The role of laparoscopic Nissen, Hill, and Nissen-Hill hybrid repairs for uncomplicated gastroesophageal reflux disease

There are several elements that constitute the lower esophageal barrier against reflux. What characterizes the abnormality seen in gastroesophageal reflux disease (GERD) is the loss of an effective barrier combined with refluxed gastric contents. Several techniques including those described by Nissen, Toupet, and Hill have become options for reconstructing the physiologic barrier. In this paper, we describe our technique of performing laparoscopic Nissen, Hill, and a combined Nissen-Hill hybrid repair for the management of uncomplicated GERD. In a randomized study comparing 46 laparoscopic Nissen to 56 laparoscopic Hill repairs, subjective and objective short term and long term (13 months) outcomes including use of antisecretory agents were equivalent. The number of failures requiring reoperation were also the same but the difference in failure types prompted us to examine the two techniques and fuse them into one to maximize the integrity of the lower esophageal barrier. A comparative study of the Nissen, Hill, and hybrid repairs with 15-month follow-up showed similar subjective and objective outcomes and specifically no increase in dysphagia for the combined repair. There was also a trend towards less recurrence the hybrid group. More recently, we studied our Nissen repairs and compared them to hybrid repairs over a 22-month median follow-up period. Quality of life outcomes were superior for the hybrid group in all domains. For the subset of patients with a mean follow-up of 60 months the anatomic recurrence rate was 5% in the hybrid group compared to 45% in the Nissen group. These data strongly suggest that the anchoring of gastroesophageal junction with Hill sutures reduces the axial stresses on the Nissen wrap to maintain its integrity. The laparoscopic Nissen, and laparoscopic Hill procedures have been proven to have excellent results for the treatment of GERD. Larger studies are underway to demonstrate the long-term durability of the hybrid Nissen-Hill procedure in the management of GERD.