Fundoplication, an anti-reflux surgery, has become popular therapy for gastroesophageal reflux disease (GERD) using a minimally invasive laparoscopic technique. The Nissen fundoplication is a surgery performed on the stomach and the esophagus, and is one type of operation used to treat GERD.
Before the widespread use of laparoscopic procedures, surgeons performed the Nissen fundoplication through an incision in the middle of the abdomen, extending from just below the ribs to the navel. Patients would stay in the hospital between 7-10 days, and recovery at home was between 6-12 weeks. The use of laparoscopy has reduced the in-hospital stay to an average of 3 days. Return to work usually occurs in 3 weeks.
The laparoscopic procedure is performed with the patient under general anesthesia in a modified sitting position. Five small incisions are made in the abdomen. The laparoscope uses one of these incisions, the other four are used for retraction and manipulation of structures in the abdomen. The stomach and the portion of the esophagus in the abdomen are freed from their attachments. 2-3 sutures tighten the hiatus to prevent the fundoplication from migrating into the chest.
The “fundus” (hence the term fundoplication) of the stomach, which is on the left of the esophagus and main portion of the stomach, is wrapped around the back of the esophagus until it is once again in front of this structure. The portion of the fundus that is now on the right side of the esophagus is sutured to the portion on the left side to keep the wrap in place.
When completed, the fundoplication resembles a buttoned shirt collar. The collar is the fundus wrap and the neck represents the esophagus overlapped into the wrap. This has the effect of creating a one-way valve in the esophagus to allow food to pass into the stomach, but prevent stomach acid from flowing into the esophagus and thus prevent GERD. The whole operation lasts one to three hours.
When is Surgery Considered?
Consider surgery if:
- Your symptoms do not improve with medications,
- If they repeatedly return after the medication is stopped,
- If lifelong medication is needed,
- If you are unwilling or unable to take medication for prolonged periods or if there is severe damage to the esophagus due to reflux.
- A large hiatus hernia, esophageal ulcer, narrowing or change in the lining of the esophagus, such as Barrett’s esophagus may be further indications for surgical therapy.
What are the Complications of Surgery?
Surgical complications are rare but do occur in 2 to 4 % of patients who undergo laparoscopic surgery. As with any surgery performed under general anesthesia, there is a less than one in a thousand chance of severe complications from the anesthesia medications. There is a less than 1 in 500 possibility of severe bleeding that may require transfusion. All surgeries carry the risk of wound infection, postoperative pneumonia or blood clots forming in the deep veins in the legs. These risks are reduced by the use of antibiotics, anticoagulant medication and the laparoscopic technique, which allows the patient to be active soon after surgery.
There are complications specific to the surgery. Damage to organs such as the stomach, esophagus, spleen or liver may occur. This may or may not be identified by the surgical team during surgery and could result in serious infection; however, these problems can usually be repaired at the time of laparoscopic surgery. Tracking of air into the chest cavity or the space around the lungs may occur.
Occasionally it is not possible to complete the operation with the laparoscopic technique because of difficulty with visualization or because of a complication. The need to convert to an open operation with an upper abdominal incision is necessary in less than one in two hundred cases. The risk of death after this operation is less than 1 in 600.
Other complications may arise after surgery. If the wrap is too tight, there may be persistent difficulty in swallowing. This can occur in 20% of patients immediately after surgery but drops to about 5% after one to two months. Four percent of patients will need dilation of the esophagus. The wrap may slip into the chest or become undone resulting in difficulty swallowing or recurring symptoms. If this occurs, re-operation may be required.