Overview of Nissen Fundoplication
Gastroesophageal reflux disease, or GERD, is a common health issue affecting many people today, especially in the United States where it affects about 1 in 5 to 1 in 4 people. GERD can cause a wide range of symptoms. The most common symptoms are heartburn and regurgitation (or feeling like your food is coming back up).
Some people might experience less common symptoms, like chest pain, difficulty swallowing, stomach pain, nausea, and bloating. GERD can even cause symptoms beyond the stomach and esophagus (food pipe), such as a cough, changes in voice, lung-related issues, and narrowing of the windpipe.
There are several treatment options available for GERD. The first line of treatment usually involves changes to your lifestyle and medication. For example, doctors might recommend changes to your diet, quitting smoking, or losing weight. They might also prescribe medications, such as proton pump inhibitors, H2 antagonists, and sucralfate, which help to reduce the amount of acid in your stomach.
If these treatments don’t work or if your GERD is severe, doctors may suggest a type of surgery called laparoscopic anti-reflux surgery (LARS), which can be done to stop the reflux. If you have a hiatal hernia (a condition where part of your stomach pushes through your diaphragm and into your chest), the surgeon might repair this at the same time.
One common type of LARS is called a Nissen fundoplication. This surgery involves wrapping the top part of the stomach around the lower part of the esophagus. This helps increase the pressure at the bottom of the esophagus, which helps to prevent stomach acid from refluxing, or flowing back into the esophagus.
Anatomy and Physiology of Nissen Fundoplication
Understanding anti-reflux surgery requires knowledge of the structure of the upper digestive tract, especially the lower esophageal sphincter and stomach.
The lower esophageal sphincter, the muscle between the esophagus and the stomach, has four components:
1. The muscle of the lower part of the esophagus, which is usually in a tight, contracted state.
2. The sling fibres of the top part of the stomach, which aid in maintaining a high-pressure zone in the lower esophageal sphincter, preventing the flow of stomach acid back into the esophagus.
3. The crura of the diaphragm (a pair of muscles extending from the lower ribs to the backbone), which encompass the esophagus where it goes through the diaphragm.
4. The conjunction of the esophagus and stomach, which should be located within the belly to allow for pressure on the lower esophagus to prevent acid reflux.
The stomach starts at the lower esophageal sphincter and stretches until it becomes the first part of the small intestine, or duodenum. It is divided into five regions: the cardia, fundus, body, antrum, and pylorus. The cardia is just beneath the point where the esophagus and stomach meet, the fundus is next to the left part of the diaphragm, and the pylorus is the part that enters the small intestine. The inner curvature of the stomach is beneath some regions of the liver and transitions to the antrum at a point called the incisura angularis. The outside curvature of the stomach is a long left border that stretches from the fundus to the pylorus, and it is connected to a layer of fatty tissue called the greater omentum. The left edge of the esophagus inside the belly and the fundus meet at a sharp corner known as the angle of His.
The stomach is anchored by several ligaments:
1. The gastrohepatic ligament connects the inner curvature of the stomach to the edge of the liver and contains the left and right gastric arteries.
2. The gastrophrenic ligament, which is without blood vessels, stretches from the fundus to the left part of the diaphragm.
3. The gastrosplenic ligament links the outer curvature of the stomach to the spleen, located in the left upper area of the belly, and contains short gastric vessels.
4. The gastrocolic ligament extends from the lower stomach to the transverse colon, a part of the large intestine, and is considered part of the greater omentum. It contains the gastroepiploic vessels.
Why do People Need Nissen Fundoplication
If you are a candidate for anti-reflux surgery, there are several tests that your doctor may require you to take before the procedure. These tests will help to evaluate your condition and guide the treatment process. Let me explain what they entail:
1. Esophagogastroduodenoscopy is mandatory: This test is used to check for inflammation and the area where your stomach and esophagus join.
2. Ambulatory pH monitoring: This is considered the best test for diagnosing gastroesophageal reflux disease (acid reflux). It’s only done to confirm the diagnosis unless a prior esophagogastroduodenoscopy has shown certain types of inflammation or narrowing that are specific signs of acid reflux.
3. Barium esophagram: This test is used before the surgery to investigate the structure of your esophagus and stomach, including checking for the presence of a hiatal hernia (a condition in which part of your stomach bulges up into your chest) and the length of the part of your esophagus that sits in your abdomen.
4. Esophageal manometry: This test is used to check out how well your esophagus is working, including whether you might have any disorders that affect its ability to move properly. It can help decide which type of procedure should be used. It also measures the resting pressure of the lower esophageal sphincter (the muscle at the lower end of your esophagus that acts like a valve to the stomach).
Laparoscopic Anti-Reflux Surgery (LARS) might be considered for patients who have severe symptoms of acid reflux and also experience one or more of the following conditions: recurrent lung infection or asthma caused by acid reflux; Barrett esophagus (a condition that can lead to cancer); inadequate response to maximal medical therapy; issues with taking medications due to side effects or compliance; or younger patients who do not want to commit to long-term medications because of potential side effects and cost.
