Modified Laparoscopic Toupet Fundoplication with Vagus Nerve Sparing via Total Left-Side Approach for Hiatal Hernia with GERD: A Pilot Study

Background: While traditional laparoscopic Toupet fundoplication with bilateral surgical approach (T-TBSA) provides regional protection of the vagal nerve, mandatory lesser omentum dissection risks irreparable damage to the hepatic and anterior gastric branches of the vagus nerve.Therefore, the objective of this pilot study is to describe a modified laparoscopic Toupet fundoplication with total left side surgical approach (MT-TLSA) and evaluate its safety and clinical efficacy in patients with gastroesophageal reflux disease (GERD) and hiatal hernia (HH).

Methods: To address these anatomical challenges, we developed and describe herein the MT-TLSA. This technique creates a 270° wrap (180° anterior and 90° posterior) around the esophagus. The MT-TLSA technique maintains the integrity of the lesser omentum, thereby anatomically minimizing the risk of direct transection to the hepatic and anterior gastric branches of the vagus nerve. We prospectively evaluated the MT-TLSA in 11 patients with gastroesophageal reflux disease (GERD) and hiatal hernia (HH) between July 2020 and May 2022.

Results: MT-TLSA was completed in 11 consecutive patients without major complications. The mean total operative time was 118 min, mean blood loss was 11 mL, and mean postoperative hospital stay was 2.5 days. During the postoperative period and follow-up, no patient developed gallstones or delayed gastric emptying. The 3-year follow-up gastroscopy examination showed well-established gastroesophageal flap valves and the mean DeMeester score decreased from 37.1 (range 18.6 – 65.5) to 3.9 (range 0.1 – 8.1), and the total esophageal acid exposure time from 11.9% (range 5.7% - 19.1%) to 1.3% (range 0.0% - 3.0%), supporting the effectiveness of anti-reflux procedures performed with MT-TLSA. Based on questionnaires, the mean total Gastroesophageal Reflux Disease Questionnaire (Gerd-Q) improved from 12.9 (range 11 – 15) to 6.1 (range 6 – 7). Postoperative 36-Item Short-Form Health Survey (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI) improved significantly compared to preoperative baselines, indicating marked quality-of-life gains.

Conclusions: In this pilot study, MT-TLSA provides a clear and broad surgical field, while ensuring maximal anatomical preservation of the hepatic and anterior gastric branches of the vagus nerve. However, due to small sample size and restricted follow-up duration, these findings should be interpreted with caution. Validation through multicenter cohorts with extended follow-up periods is needed.