Gastro-esophageal Reflux Disease (GERD)

Nissen Fundoplication surgery is a procedure to treat gastro esophageal reflux disease (GORD). GORD occurs when stomach contents reflux and enter the lower end of the esophagus (LES) due to a relaxed or weakened sphincter. GORD is treatable disease and serious complications may occur if left untreated.

Heartburn is a form of indigestion and the most common symptom when acid from the stomach refluxes into the esophagus (food pipe). It is the sensation of discomfort in your chest. It is usually temporary and if persistent or long standing (2 or 3 times a week) it could be gastro esophageal reflux disease or GORD.

Gastro Esophageal Reflux Disease

Surgical Introduction

If conservative treatment options fail to resolve your GORD, your doctor may recommend a surgical procedure called Nissen Fundoplication. Nissen Fundoplication surgery reinforces the lower esophageal sphincter’s ability to close and helps to prevent gastro esophageal reflux from occurring. The surgery involves wrapping the top part of the stomach, the fundus, around the lower end of the esophagus and suturing it in place. Sutures are also placed to narrow the hiatus, the opening in the diaphragm that the esophagus passes through, to prevent or treat concurrent hiatal hernia. Hiatal hernia is a condition that occurs when the upper part of the stomach slides up into the esophagus.

This surgery can be performed laparoscopically through tiny incisions in the abdomen as opposed to an “open” approach with a large abdominal incision. A laparoscope is a long, narrow telescope with a light source and video camera at the end. The scope is passed through a tiny incision into the abdomen where images from the camera are projected onto a large monitor for the surgeon to view. Laparoscopes have channels inside the scope enabling the surgeon to pass gas in and out to expand the viewing area or to insert tiny surgical instruments for treatment purposes. The surgical instruments used in operative laparoscopy are very small but appear much larger when viewed through a laparoscope.

Surgical Procedure

Nissen Fundoplication is performed as day surgery either in the hospital or outpatient surgery center usually with the patient under general anesthesia.

  • The surgeon uses a needle to inject a harmless gas into the abdominal cavity near the belly button to expand the viewing area of the abdomen giving the surgeon a clear view and room to work.
  • The surgeon makes a small incision in the upper abdomen and inserts a tube called a trocar through which the laparoscope is introduced into the abdomen.
  • Additional small incisions may be made for a variety of surgical instruments to be used during the procedure.
  • With the images from the laparoscope as a guide, your surgeon wraps the upper part of the stomach, the fundus, around the lower esophagus to create a valve, suturing it in place.
  • The hole in the diaphragm through which the esophagus passes is then tightened with sutures.
  • The laparoscope and other instruments are removed and the gas released.
  • The tiny incisions are closed and covered with small bandages.

Laparoscopy is much less traumatic to the muscles and soft tissues than the traditional method of surgically opening the abdomen with long incisions (open techniques).

Post-Operative Guidelines

After surgery, your surgeon will give you guidelines to follow.

Common post-operative guidelines following laparoscopy include the following:

  • You will need someone to drive you home after you are released as the anesthesia may make you feel groggy and tired.
  • Do not remove the dressings over the incisions for the first two days and keep the area clean and dry. No showering or bathing during this time. The incisions usually heal in about 5 days.
  • Your surgeon may give you diet and activity restrictions. It is very important that you follow your surgeon’s instructions for a successful recovery.
  • You may feel soreness around the incision areas. Your surgeon may give you a prescription pain medicine or recommend NSAID’s (non-steroidal anti-inflammatory drugs) for the first few days to keep you comfortable.
  • If the abdomen was distended with gas, you may experience discomfort in the abdomen, chest, or shoulder area for a couple days while the excess gas is being absorbed.
  • Contact your doctor immediately if you have a fever, chills, increased pain, bleeding or fluid leakage from the incisions, chest pain, shortness of breath, leg pain, or dizziness.

Risks & Complications

  • As with any surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.
  • It is important that you are informed of these risks before the surgery takes place.

Most patients do not have complications after Nissen Fundoplication; however complications can occur and depend on which type of surgery your doctor performs as well as the patient’s health status. (i.e. obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to Nissen Fundoplication.

Medical complications include those of the anesthesia and your general wellbeing. Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reaction to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attack, strokes, kidney failure, pneumonia, bladder infections
  • Complications from nerve blocks such as infection or nerve damage
  • Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Because the abdominal muscles are not cut in laparoscopic surgery, the pain and complications associated with abdominal surgery are lessened. However, complications can occur with any surgery. Your surgeon feels that you should be aware of complications that may take place so that your decision to proceed with this operation is taken with all relevant information available to you.

Specific complications for Nissen Fundoplication include:

  • Post-operative fever and infection- Antibiotics given at the time of surgery lessen this risk but symptoms of infection should be reported to your physician and can include: fever, chills, increasing pain, bleeding, and foul smelling drainage.
  • Surgical injury to blood vessels: A rare complication that is usually recognized during surgery and repaired. Rarely, a blood transfusion may be necessary.
  • Surgical injury to stomach or esophagus- Also a rare complication that is usually recognized during surgery and repaired.
  • Swallowing difficulties: If the new valve is too tight, swallowing can be difficult and may require dilation to loosen the valve.
  • Gas embolism: If gas is used to distend the abdominal cavity for better viewing there is a risk of gas embolism or gas bubbles in the bloodstream. This is a serious condition that can impede blood flow to vital organs or cause a blood clot to occur in a blood vessel.
  • Adhesions– Extensive scar tissue formation can form in the surgical area. Rarely adhesions can obstruct the valve opening requiring additional surgery.
  • Conversion to Laparotomy: There are occasions when a laparoscopy cannot be completed successfully without converting to a traditional “open” surgery called a laparotomy. A laparotomy is similar but is done through a larger abdominal incision.
  • Repeat Surgery: Sometimes the new valve weakens or loosens months or years after the surgery causing symptoms again. If symptoms are severe, the surgery may need to be repeated.

Risk factors that can negatively affect adequate healing after surgery include:

  • Poor nutrition
  • Smoking
  • Obesity
  • Age (over 60)
  • Alcoholism
  • Chronic Illness
  • Steroid Use

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