The anti-reflux surgery may be conducted either through a traditional (open) approach or by a less invasive (laparoscopic) method. Laparoscopy is often preferred as it often leads to easier recovery and shorter hospital stays. Various specific techniques can be employed in LARS including Dor fundoplication, an anterior 180-degree wrap; Toupe fundoplication, a posterior 270-degree wrap; and Nissen fundoplication, a total posterior 360-degree wrap. Your surgeon will decide the most suitable method based on your specific situation and their preference.
There is ample research comparing the effectiveness of partial to total wraps, but results have been mixed. The consensus is that both methods are comparably effective in relieving symptoms, but with a partial wrap, symptoms may come back more frequently. It’s also important to note that less favorable outcomes have been associated more consistently with an anterior partial wrap, and is therefore considered a less reliable form of repair. There’s no one-size-fits-all approach and the most common anti-reflux surgery performed in the US is the Nissen fundoplication.
When a Person Should Avoid Nissen Fundoplication
Just like other surgeries done through small incisions (laparoscopic surgery), there are certain conditions that make LARS (a surgery to treat serious acid reflux disease) completely impossible:
– If a patient can’t have general anesthesia (medicine that puts you to sleep for surgery), they cannot undergo LARS.
– If a patient has a blood disorder that can’t be corrected and makes it hard to stop bleeding (called uncorrectable coagulopathy), they can’t have this operation.
There are also a few conditions which might not make it entirely impossible, but could make LARS more challenging or riskier. These include:
– If the patient has had surgery in their upper abdomen before (the area around the stomach)
– If the patient is very overweight, with a Body Mass Index (BMI) over 35
– If the patient has a disorder which affects the movement of their esophagus (the tube from the mouth to the stomach)
Interestingly, patients with a BMI over 35 may find a different procedure – gastric bypass surgery, used to treat severe obesity – more suitable for them.
Equipment used for Nissen Fundoplication
The necessary equipment for this type of minimally invasive surgery includes items for inflating the abdomen with CO2 (to make it easier to see and work), drapes (for maintaining a sterile environment), monitors (to view what’s happening inside the patient), laparoscopic instruments (slim tools designed for minimally invasive surgery), and electrocautery (a device using heat to control bleeding).
There are also some tools that are specifically needed for this procedure:
- Four trocars – these are tubes of 5mm to 10mm that allow instruments to be inserted into the patient.
- A liver retractor – this is a tool used to gently move and hold the liver to one side during the surgery.
- A 30-degree angled laparoscope – this is a small tube with a light and camera used to see inside the patient.
- A size 52 to 60 French bougie – this is a long and thin instrument that helps in the placement of structures or devices within the body.
- An endoscope – this is also a small tube with a light and camera, but it’s flexible and often used to view the digestive tract.
- Laparoscopic ultrasonic energy device dissector – a fancy name for a specialized tool that uses sound waves to break down or remove tissue.
Who is needed to perform Nissen Fundoplication?
Before the operation begins, if the doctor doing the surgery is not confident with using an endoscope (a long, flexible tube with a light and camera attached to it, used for viewing the inside of your body), they may bring in a gastroenterologist. A gastroenterologist is another type of doctor who specializes in diagnosing and treating diseases of the digestive system.
The main part of the operation will need a group of healthcare professionals. These include an anesthesiologist (a doctor who gives you the medicine that makes you sleep or numb so you won’t feel the operation), the surgeon (the doctor doing the operation), a scrub nurse (a nurse who assists the surgeon and maintains the sterile field—the area that has been prepared to be germ-free for surgery), and a first assistant (another person who helps the surgeon with the procedure).
Preparing for Nissen Fundoplication
Before the operation begins, the patient will be given antibiotics around 30 minutes ahead to prevent infections, and a treatment to prevent blood clots. The hair on their belly area is also trimmed off beforehand. After the patient has been carefully placed on the operation table, they are put under anesthesia.
An orogastric tube, which is a thin flexible tube, is inserted through the mouth into the stomach to remove air and stomach fluids. The patient is then positioned so that their legs are elevated and spread apart, and their arms are extended. The skin from the chest area to the lower abdomen area is cleaned and prepared for the operation. This is done to eliminate as much bacteria as possible, thus reducing the risk of infection. Finally, a time-out is carried out. This is when the surgical team checks everything before starting to ensure the right patient is having the right procedure.
How is Nissen Fundoplication performed
The Nissen fundoplication, a surgical procedure, can be conducted in various ways, and I’ll explain the steps of one common method.
1. First part is about placing the trocar and getting the area ready for surgery.
The stomach is inflated using a Veress needle to make the surgical region more accessible, and a camera is placed near your belly button to get a clear view inside. Other small instruments are placed through tiny incisions under the rib cage and belly. A tool is used to shift your liver a bit away from the surgical area. After setting the patient in a specific position, the surgeon uses these instruments to perform the surgery while an assistant operates the camera.
