A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair

Hypothesis: The technique used for repair of the esophageal hiatus during l aparoscopic Nissen fundoplication can influence the likelihood of postopera tive dysphagia. Design: A prospective double-blind randomized control trial. Setting: A university teaching hospital. Participants: A total of 102 patients with proven gastroesophageal reflux d isease, undergoing a laparoscopic Nissen fundoplication were randomized to undergo fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. Patients were excluded for th e following reasons: they had esophageal motility disorders, required a con current abdominal procedure, had undergone previous antireflux surgery, or had very large hiatus hernias. Interventions: Laparoscopic Nissen fundoplication with anterior vs posterio r hiatal repair. Main Outcome Measures: Independent assessment of dysphagia, heartburn, pati ent satisfaction, and other symptoms 1, 3, and 6 months following surgery, using multiple standardized clinical grading systems. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, distal e sophageal acid exposure, and endoscopic assessment of postoperative anatomy and esophageal mucosa. Results: Symptoms of postoperative dysphagia, relief of heartburn, and over all satisfaction 6 months after surgery were not influenced by the hiatal r epair technique. However, to achieve a similar incidence of dysphagia, more patients who initially underwent posterior hiatal repair required a second surgical procedure (6 vs 0 patients). The hiatal repair technique did not affect the likelihood of early postoperative paraesophageal herniation. Conclusion: Anterior suturing of the hiatus appears to be at least as good in the short-term as posterior suturing as a method of narrowing the hiatus during laparoscopic Nissen fundoplication.