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(Laparoscopic
Nissen Fundoplication)
The following patient information are derived from those
provided by the Association
of Endoscopic Surgeons of Great Britain & Ireland,
of which I am a full member.
What is laparoscopic anti-reflux surgery?
Antireflux surgery is performed to correct the reflux
of acid up into the gullet from the stomach. The main
symptom of reflux is heartburn (a burning pain felt under
the breast bone). In the past the only surgical option
was the open method, which involved a large cut in either
the upper part of the abdomen or the chest. This was a
very painful procedure and involved at least 5-7 days
in hospital, plus a long recovery period. The same procedure
is now performed laparoscopically, using what is popularly
known as the keyhole approach. The operation is performed
through 5 small puncture holes instead of through a large
incision, and involves usually only an overnight stay
in hospital though some patients may be discharged home
on the same day.
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What is gastro-oesophageal reflux disease?
As the term implies, gastro-oesophageal reflux disease
is reflux of the stomach contents into the lower part
of the gullet. The majority of the stomach contents are
acid; this acid burns the lower part of the gullet causing
damage. The burning is felt as heartburn, a burning sensation
that radiates through the chest and may radiate up to
the throat and neck. The basic cause of this problem is
the break down of a valve that normally exists between
the stomach and the gullet preventing reflux occurring.
Other symptoms that may occur are acid regurgitation where
acid is felt coming back into the mouth; vomiting, particularly
on stooping and bending; choking attacks, particularly
at night; chronic cough and difficulty in swallowing.
If this acid regurgitation is allowed to continue, it
may cause damage which can lead to narrowing of the gullet
and thus lead to difficulty in swallowing.
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What contributes to causing gastro-oesophageal reflux?
Some people are born with a naturally low sphincter pressure
and reflux from a very early age. In adult life, reflux
may be precipitated by fatty and spicy foods, tight clothing,
smoking, alcohol and being overweight. In pregnancy, reflux
nearly always occurs due to the pressure of the baby pushing
the stomach up and aiding reflux. A hiatus hernia may
also be present. Under these circumstances, a small part
of the stomach has ridden up through the diaphragm into
the chest and this situation tends to lead to reflux.
However, the presence of a hiatus hernia does not necessarily
imply that reflux will occur.
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Medical treatment of reflux
Lifestyle changes:
The most important lifestyle change to improve the symptoms
of reflux is losing weight. If you are overweight, there
is often a critical weight. Below this the symptoms of
reflux will improve dramatically, above it, reflux will
be prominent. Reducing smoking and alcohol consumption
will also be helpful. Changing eating habits will also
improve symptoms. It is important to have regular meals
and to have the last meal several hours before going to
bed.
Drug therapy:
Drug therapy is usually very successful at improving the
symptom of heartburn. Antacids neutralise the stomach
acidity and will relieve relatively mild symptoms. If
these fail then stronger prescription drugs may be necessary.
These are known as proton pump inhibitors. There are several
different types of proton pump inhibitors. These drugs
dramatically reduce the gastric acid shutting it down
to minimal levels. These drugs are usually very effective
at relieving heartburn.
Surgery:
Surgery is required if medical treatment fails to relieve
the symptoms, or, if the medication satisfactorily relieves
the symptoms but as soon as the medication is stopped,
the symptoms recur. Under these circumstances a large
number of patients prefer to go to surgery rather than
take medication for the rest of their lives. This particularly
applies to the younger aged patients. Surgery now is performed
using laparoscopic (key hole) techniques.
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How is laparoscopic anti-reflux surgery performed?
In laparoscopic surgery, we use small incisions, ¼
- ½" long to enter the abdomen through cannulae.
These are small tube like instruments. Through these tubes,
the laparoscope, which is connected to a tiny video camera,
is inserted. This gives the surgeon a magnified view of
the inside of the abdominal cavity. The entire operation
is performed inside, after the abdomen has been expanded
by pumping gas into it. In anti-reflux surgery, the top
part of the stomach is mobilised using special instruments.
This part of the stomach is then passed around the lower
part of the gullet and the stomach is sutured onto itself
to form a very loose wrap of stomach enclosing the lower
part of the gullet. This acts as a valve which prevents
the acid contents of the stomach refluxing back into the
gullet. This operations is called "laparoscopic Nissen
Fundoplication".
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What are the advantages of laparoscopic anti-reflux surgery?
Reduced post operative pain. Following laparoscopic anti-reflux
surgery you should feel abdominal discomfort for 1-2 days
and minimal pain thereafter.
Shorter hospital stay. Your hospital stay should only
involve 1-2 nights.
