‘Critical circle of fundoplication’ – A key concept towards creating identical, replicable and consistent fundoplication wraps

BACKGROUND: There is a significant learning curve associated with laparoscopic Nissen’s fundoplication, during which, complications due to surgical errors are more likely to occur. Moreover, length of the wrap, its situation on the lower esophagus and the points of the fundus brought together to create the wrap are arbitrary and as per the surgeon’s judgement and estimation. This leads to a lot of variation in the wraps created, not only from surgeon to surgeon, but also from case to case for each individual surgeon. We propose a new concept of ‘Critical Circle of Fundoplication’ and the new approach to construct the fundoplication based on this concept, by application of which, a mathematically precise fundoplication can be created which is consistent, accurate and optimum. PATIENTS AND METHODS: A total of 132 patients were operated based on the concept of ‘Critical Circle of Fundoplication’ between 2015 and 2020, of which 116 patients completed one year of follow-up and are included in the paper. RESULTS: The demographic characteristics, intraoperative findings and postoperative are described in detail. An additional average time of 10.5 minutes (range: 8-26 minutes) was required in the precise measurements and markings that were required by this approach. CONCLUSION: By application of the concept of ‘Critical Circle of Fundoplication’, precise, consistent and optimum wraps can be created. By eliminating the errors of structural construction and placement of the wrap, overall results can be improved.