Nissen fundoplication

Nissen fundoplication is a laparoscopic (keyhole) surgical procedure for the treatment of gastro-oesophageal reflux disease (GERD), the main symptom of which is heartburn. Acid reflux occurs when the acid from the stomach travels back into the oesophagus (food pipe). GERD usually occurs due to weakening of the valve that connects the oesophagus to the stomach - lower oesophageal sphincter.

In this surgery, the top part of the stomach is wrapped around the bottom end of the oesophagus. This method is called a fundoplication. The surgery helps prevent acid reflux by strengthening the lower oesophageal sphincter. 

The doctor may initially recommend medications and lifestyle changes to treat acid reflux. If you do not respond to these measures, Nissen fundoplication may be suggested.

This surgery is performed if you have acid reflux or gastroesophageal reflux disease (GERD). Some of the symptoms of GERD are as follows:

• Heartburn, which is a painful, burning sensation in the middle portion (centre) of the abdomen and chest
• Nausea
• Bad breath
• Vomiting 
• Pain in the upper abdomen 
• Wearing away of teeth 
• Respiratory problems 
• Problem or pain while swallowing Read more: Dysphagia causes

The doctor may not recommend this surgery if you:

• Cannot tolerate general anaesthesia, i.e., if you show any allergic reaction to it
• Have coagulopathy (a condition in which the blood clotting ability is impaired)

The relative contraindications (surgery can be performed, but caution is advised) related to this surgery involve:

• History of abdominal surgery
• Oesophageal motility disorder
• Severe obesity

Before this surgery, you will need the following preparation:

• The doctor will perform a physical examination and take your medical history. The following tests will be done before the surgery:

  • Endoscopy/gastroscopy: This is performed to see inside the stomach and oesophagus and to make sure that your symptoms are not from any other cause.
  • Oesophagus manometry: This procedure checks the pressure of the oesophagus. and helps assess the function of the lower sphincter of the oesophagus.
  • Barium swallow X-ray test: The test helps to diagnose GERD.
  • 24-hour pH study: This helps to check how often the acid reaches the oesophagus.
• You need to abstain from eating or drinking anything after midnight, the night before the surgery.
• You will need to sign a consent form that gives your approval for the procedure.
• Inform your surgeon if you:
  • Take any medicines, including prescribed medicines, minerals, vitamins, supplements, or natural medicines.
  • Are on blood-thinning medicines like aspirin, warfarin, or vitamin E.
  • Are allergic to any medicine or surgical materials like latex, tape, adhesive, skin cleansing solution, or iodine.
• Avoid smoking before the surgery and inform your doctor if you drink more than one or two drinks of alcohol a day.
• You will need to make arrangement for someone to drive you home after the surgery.

Nissen fundoplication involves the following steps:

• The surgeon will give you general anaesthesia to keep you asleep during the surgery. 
• He/she will make five tiny cuts in the upper portion of your abdomen to insert an endoscope (an instrument with a camera) and other surgical tools.
• The surgeon will then pass carbon dioxide gas inside your abdomen to create a space for the operation.
• Once that is done, the surgeon will bring the upper end of your stomach behind the lower end of the oesophagus and wrap it around your oesophagus, bringing it back to the front of the oesophagus from both sides.
• Finally, the surgeon will stitch the wrapped stomach into place and stitch up the cuts on your abdomen.

This surgery takes about 60 to 90 minutes. When the surgeon is not able to perform the surgery with this approach, an open surgery is carried out. Here, a single large cut (instead of multiple small cuts) is made in the abdomen.

After the surgery, you will be moved to the recovery ward, where the nurse will monitor your blood pressure. Initially, you will only be given a liquid diet, which will then be progressed to include soft food. You will be sent home two to three days after the surgery but will have to revisit the hospital in seven to 10 days to remove your stitches.

Once you are home, you will need to take the following care:

• You may need to take painkillers after the surgery. The doctor may also prescribe anti-sickness medicines to help reduce nausea/vomiting.
• The dietary recommendations include the following: 
  • For the initial few weeks, you will be advised to eat soft foods that are easy to swallow. 
  • Avoid eating food that stick to the oesophagus like bread or hard biscuits.
  • Limit the intake of foods that cause irritation or gas in the stomach, e.g., onions, tomatoes, beans, or citrus fruits. 
  • Maintain a gap of two hours between the last meal and time to bed.
  • Eat your food slowly with a relaxed mind. 
  • Drink plenty of fluids along with your meals to moisten the food.
  • Avoid fizzy drinks as you may not feel comfortable while burping for some time after the surgery.
  • Consult your dietician if you need any adjustments to your diet.
• Wound care: 
  • Clean the wound with water and soap, and pat it dry. 
  • Avoid scrubbing or soaking the wound area in water.
• You can take a shower the day after the surgery, but tub baths should be avoided for four to five days.
• You can resume work three to six weeks after surgery. 
• You should avoid strenuous exercises or lifting heavy objects for up to six weeks.
• You can start driving after 10 days of surgery.

This surgery will reduce the problem of long-term acid reflux, which does not get better with healthy lifestyle and medications.

When to see the doctor?

You must inform your healthcare practitioner immediately if you experience the following:

• Severe chest pain or abdominal pain
• Excessive swelling at the surgery site
• Increasing pain 
• Redness 
• Vomiting 
• Fever 
• Bleeding

This surgery has the following possible risks:

• Damage to other abdominal organs 
• Gas bloat (feeling bloated)
• Difficulty in swallowing (long-term)
• Inability to control the acid reflux
• Bleeding 
• Wound infection 
• Lung injury and pneumothorax 
• Heart attack 
• Delay in stomach emptying 
• Blood clots in veins of the lung or leg

A follow-up will be scheduled for six weeks after the surgery.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.