Technical factors in the creation of a "floppy" Nissen fundoplication.

The original description of "floppy" Nissen fundoplication was that of an open procedure involving a large esophageal bougie, complete fundic mobilization, ligation of the short gastric vessels, and placement of a finger or a dilator under the completed fundoplication to assure laxity. A maneuver equivalent to the latter step during laparoscopic Nissen fundoplication has not been described. The consensus in the literature appears to be that the element of a fundoplication that defines it as floppy is complete mobilization of the fundus. We report an intraoperative maneuver that assures the fundoplication has adequate laxity. We also discuss several other maneuvers to assure proper formation of the fundoplication and to minimize side effects such as long-term dysphagia.