Diseases and Surgical Procedures

Laparoscopic Nissen Fundoplication

This operation corrects the problem of acid reflux. Although the most common symptom of reflux is heartburn, other symptoms such as regurgitation, choking, and chest pain can also occur. Patients who suffer severe heartburn often have incomplete relief of their heartburn with medical treatment. For these patients this surgery treats the reflux by making a new valve mechanism at the lower esophagus as a barrier to reflux. Most patients go home on the day after the surgery, and most return to work within 2 weeks.

Techniques

Fundoplication is done as either an open or a laparoscopic procedure. The open procedure involves an incision of about 8 inches in the abdomen, while the laparoscopic approach is a minimally invasive technique producing 4 to 5 half inch incisions. Although the laparoscopic approach offers many advantages over the open technique, such as a quicker recovery and less complications, it may not be appropriate for some patients, including those who have had previous abdominal surgery or who have some pre-existing medical conditions. In addition, some patients may have to be converted from the laparoscopic procedure to the open technique during surgery. However, this is uncommon and most patients (95%) can undergo the laparoscopic procedure without difficulty.

During the operation, the surgeon raises the liver to expose the junction between the stomach and the esophagus. A space is created behind the esophagus and the fundus of the stomach and freed from its attachment to the spleen. The fundus is then pulled behind the esophagus and secured in place. Depending on the type of procedure, the wrap is either sutured to the esophagus itself (as in the Toupet), or it is sutured to the stomach on the other side of the wrap (as in the Nissen). If a hiatal hernia is present, it is repaired before then.

In the laparoscopic procedure, surgeons use a trocar (a narrow tube-like instrument) to gain access to the abdomen. A laparoscope ( a thin telescope connected to a video camera) is inserted through the trocar, giving the surgeon a magnified view of the patient's internal organs on a television monitor. Four additional trocars are then inserted to accommodate special instrumentation.

Following the procedure, the incision(s) are closed with stitches or with surgical tape and bandages are applied.

Surgical Complications

Perforation of the stomach or esophagus can occur in about 1% of patients. In rare cases, bleeding or perforation is not identified at the time of operation and a re-operation is necessary. Approximately 5% of patients require conversion to general anesthesia because of bleeding, perforation or other complications. In all, about 95% of all cases can be performed laparoscopically, while 5% of laparoscopic cases can result in a conversion to the open procedure.

After Surgery

When patients wake up from surgery, they often have a tube leading from their nose down into their stomach to decompress the area around the wrap. Their diet is restricted to liquids for the first day after the tube is removed. A soft diet is recommended for several weeks after surgery.

Hospital Stay and Recovery

Most patients are able to return home the first or second day after laparoscopic surgery and 4 to 7 days after the open operation.

Return to full activity usually takes 1 to 2 weeks following most laparoscopic anti-reflux repairs and 4 to 6 weeks after an open repair. For about 2 weeks after your surgery, you will need to take an acid reducing medication such as Zantac. A follow up appointment should be made with your surgeon 7 to 10 days after discharge so that your questions can be answered, your progress can be assessed and you can be examined.

Post-Op Complications

Since the operation creates a valve mechanism at the bottom of the esophagus to prevent reflux, it may also cause resistance to the passage of food causing more air to be swallowed than before surgery.

Therefore, following fundoplication, patients often experience periods of gas-bloat syndrome. During these episodes, which can last up to 2 to 3 hours, an increase in swallowed air makes it difficult to belch or vomit. In addition, patients often experience abdominal distention, nausea and an increase in flatulence. The soft diet should help prevent this syndrome.

In addition, for about 6 weeks after the laparoscopic repair, patients may experience dysphagia (difficulty swallowing) due to a post-surgical swelling at the wrapped site. In order to ease these symptoms, your doctor will recommend a soft diet for 4 to 6 weeks after surgery. Although dysphagia is almost always temporary, 2% of patients experience long term symptoms. These patients may be treated with balloon stretching of the area, or in rare cases, revision surgery.

Gas-Bloat Syndrome

This occurs in patients who have been operated for gastroesophageal reflux disease (GERD) or heartburn. The most common operation is (Nissen's fundoplication). This procedure involves wrapping stomach around the valve at the junction of esophagus and stomach (LES) so as to make it tighter and prevent upward flow of acid.

A natural consequence of that is that the tightened valve does not allow for upward expulsion of air either, thus preventing belching. Patients feel full of gas and bloated especially after a meal. They develop discomfort because of their inability to belch and get rid of that gas. Not only do they develop abdominal cramps, but may also pass large amounts of flatus resulting in socially embarrassing situations.

This syndrome occurs in 25-50% of patients after the fundoplication surgery, but symptoms resolve over time in most cases. Revision surgery may rarely be to correct the problem.

Gas-Bloat syndrome may also occur in patients who are learning to use their upper food pipe (esophagus) for their speech after their voice box (larynx) has been surgically removed due to cancer etc. This new form of speech involves sucking air into esophagus, and then expelling it immediately in the form of words. Increased aerophagia into the stomach may occur in these patients.