Laparoscopic Fundoplication

Laparoscopic fundoplication, or Nissen fundoplication, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia, which is an enlargement in the hole in the diaphragm muscle where the esophagus passes through just before it connects to the stomach.

The initial surgery was performed by Dr. Rudolph Nissen in 1955. The procedure was done quite commonly in the 60’s and 70’s through large incisions in either the abdomen or chest. With the advent of laparoscopic techniques, the procedure was quickly adapted to an approach typically using 5 small incisions. The technique typically involves repair of any hiatal hernia, coupled with uncoupling the connections of the upper part of the stomach from the surrounding organs, and using that part of the stomach to wrap back around the esophagus just above its connection to the stomach itself.

The Nissen fundoplication is total (360°), but partial fundoplications known as Belsey fundoplication (270° anterior transthoracic), Dor fundoplication (anterior 180-200°) or Toupet fundoplication (posterior 270°) are also alternative procedures with somewhat different indications.

The procedure involves a general anesthetic and typically an overnight hospitalization. Patients typically are placed on a soft or liquid diet for 7-14 days after the procedure to allow for any swelling to go down, and then the diet is slowly advanced. Patients are typically limited with regards to heavy lifting or strenuous activity for 4-6 weeks following the procedure.

Because of the change in the shape of the stomach, the fundoplication has the potential to lead to side effects following the surgery. Some patients experience dysphagia, or trouble swallowing, if the wrap stays full or is created to tightly. Because the wrap is part of the stomach, anything that tries to go backwards will get caught up in the wrap and lead to a closing pressure, so it typically does not allow patients to belch or vomit properly following the procedure. In addition, since the wrap is held together by a seam of sutures, if the stomach fills it can cause tension on the seam and lead to discomfort, or a syndrome called “gas-bloat.” In general, the outcomes following the procedure are excellent, and primarily based on the severity of the reflux symptoms before the surgery, and the degree of side effects experienced after the surgery. Most patients are off anti-reflux medications entirely following the procedure, and generally 70-80% of patients are satisfied with their results 5 years following the surgery.

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