Types of Fundoplication

1. Complete (360-degree) Fundoplication

Nissen Fundoplication (360°)

• The gastric fundus is circumferentially wrapped 360 degrees around the distal esophagus
• Creates a "nipple" valve mechanism at the gastroesophageal junction (GEJ)
• Typically fashioned as a 2-3 cm "short, floppy" wrap (modified from Nissen's original 3-6 cm wrap) over a 56-Fr esophageal dilator
• Short gastric vessels are usually divided for full fundal mobilization ("short, floppy Nissen")
• Approach: laparoscopic (standard) or open

• Rossetti-Hill modification: Wraps the anterior fundus around the esophagus without dividing short gastric vessels; requires less mobilization
• Original Nissen: Longer wrap (3-6 cm), posterior wall of fundus used, short gastric vessels intact

2. Partial Fundoplications

Toupet Fundoplication (270° Posterior)

• Most common partial fundoplication in clinical use
• The fundus is wrapped posteriorly, with each edge sutured to the anterior esophageal wall, leaving an anterior gap
• Equivalent reflux control to Nissen in multiple RCTs, with fewer wind-related side effects (less flatulence, less gas-bloat, less dysphagia)
• Slightly higher long-term wrap disruption rate than Nissen (anchoring sutures in esophagus may be less secure)
• Preferred by many surgeons for all antireflux cases, not just impaired motility

Dor Fundoplication (180-200° Anterior)

• The fundus is folded anteriorly over the esophagus
• Initial suture incorporates the fundus, the lateral esophageal wall, and the left crus to recreate the angle of His
• Seven interrupted sutures carry the fundus across the anterior esophagus to the right crus (9 o'clock position)
• Most commonly used after Heller myotomy for achalasia - it covers the myotomy site while providing partial reflux protection
• The difference between Dor and Toupet: Dor = anterior flap valve; Toupet = posterior flap valve

Belsey Mark IV (270° Anterior, Transthoracic)

• Performed via a left thoracotomy (not laparoscopic)
• Creates a 270° anterior fundoplication
• Now largely replaced by laparoscopic approaches but still used when thoracic access is required (e.g., short esophagus, prior abdominal surgery)
• The preferred partial fundoplication for patients with severe esophageal dysmotility requiring a thoracic approach

Watson Fundoplication (120° Anterolateral)

• A less common anterior partial wrap, 120 degrees
• Used in some centers as a low-resistance option

Hill Repair (Lesser Curve Plication)

• A 90° plication of the lesser curve rather than the fundus
• The only major antireflux operation originating in the United States
• Less commonly performed today

3. Endoscopic / Transoral Approaches

Transoral Incisionless Fundoplication (TIF 2.0)

• Performed endoscopically using the EsophyX device (EndoGastric Solutions) or Xylo Technologies system
• Creates a 270-degree, ~3 cm fundoplication using polypropylene H-fasteners
• No incisions; requires general anesthesia and two skilled operators
• Superior to PPI in multiple RCTs for subjective/objective reflux resolution
• 2.4% rate of severe complications (perforation, bleeding, pneumothorax)
• Current guidelines favor surgical fundoplication over TIF 2.0; TIF may be suitable for patients wishing to avoid surgery without contraindications to endoscopic management
• Surgical fundoplication after TIF can be technically challenging (Sabiston Textbook of Surgery)

MUSE System

• Endoscopic stapling device with ultrasound guidance
• Creates an anterior fundoplication by stapling the fundus to the esophagus in retroflexion
• Limited to small observational studies; not widespread

4. Choosing the Right Fundoplication