageal reflux disease (GERD) and improving quality of life for patients. Postoperatively, most individuals experience significant reductions in symptoms such as regurgitation, bloating, chest pain, and heartburn. Studies, including systematic reviews and meta-analyses, have demonstrated high rates of long-term symptom relief and patient satisfaction across all three techniques. However, the potential for complications remains, and outcomes can vary depending on the specific procedure and patient factors.

Postoperative dysphagia is a common concern, particularly following Nissen fundoplication, due to the increased pressure created by the complete 360° wrap. While this can often resolve over time, severe or persistent dysphagia may require additional intervention. The Toupet fundoplication, with its partial 270° wrap, poses a lower risk of dysphagia while still providing effective reflux control, making it a preferred option for patients with pre-existing esophageal motility disorders. The Dor fundoplication, with its 180° anterior wrap, has the lowest likelihood of postoperative dysphagia and is particularly advantageous for patients undergoing additional procedures, such as Heller myotomy.

Other potential complications include bloating, stenosis, or recurrence of GERD symptoms. Rarely, complications such as esophageal injury or mesh-related issues (if mesh is used during hiatal hernia repair) can occur. Factors such as surgeon expertise, proper preoperative planning, and adherence to postoperative care guidelines play a critical role in minimizing risks. Despite these concerns, the overall efficacy and durability of fundoplication surgeries make them a highly reliable option for patients with GERD or hiatal hernias who have not responded to medical therapies like proton-pump inhibitors.

Dr. Iskandar’s Thoughts on the Technique

• the choice of technique depends mostly on the symptoms, size of the hernia, esophageal motility. Larger hiatal hernias also known as paraesophageal hernias are approached differently than smaller hiatal hernias.
• Absorbable mesh is selectively used in larger hernias, or in the case of recurrent hernias

 

Conclusion

The choice among Nissen fundoplication, Toupet fundoplication, and Dor fundoplication depends on patient-specific factors, including the severity of GERD, the presence of a hiatal hernia, and findings from preoperative diagnostics like esophageal motility studies. While the role of surgical mesh remains controversial, selective use of absorbable mesh shows promise in reducing short-term recurrences without increasing long-term complication rates. As research evolves, evidence-based approaches will continue to improve outcomes for patients undergoing these procedures.

source https://iskandarcenter.com/hernia-surgery/nissen-fundoplication-or-toupet-or-dor-fundoplication-with-or-without-absorbable-mesh-hiatal/