Nissen Fundoplication
What the Examiner Expects
A 360-degree gastric fundus wrap around the distal esophagus performed to treat gastroesophageal reflux disease refractory to maximal medical therapy. The examiner expects you to justify the indication (failed PPI therapy, large paraesophageal hernia, Barrett's with persistent reflux), describe the preoperative workup (EGD to rule out Barrett's/stricture, manometry to exclude motility disorders, pH study to confirm acid reflux), and walk through the key operative steps: reduction of the hiatal hernia, circumferential esophageal mobilization, posterior crural closure, division of short gastrics, and creation of a short floppy 360° wrap. You must know when to choose a partial wrap (Toupet 270° or Dor 180°) instead — specifically in patients with impaired esophageal motility.
Key Examiner Focus Points
- Preop workup: EGD, esophageal manometry, 24-hr pH study
- Must rule out achalasia or severe dysmotility before 360° wrap
- Divide short gastric vessels; close crura posteriorly
- Wrap should be short (2–3 cm), floppy, and over a 56–60 Fr bougie
- Recognize postop dysphagia vs wrap herniation vs slipped wrap
Common Curveballs
Manometry shows ineffective esophageal motility
Switch to a partial (Toupet 270° posterior) wrap to reduce postoperative dysphagia risk. A full Nissen in a patient with poor motility causes intractable dysphagia.
Postop patient cannot belch or vomit and has gas bloat
This is gas-bloat syndrome from an overly tight wrap. Initial management is conservative (simethicone, dietary changes). If persistent dysphagia, obtain a barium swallow and EGD. May need dilation or, rarely, revision.
Patient returns 6 months later with recurrent reflux and an upright chest X-ray shows a retrocardiac air-fluid level
Wrap herniation into the chest. Obtain CT and barium swallow. This typically requires reoperation with reduction and re-fixation of the wrap, repeat crural closure, and possibly mesh reinforcement.
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