Lord's Fundoplication for GERD
Clarification: Lord's Fundoplication Does Not Exist as a Standard Procedure
There is no recognized surgical procedure called "Lord's fundoplication" in the treatment of gastroesophageal reflux disease. The established fundoplication techniques for GERD are Nissen (360° wrap), Toupet (270° posterior wrap), and Dor (anterior wrap) fundoplications 1, 2.
Standard Fundoplication Indications for GERD
If you are asking about laparoscopic fundoplication in general, the indications are:
Primary Indications
Laparoscopic fundoplication is indicated for patients with objectively documented pathologic GERD who have failed optimal medical therapy with proton pump inhibitors (PPIs), particularly those with PPI-responsive symptoms who develop untoward side effects or complications from PPI therapy 3, 2.
- Surgery is recommended for patients with severe esophagitis (LA grade C or higher) that is uncontrollable with medical therapy 1
- Patients with regurgitation-predominant GERD symptoms respond particularly well to mechanical anti-reflux procedures 4, 5
- The procedure is appropriate for medically recalcitrant GERD with documented abnormal esophageal acid exposure on pH monitoring 6, 7
Essential Preoperative Requirements
Before proceeding with fundoplication, the following must be documented:
- Objective confirmation of pathologic GERD through ambulatory pH or impedance-pH monitoring showing abnormal acid exposure 5, 2
- High-resolution manometry confirming normal esophageal peristaltic function and excluding achalasia 1, 5
- Complete endoscopic evaluation documenting presence/absence of erosive esophagitis, hiatal hernia size, and Barrett's esophagus 4, 5
- Barium swallow to identify hiatus hernia, strictures, or short esophagus 1
Contraindications
Fundoplication should not be performed in:
- Large hiatal hernias (>2 cm) without concurrent hernia repair 5
- Esophageal motility disorders or impaired peristaltic function 5, 2
- Achalasia or other primary esophageal motility disorders 1, 5
- Lack of objective GERD confirmation (negative pH studies) 5
Surgical Technique Selection
Nissen Fundoplication (360° Wrap)
- The Nissen fundoplication remains the gold standard for durable relief of GERD symptoms with an 80% success rate at 20-year follow-up 1, 2
- This is the most commonly performed antireflux operation 8, 7
- It provides superior long-term reflux control but carries higher risk of postoperative dysphagia 1
Toupet Fundoplication (270° Posterior Wrap)
- The Toupet is an alternative with potentially lower rates of postoperative dysphagia, gas bloat syndrome, and inability to belch 1
- It should be considered in patients with borderline esophageal motility or concerns about postoperative dysphagia 8, 6
- The choice between total and partial fundoplication should be based on the quality of esophageal peristalsis documented by preoperative manometry 1
Hiatal Hernia Repair
- Routine addition of an antireflux fundoplication is recommended when repairing large hiatal hernias, as omission leads to esophagitis in 28% and abnormal acid exposure in 39% of patients 9
- Closure of the diaphragmatic hiatus using non-absorbable sutures is essential 1
Expected Outcomes
- Heartburn and regurgitation are completely eliminated in 90% of patients 8
- GERD symptoms are relieved in 93-95% of patients at intermediate and long-term follow-up 6, 7
- Daily PPI intake after surgery drops to 8% 6
- Laparoscopic approach has excellent safety with in-hospital mortality of 0.14% 1
- Conversion to open surgery occurs in only 0.5-2% of cases 6, 7
Common Postoperative Issues
- Dysphagia, early satiety, and bloating are typical in the immediate postoperative period but generally improve substantially within 4-8 weeks 8
- Gas bloat syndrome and inability to vomit may persist in some patients 3
- Reoperation rates range from 4-5% for complications including recurrent reflux or severe dysphagia 6, 7