LAPAROSCOPIC TOUPET FUNDOPLICATION
C. Zornig
Department of Surgery, Israelitisches Krankenhaus Hamburg, Germany
Summary
Toupet described his technique of fundoplication in 1963 [1]. He had little clinical experience, but saw the importance of a partial wrap to avoid postoperative dysphagia. He recommended closure of the hiatus only in case of large hernias and never divided the short gas- tric vessels. If we talk about a Toupet procedure today, we mean a posterior partial fundoplication. In contrary to his original technique we have learned that hiatal closure is important to avoid recurrent hernia and that the wrap can be tailored more nicely, if the short gastric vessels are divided. This modern adaptation of Toupet’s operation is a very successful tool to treat gastro- oesophageal reflux disease.
Introduction
Toupet has described his technique of partial fundopli- cation in 1963 [1]. This technique has had an in- creasing success during the last years of laparoscopic surgery. Lots of technical variations have been used un- til today. Also in my department, in which the Toupet procedure is performed almost exclusively since 4 years, we have developed an individual technique. For a bet- ter understanding, Toupet’s own technique is described first. I do this according to the original publication which followed a session at the French Academy of Surgery and according to an article of Katkhouda et al [2], which gives some further information about Toupet’s work. Afterwards I will describe our tech- nique of today after having performed about 1200 par- tial fundoplications out of about 1800 fundoplications that we have done on the whole.
Toupet’s original technique
To avoid reflux in a patient with hiatal hernia Toupet aimed at replacing the lower oesophagus
down into the abdominal cavity, at reconstructing the angle of His and at avoiding the cardia to migrate again into the chest. The operation was per- formed through a midline incision and consisted mainly of three steps:
(1) Mobilization of the abdominal oesophagus (2) Mobilization of the posterior aspect of the
fundus
(3) Oesophagogastroplasty with phrenogastro- plasty.
After incision of the peritoneum overlying the oesophagus the lower part of the oesophagus and the crura were dissected. The two vagus nerves were iden- tified and preserved at all steps of the operation. After incision of the lesser omentum the posterior aspect of the fundus was widely dissected. It seems to me, that Toupet has performed this dissection more intensely than we imagine today, as he has even sometimes di- vided the left gastric artery. Then he could easily pull the posterior wall of the fundus behind the oesopha- gus to the right side. This part of the fundus was fixed to the right side of the oesophagus and to the right crus with 4–5 sutures each. On the left side the fundus was then fixed to the oesophagus and the left crus.
Toupet stresses the fact that this procedure is dif- ferent from the one of Nissen [3], as it does not create a total sleeve around the oesophagus. He believes, that it is preferable to leave the hemicircumference of the oesophagus free from any fundus to avoid the inability to belch, a complication that occured after the Nissen procedure, as he said. It must also be mentioned that Toupet did not divide the short gastric vessels. The extreme mobilization of the posterior aspect of the fundus allowed him to pull it easily to the right side.
Toupet recommended closure of the hiatus only when it was very enlarged. This should be done by one or two stitches in front of the oesophagus. He
oesophagus should finally stay in the abdominal cavity without any tension. Both vagus nerves are visualized. A posterior hiatoplasty is performed by 2 z-formed sutures with non resorbable mersilene 1 (Figs. 2 and 3). This thick material does not tend that much to cut into muscle fibres and the z- stitches put the tension on a large region. The poly- filament thread makes intraoperative knotting (which should be gentle) easy and probably causes more scar tissue than a monofilament suture.
found, that the suturing of the crura is difficult to calibrate and was afraid of dysphagia. He could not imagine, that these sutures, which tend to cut into the muscle fibres, could create a normal oesophageal hiatus. He understands a hiatal hernia similar to a rectal prolaps. As a consequence, he aims at pulling the herniated organs (distal oesophagus, proximal stomach) back into the abdominal cavity, and of course, they should stay there. This should be man- aged by the fixating sutures, the obliteration of the cul-de-sac and the irritation of the serosal surfaces.
He then hopes that the muscular fibres of the crura could regain tonicity, because they are not stretched anymore by the fundic prolaps (as the anal sphincter becomes better after treatment of a rectal prolaps).
Toupet published his technique after having per- formed a series of cadaveric operations, but with the experience of only 4 patients with limited follow-up.
On the whole Toupet only performed 20 hiatal her- nia operations in his career.
Our Toupet technique
We use 4 trocars (two 10 mm, two 5 mm) besides the optic trocar. The surgeon stands between the legs, the first assistent sits on the patient’s left side and holds the camera and the Babcock clamp. The second assistent stands on the right side and retracts the liver. A 45 optic is our standard. If intense dis- section in the mediastinum is needed, we change to a 30 optic. Dissection is performed with the ultraci- sion scissors (Ethicon, Norderstedt, Germany). The lesser omentum is opened. If necessary vagal hepatic branches or an arterial branch from the left gastric artery to the left liver are divided. A good exposure of the operative field is more important than the questionable problems of the division of these struc- tures. The right crus is dissected free and then the anterior part of the left. As the posterior part of the left crus is covered by fundus, we then divide the short gastric vessels. Afterwards the fundus can be pulled to the right side. The posterior part of the left crus is now nicely exposed and can be freed. Conse- quent dissection of the crura automatically results in a tunnel behind the oesophagus (Fig. 1). The oe- sophagus is pulled down and dissection is carried out in the mediastinum. The lower 5–8 cm of the
Fig. 1. Dissection of the crura and up into the mediastinum is finished. The region of the lower oesophageal sphincter is located in the abdominal cavity. The oesophagus is lifted by a Babcock clamp, which is inserted in the left lower abdomen
Fig. 2. The crura can nicely be approximated by the first z-formed suture with Mersilene 1
A part of the fundus is pulled behind the oe- sophagus to the right side. Tayloring of the wrap is controlled by the shoe shine test (Fig. 4). The right part of the fundus is fixed to the right crus or both with a running suture of mersilene 2/0. Another su- ture fixes this part of the wrap to the right side of the oesophagus. The corresponding left part of the fundus is chosen and fixed to the left side of the oesophagus (Fig. 5). A single suture fixes the left fundus to the diaphragm. Care is taken that the vagal nerves stay outside the sutures.
