Various surgical procedures have been developed
since the early reports by Dr. Rudolf Nissen in the mid
50's about the fundoplication that he described for
people with severe gastroesophageal reflux. Surgery was
seen a last resort and when it was first performed was
accompanied by frequent problems with patients unable to
burp or vomit. This could lead to episodes of severe pain
that required insertion of a special tube to decompress
the stomach (naso-gastric tube). This so called "gas
bloat syndrome" was a nuisance and effected the
reputation of this operation. In the 70's and 80's, the
"floppy Nissen" fundoplication was devised that enabled
the patient to burp and vomit. This meant that the
operation was much more acceptable.
In the early 90's, surgery underwent a revolution with
the advent of laparoscopic cholecystectomy (removal of
the gallbladder). As surgeons grew in their facility with
the laparoscopic/videoscopic technique, they began
adapting open operations to the videoscopic mode. One
such operation first performed in Belgium was the
laparoscopic Nissen fundoplication. Pictured above is the
stomach wrapped around the distal esophagus. This
effectively creates a valve that prevents stomach juices
from running back up into the esophagus and burning the
tender lining of the esophagus.
The operation is performed with the patient lying flat
and asleep with a tube in to breathe for the patient. The
videoscope is passed into the abdomen and carbon dioxide
gas inflates the abdomen enabling the surgeon to see.
Four other ports are placed in the upper abdomen through
which the surgeon creates a tunnel behind the esophagus
and through which he pulls the stomach around the
esophagus to create the wrap.
The stomach is sewn in place usually calibrating the
size of the wrap with a dilator that is passed through
the esophagus. If there is a hole in the esophageal
hiatus, this may be closed with sutures placed to make
this hole smaller.
Following the operation, the patient is started on
liquids for a short time and then is advanced to a soft
diet for a couple of weeks. They may then resume a solid
diet. The goal of this operation is to have the patient
off medications for heartburn and allow them to sleep
flat and eat later in the evening.
The risks of this operation include ( but are not
limited to ) esophageal perforation when the dilator is
passed and when the esophageal tunnel is created, splenic
bleeding possibly requiring open splenectomy to correct,
gastric or intestinal perforation, and wrap failure.
For people with severe reflux disease, this operation
offers the opportunity for a return to some normalcy to
their lifestyle. Improvement in hoarseness, breathing,
absence of heartburn and sour reflux, ability to sleep
flat and eat late are all goals of successful
surgery.
Informed Consent: This procedure carries the
usual risk of general anesthesia which varies depending
upon age and other medical conditions that may make
anesthesia more risky ( eg severe lung disease). Those
risks that are particular to this procedure involve
perforation of the GI tract (by an esophageal dilator
during the operation, during the dissection of the
esophagus to perform the wrap, or due to a laparoscopic
instrument perforating a part of the GI tract). During
the dissection of the stomach, the spleen can bleed and
require the operation to be completed in an open rather
than laparoscopic fashion and could mean that the spleen
would need to be removed. The long term consequences of
the operation may include difficulty swallowing,
recurrent reflux, wrap failure, incisonal hernias,
adhesions, and nonspecific discomfort when swallowing.
Finally, as the risk in any major abdominal operation is
always present that the patient could die from the
operation.