During laparoscopic Nissen fundoplication for GERD, which intraoperative maneuver is CRITICAL to prevent post-operative dysphagia from an overly tight wrap?

• A Using a 58-60 French intraesophageal bougie to calibrate the wrap tightness
• B Reapproximating the crura anterior to the esophagus only
• C Wrapping only 180° (Toupet partial fundoplication) in all patients
• D Dividing the short gastric vessels to achieve a tension-free fundus wrap ✓

Explanation

Division of the short gastric vessels (gastric-fundal vessels) is the critical step in Nissen fundoplication that enables the gastric fundus to reach the right side of the esophagus without tension. Without dividing the short gastrics, the fundus is 'twisted' rather than wrapped, creating tension that causes dysphagia and wrap herniation. A tension-free 360° wrap (2-3 cm length, calibrated with a 56-60 Fr bougie) should appear loose ('floppy Nissen'). Crural repair with posterior sutures prevents reherniation. The bougie provides calibration but is considered by some surgeons as optional if the wrap is assessed intraoperatively; division of short gastrics is non-optional for a true tension-free wrap.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.