2. Second part is about dissecting the left side of the diaphragm and dividing some vessels on the stomach’s curvature.
By moving around the stomach and the surrounding fat, the surgeon can expose a membrane connecting the diaphragm and stomach. This is cut to expose small vessels on the stomach, which are then divided using an ultrasonic tool. The right side of the diaphragm is also dissected evenly to make a space around the esophagus or gullet for the fundoplication.
3. The third part is mobilizing the esophagus.
In simple terms, the surgeon carefully moves the esophagus (tube that transports food to the stomach) for getting enough length of it in the abdomen. This is done with utmost care, ensuring no damage to the nerves around.
4. Crural approximation is next.
The fibers on the right and left sides of the diaphragm are carefully brought together with permanent sutures (stitches) at the back.
5. Preparation for wrap creation is the fifth part.
A marking stitch (a suture used for orientation) is placed on the stomach, and a special tube is inserted down your gullet to guide the next phase of the operation.
6. The sixth phase is creating the wrap.
The upper part of the stomach is guided behind and then around the esophagus to construct a wrap, secured with a few sutures. This creates a valve-like structure to control the reflux of stomach contents.
7. Anchorng the wrap is the next step.
The wrap is then attached to the diaphragm at several spots to ensure it remains secure and in position.
8. The eighth part is the closure.
The surgeon closes the larger cuts in the skin with sutures.
After the surgery, you’ll be able to have a clear liquid diet the same day, then a full liquid diet the day after, and slowly reintroduce soft foods over the following weeks. The objective of the surgery is to prevent acid reflux from the stomach into your esophagus, which can cause discomfort and a burning feeling in your chest or throat.
Possible Complications of Nissen Fundoplication
During surgery called LARS, which stands for laparoscopic anti-reflux (heartburn) surgery, several unlikely complications might happen. For example, there could be a slight chance (less than 2%) of developing a condition called pneumothorax, where air leaks into the space between the lungs and chest wall. This problem could happen if the thin layer of tissue lining the chest cavity (the pleura) gets punctured during surgery – but don’t worry, the lungs won’t get hurt. If the problem is spotted in the operating room, doctors will fix the opening with special medical cords called sutures. If it’s seen later on an X-ray, it can often be managed without invasive treatments, just with oxygen therapy.
Gastric or esophageal perforation (a hole in the stomach or esophagus) can also occur during LARS. This complication is rarer with less than 1% incidence. If the doctors spot this during operation, they mend the hole with sutures. If it is recognized after the surgery, a second surgery might be needed unless the condition is not severe.
The spleen is an organ near the stomach and sometimes it can get inadvertently injured during the surgery but this complication is also rare. In worst cases, if the spleen is severely injured, it might have to be removed.
After the surgery, patients might experience symptoms like feeling of fullness in the stomach, nausea, and the inability to consume liquids. These effects are generally temporary and usually disappear over time. If the symptoms persist and an X-ray shows stomach distention (enlargement), a nasogastric tube may be used to alleviate the symptoms temporarily. Sometimes the patient has difficulty swallowing (dysphagia) after LARS because of the normal swelling at the surgery site. Doctors usually watch the symptom unless it lasts more than a few weeks or prevents the patient from getting enough fluids.
Recurrent symptoms after LARS are fairly rare (less than 10% of patients). If the symptoms continue, doctors will conduct a few more tests to check the acid level in the esophagus and examine the esophagus, stomach, and first part of the small intestine via endoscopy (a tube with a tiny camera). Treatment will be recommended based on these tests, and usually involves medicines to reduce acid reflux. If the symptoms don’t improve, a repeat surgery might be considered.
A slipped wrap is another potential complication which happens due to surgical mishaps. This problem could be avoided by certain measures taken during the surgery. If the slipped wrap happens, it can lead to severe inflammation of the esophagus or stomach, or an ulcer. Diagnosis is made through an X-ray or endoscopy and the treatment usually involves a repeat surgery.
What Else Should I Know About Nissen Fundoplication?
Thanks to advancements in technology, laparoscopy, a surgery technique that uses a small camera to see inside the body, has made anti-reflux procedures a popular way to treat gastroesophageal reflux disease (heartburn). When we talk about anti-reflux procedures, there are three main types, and two of them, called complete and partial posterior wraps, are performed more often.
Among these, the anterior wrap method hasn’t been considered as effective as the other two when it comes to relieving symptoms. Many studies suggest that the Toupe procedure, which is a type of partial posterior wrap that only covers 270 degrees of the esophagus, may be the best option. It seems to be just as effective as the other methods, but with fewer minor side effects after surgery, like bloating and difficulty swallowing.
There’s strong evidence supporting the use of partial wraps for patients who have problems with the movement of their esophagus. Ultimately, since the differences in outcomes are small, most experts recommend that surgeons should use the technique they are most comfortable with.
