Laparoscopic Nissen Fundoplication

This operation corrects acid reflux.

Although heartburn is the most common symptom, other symptoms, such as regurgitation, choking, and chest pain, can also occur. Patients who suffer severe heartburn often have incomplete relief from their symptoms with medical treatment. For these patients, this surgery treats reflux by creating a new valve mechanism at the lower esophagus, which acts as a barrier to reflux. Most patients go home the day after the surgery, and most return to work within two 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 method, such as a quicker recovery and fewer 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; most patients (95%) can undergo the laparoscopic procedure easily.

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 stomach fundus and freed from its attachment to the spleen. The fundus is then pulled behind the esophagus and secured. Depending on the type of procedure, the wrap is either sutured to the esophagus (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 unique instrumentation.

Following the procedure, the incision(s) are closed with stitches or 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 during operation, and a re-operation is necessary. Approximately 5% of patients require conversion to general anesthesia because of bleeding, perforation, or other complications. About 95% of all cases can be performed laparoscopically, while 5% of laparoscopic cases can result in a conversion to an 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 removing the tube. A soft diet is recommended for several weeks after surgery.

Hospital Stay and Recovery

Most patients can 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 with your surgeon should be made 7 to 10 days after discharge so 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 challenging to belch or vomit. In addition, patients often experience abdominal distention, nausea, and an increase in flatulence. A 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 post-surgical swelling at the wrapped site. To ease these symptoms, your doctor recommends a soft diet 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 the stomach around the valve at the junction of the esophagus and stomach (LES) to make it tighter and prevent the upward flow of acid.

A natural consequence 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 they 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 the esophagus and then expelling it immediately in the form of words. Increased aerophagia into the stomach may occur in these patients.