Laparoscopic Fundoplication (Nissen, Partial) Denver
Laparoscopic “Nissen” Fundoplication (Complete or 360 Degree Fundoplication)
In 1956, Rudolph Nissen described a technique for treating gastroesophageal reflux disease (GERD) by folding the stomach up and around the lower esophagus, and called it a “gastric fundoplication”. The procedure has changed over 50 years, most notably when it went from an open surgery requiring a long midline incision to a laparoscopic procedure done through 5 or 6 small incisions. Laparoscopy significantly improves recovery time and lessens postoperative pain while providing an excellent surgical repair.
The goal of a gastric fundoplication is to restore the normal function of the gastroesophageal junction by:
- Restoring the oblique angle at which the esophagus enters the stomach, creating a one-way flap valve.
- Increasing the resting pressure of the lower esophageal sphincter to normal levels (the high pressure zone at the end of the esophagus that relaxes when you swallow and then should tighten up afterwards to prevent reflux).
- Preventing shortening of the lower esophageal sphincter as the stomach distends, keeping the valve more competent.
- Repairing the opening in the diaphragm through which the esophagus comes – the diaphragmatic hiatus – which is often enlarged in patients with severe gastroesophageal reflux.
Laparoscopic Partial Fundoplication
For certain patients, we will perform a partial instead of a complete fundoplication, where the stomach is folded only part-way around the lower esophagus. Most often this is performed in patients who have weakened or absent esophageal peristalsis (the force with which the esophagus pushes food or liquid down the esophagus). A properly performed motility study is required to determine whether a partial or complete fundoplication should be performed, and recommendations are made on a case-by-case basis. We have extensive experience with partial fundoplications, and have found them to be very effective.
A hiatal hernia requiring repair
Improving Our Laparoscopic Fundoplication Results
We are continually striving to improve our results. We found that, when patients had a mechanical breakdown of the procedure, the hiatal hernia repair was almost always at fault. Since 2007, we have often utilized a biologic patch to reinforce hiatal hernia repairs. This patch allows for a patient’s own tissue to grow into the patch as the patch gradually reabsorbs. This increases the overall strength of the repair considerably. No permanent foreign body is left behind.The biologic material is replaced by the patient’s own native tissues to form a stronger bond than sutures alone. Studies have shown this may decrease the risk of breakdown of the hiatal hernia repair, and our experience to date confirms the benefit of this addition.
Hiatal hernia repair performed during Nissen fundoplication
Recovery From Laparoscopic Fundoplication and Hiatal Hernia Surgery
Most patients stay in the hospital overnight, occasionally longer. After surgery you will be given liquids to drink, and you should be up and walking around. You will likely experience some pain either in the upper abdomen or the back/shoulder area, so you will be given pain medication to help control this. Intravenous (IV) fluids, IV pain medications, and anti-nausea medications are given until you are able to take in adequate fluids. Patients are ready for discharge from the hospital when they have adequate oral intake, their pain and/or nausea controlled on oral medications, and are otherwise ready.
Upon discharge from the hospital, you will receive prescriptions for pain medication and anti-nausea medication. You can resume normal, non- strenuous activities of daily living. 50% of patients are able to discontinue narcotic pain medication within 3-4 days of surgery, 90% a week after surgery. You can return to non-manual labor as soon as you feel capable of returning. Generally we recommend 2-3 weeks if feasible to allow time for your body to recover (although some patients have gone back to work much sooner, and others take longer – there is always a lot of variability). Manual labor involving lifting more than 30 pounds and vigorous physical exercise is restricted for a month after surgery. In Colorado, we have many athletic individuals, so light cardio (70% of maximal heart rate, or so that you can carry on a normal conversation while exercising) and light weights that do not stress the diaphragm are permitted.
For a period of time after surgery the esophageal wall becomes swollen, so the consistency of food intake is restricted for 3-4 weeks after surgery. We have a diet progression that we will provide you upon discharge, and which can be found here.
What Are the Risks and Side Effects of Laparoscopic Fundoplication?
Laparoscopic fundoplication is a surgical procedure with inherent risks of bleeding, infection, and injury to internal organs. These risks occur fairly infrequently (6 months after surgery), with about 1 in 10 patients report having to watch how they eat, or having to chew foods thoroughly before swallowing and eating small bites. The newly created valve functions very well at preventing reflux, however this causes difficulty for swallowed air to vent up out of the esophagus. About 30% of patients report increased flatulence, and 1 in 20 may experience some uncomfortable bloating or urgency/looseness to their bowel movements, which may not go away.
How Long Will Laparoscopic Fundoplication Surgery Last?
The laparoscopic Nissen fundoplication was first performed in 1990, and studies evaluating its long-term effectiveness are now available. Most of these studies look at recurrent reflux symptoms, patient satisfaction with the procedure, and the need for restarting medications as indicators of success. A few studies have reported more objective information such as the results of pH testing or barium swallow. These studies indicate that incomplete symptom control develops in 10-20% of patients over 5-10 years of follow-up. Interestingly, only 1 in 4 patients who restart anti-acid medication actually have documented GERD, and the other 3/4 probably do not need the medication. Many of these patients report no perceived benefit to taking the acid-suppressive medication. For this reason, we encourage postoperative patients to come see us if they think they are having recurrent reflux to ensure that treatment is directed towards the correct diagnosis.
What Happens If the Laparoscopic Fundoplication Stops Working?
If GERD recurs after a laparoscopic procedure that worked well initially, medication will be tried first. If medication does not work and the recurrence is due to an identifiable anatomic issue, such as a recurrent hiatal hernia or a loosened fundoplication, then laparoscopic or open revision can frequently be performed with good outcomes.