A faster return to work. Those with sedentary jobs should
be able to resume work within 1-2 weeks and for heavy
manual work, within 3-4 weeks.
Improved cosmetic result. Minimal scarring is present.
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What are the risks of laparoscopic anti-reflux surgery?
The complications of laparoscopic anti-reflux surgery
are considerably less than with open anti-reflux surgery.
However complications may occur as with any operation.
Complications during operation may include anaesthetic
complications, bleeding, injury to the oesophagus, stomach
or very rarely the spleen. Complications after the operation
may include wound infection although this is very rare,
chest problems such as pneumonia.
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What will happen if the operation cannot be completed
laparoscopically?
Should it become unsafe to complete the operation by the
keyhole method due to difficulties with the operation,
we will need to convert to an open operation where a much
larger cut is made. The usual reasons for this occurring
are because it is unsafe to continue with the laparoscopic
approach, usually because the vision is not satisfactory,
or if complications such as bleeding do occur during the
process of the laparoscopic procedure. If you have had
a lot of previous abdominal surgery then adhesions may
well be present in the abdominal cavity which may make
the operation difficult or even impossible. The chance
of conversion to an operation in our hands however is
less than 1 in 50 patients.
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What are the side effects
of this operation?
Longterm side effects are uncommon. The main side effects
that do occur are an increased passage of wind (flatus)
per rectum. This may be a permanent situation. One of
the problems of inserting a valve between the stomach
and the gullet is that air cannot be freely belched out.
This means that the air passes through the intestines
and leads to more air being produced per anum. Another
side effect is that you will not be able to bolt your
food. After laparoscopic anti-reflux surgery it is important
to chew food completely and to eat slowly. Stomach bloating
may also occasionally occur.
On the longterm (10-20 years after surgery), some 1 in
10 patients may have recurrence of some of the reflux
symptoms and require a proton pump inhibitor to decrease
the stomach acidity.
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What tests to expect before deciding upon anti-reflux
surgery?
Before proceeding to anti-reflux surgery, we will need
to carry out a series of tests (unless your physician
has already done so) in order to confirm the diagnosis
of gastro-oesophageal reflux, to assess what damage this
might have caused to the gullet, and to rule out other
possible explanations for your symptoms or complaints.
These tests include:
Endoscopy:
This test involves the passage of a camera through the
mouth and down the gullet to look at the oesophagus and
assess the degree of damage that is being caused by the
acid.
Oesophageal
manometry:
This test determines how your gullet works. It demonstrates
whether the sphincter between your gullet and oesophagus
has broken down and it ensures that your gullet is working
normally (has normal peristalsis).
24-hour
oesophageal pH monitoring:
In this test a fine probe is placed in the lower part
of your gullet so that the amount of acid that flows into
the gullet can be measured over a 24 hour period. This
shows just how much acid refluxes each day.
Ultrasound
of abdomen:
Some patients complain of various symptoms, some of which
may not necessarily be related to acid reflux, and could
possibly be related to gallstones.
An ultrasound of the abdomen can answer this question.
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What to expect prior
to surgery?
Before undergoing surgery you will have your blood checked
to ensure that your blood count and biochemistry are normal.
It is customary also to determine your blood group and
have serum available should blood be necessary. You may
be admitted to hospital the night before the operation
or on the day of the operation itself. The operation is
done under a general anaesthetic. You will not be aware
of the operation being performed.
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What to expect after
surgery?
After the operation, you will recover in a special recovery
area near to Theatre until you are fully awake before
you return to the ward. Although some patients may go
home on the same day as their operation, most patients
stay in hospital for one night and sometimes two. If you
are feeling sick after the operation, which may occur
due to the anaesthetic, you will be given nil by mouth
until the nausea and sickness wears off. Usually you will
be drinking fluids, and perhaps a soup and icecream a
few hours after the surgery and may start on a light diet
on the first post operative day. It is advisable to avoid
bread and fizzy drinks for the first 4-6 weeks. You will
often notice during the first few weeks that food tends
to stick. It is very important during this early post
operative phase to eat slowly and to chew food thoroughly.
It often helps to take some liquid with your food. Immediately
after your operation you will have 5 little patches on
your abdominal wall. These are usually removed at 5 days.
We use either stitches that dissolve and do not need to
be removed, or a special skin glue. You can usually therefore
take a bath at about 5 days. For a few days after the
operation you may need some gentle pain killers. These
should not be necessary after about 5-7 days. Your anti-reflux
medication should stop at the time of the operation and
should not be necessary thereafter. If, when you go home,
you vomit, have severe pain or severe difficulty in swallowing,
you should call your doctor immediately.
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