3.3.1 Hiatal closure and fundoplication

In the presence of reflux disease and/or a diaphragmatic hernia, the gap in the diaphragm must be closed with sutures and, in addition, a barrier created against backflow of chyme (partially digested food from the stomach) into the oesophagus. To that effect, endoscopy is conducted to expose the defect in the diaphragm and this is then closed by endoscopic sutures [Fig. 40]. Overall, 3 to 4 sutures are needed [Fig. 41]. If the diaphragm gap is very large or there is a recurrent hernia, additional support by means of a light synthetic mesh, might be needed; this can be easily fixed at this location with fibrin glue [Fig. 42]. Next the mobilised upper portion of the stomach (fundus of the stomach) is folded as a new valve by either 360 º (Nissen fundoplication) [Fig. 43] or 270 º (Toupet fundoplication) [Fig. 44] around the oesophagus and sutured before the oesophagus. In certain cases where there is only a diaphragmatic hernia and no reflux disease there will be no need to fold the upper portion of the stomach around the oesophagus. Then the fundus of the stomach is only sutured to the undersurface of the diaphragm (fundophrenicopexy).
Endoscopic suture closure of an oesophageal hiatus and fundoplication or fundophrenicopexy can only be carried out under general anaesthesia.

Fig. 40: Defect closure with sutures (hiatal closure)

Fig. 41: Defect closure with additional sutures (hiatal closure)

Fig. 42: Insertion of synthetic mesh (hiatal closure)

Fig. 43: Nissen operation (fundoplication)

Fig. 44: Toupet operation (fundoplication)