Our results
Between May 1999 and May 2000 we conducted a prospective randomized trial to compare the Nissen fundoplication to the one of Toupet [4], [5]. In this study we also examined the influence of preexisting oesophageal motility on the operative result in ac- cordance to the technique. Follow-up studies were perfomed after 4 months and 2 years. Here I want to focus on the results of the 100 patients who re- ceived a Toupet fundoplication.
The mean operative time was 50 minutes. All operations were finished laparoscopically. The mean postoperative stay was 5 days. After 4 months and 2 years the overall satisfaction rate was 89% and 85%, respectively. After 2 years 12 patients complained about clinical reflux. Only half of them had objective pathological findings in a 24-h-pH-monitoring and/or endoscopically. On the other hand 22 pa- tients had pathological findings in the 24-h-pH- monitoring and/or endoscopy. But only 6 of them had clinical symptoms. Dysphagia according to our very sensible scoring system was present preopera- tively in 33 patients, whereas postoperatively only 8 patients complained about dysphagia.
Comparing the two operative techniques reflux con- trol was equal, but the complication rate (dysphagia, need for reoperation) was higher after a Nissen fundo- plication. The preoperative oesophageal motility did not influence the results with statistical significance.
Fig. 3. The hiatus is closed sufficiently by 2 z-formed sutures.
There is only an 18 ch gastric tube in the oesophagus
Fig. 4. Shoe shine test to chose the ideal parts of the fundus
to create the wrap Fig. 5. The posterior partial fundoplication is completed
Despite our overall success with this operation the postoperative problems remained the same as in con- ventional surgery – mainly dysphagia and recurrent reflux. For several years we then followed the “tai- lored concept”. Its proponents argued that the choice between a partial or total fundoplication should depend on the presence or absence of preexisting oe- sophageal motility disorders [7]–[10]. Many studies had shown, that the Nissen procedure was to be the more successful in terms of reflux control [7], [11]–
[14]. However it was also associated with a higher rate of postoperative dysphagia [15]–[20]. While the Nissen procedure was the preferred technique, the partial wrap was recommended for patients with motility disorders [7], [9], [21], [22].
With increasing experience in this field of sur- gery a growing body of evidence suggested that the concept may be invalid [16], [17], [23]–[26]. We noticed that dysphagia also developed after a Toupet procedure and that we had recurrent reflux after Nissen fundoplications and a higher rate of reopera- tions. Therefore we decided to evaluate the tailored concept by comparing the two operations in a pro- spective randomized trial [4], [5]. In conclusion, at least in our hands the Toupet procedure compared to the one of Nissen had the same success rate con- cerning reflux control but a lower complication rate (dysphagia and the need for reoperations). And, tai- loring of the technique according to the oesophageal motility proofed not to be valid. Therefore, we prin- cipially perform the partial fundoplication.
In conclusion I would like to highlight some points that seem to be important from my personal point of view:
(1) Toupet has invented the principal of partial fundoplication.
(2) Toupet’s original technique is rarely performed today.
(3) Reduction of the hernia is mandatory.
(4) Dissection of the oesophagus must be perfor- med to an extent that the region of the lower oesophageal sphincter stays in the abdominal cavity without tension.
(5) The short gastric vessels should be divided.
(6) A (posterior) closure of the hiatus is manda- tory.
(7) A posterior partial fundoplication should be performed.
Discussion
I totally agree with the aims, that Toupet followed with his operation. The hernia must be reduced. The oesophagus must be dissected as far up into the me- diastinum as necessary to get the segment of the lower oesophageal sphincter completely down into the abdominal cavity without any tension. The angle of His must be reconstructed. The ensemble of these operative steps with the anatomical situation (and the consecutive function) that we create avoids suc- cessfully reflux, already on the first postoperative day. As we are heading at a long-term effect, this anatomical situation must remain unchanged for the rest of the patient’s life. And this effect should be connected with the lowest complication rate possible (dysphagia!).
The question is, how to achieve this aim. The re- duction of the hernia and extensive dissection of the lower oesophagus is agreed by all specialists in this field. The fundoplication (whether complete or par- tial) certainly is the best and most stable way to recon- struct the angle of His (compared to the single suture line of Lortat-Jacob [6] or a simple gastropexy). Each sort of fundoplication creates a certain mass that should not be able to herniate up through the recon- structed hiatus. Toupet achieved a mobile fundus by extensive dissection at the posterior gastric wall. In my opinion the division of the short gastric vessels makes the tayloring of the wrap even easier. The crucial point is to avoid the recurrence of the hernia, which often is associated with recurrent reflux. In my opinion the closure of the hiatus plays an important role. Here I do not agree with Toupet. We can avoid to injure muscle fibres by suture material and technique. And by suturing the crura we create more scar tissue in this region, what Toupet principially aimed at by irritaion of the serosal surfaces, as mentioned above. His argu- ments concerning hiatal closure seem inconsequent to me. We always close the hiatus.
Then it remains the question whether to use a complete or partial wrap. This question will be an- swered in the next chapter. Therefore I will not dis- cuss this problem but only explain our own decision making. We performed our first laparoscopic fundo- plication in 1992 using the Nissen technique, which has been recognized as the leading technique since the era of conventional surgery, at least in Germany.
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