Nissen Fundoplication

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Nissen fundoplication, also referred to as a Lap Nissen, is a laparoscopic procedure performed for patients with gastroesophageal reflux disease (GERD). Many patients with reflux can be treated with medicines to decrease acid production in the stomach. This will minimize the damage to the esophagus from acid refluxed up from the stomach, and allow the esophagus to heal. However some patients continue to have severe symptoms of either regurgitation or incomplete healing of their esophagus despite high doses of medical therapy. These patients should consider surgery as another option.

The problem lies at the junction of the esophagus and stomach where a muscular value (sphincter) should prevent acid from flowing upwards. If this sphincter mechanism fails, acid is free to reflux up into the esophagus causing damage. Surgery basically augments this lower esophageal sphincter by wrapping a portion of the stomach known as the fundus around the lower esophageal sphincter. If performed properly, this procedure will prevent further reflux with minimal side effects, and eliminate the need for long term medical therapy.

An illustration showing the Nissen Fundoplication procedure.

Prior to undergoing such a procedure the patients require several investigations such as upper endoscopy and a barium swallow x-ray. This is important to assess any narrowing in the esophagus and also to look for any hiatal hernia (a herniation of the junction of the esophagus and stomach through the diaphragm into the chest). A hiatal hernia may exacerbate reflux disease.

Other investigations include esophageal manometry which measures the pressures generated within the esophagus with swallowing. This is performed by passing a small thin catheter through the nose down the esophagus. The catheter measures pressures at various points within the esophagus. The patient is then asked to swallow several small gulps of water which initiate muscle movement within the esophagus known as peristalsis. This should continue down the esophagus in a coordinated fashion and generate adequate pressure to allow the water to pass into the stomach. It also studies the pressures within the lower esophageal sphincter. This is a crucial test pre-operatively because it gives information on both the lower esophageal sphincter tone and esophageal function. Certain conditions within the esophagus can mimic reflux disease but are treated in an entirely different way.

Also, there are variations in the type of anti-reflux or fundoplication procedure performed depending on the esophageal function. Occasionally, a 24 hr. pH monitor is also performed. It involves the passage of a small probe down the nose and into the esophagus which remains in place for 24 hours. This probe measures the number of times that acid refluxes up from the stomach into the esophagus. After 24 hours, this probe is removed and the data analyzed to get an idea of how much acid exposure is actually occurring within the esophagus.

Before the a laparoscopic approach was developed, fundoplication surgery required a large incision in the upper abdomen or the chest [thoracotomy]. These incisions were very painful and resulted in hospital stays up to ten days. The laparoscopic procedure requires placement of two 10mm holes (ports) and three 5mm holes (ports). Ports are placed to allow exposure of the gastroesophageal junction by elevating the liver with a retractor. The stomach is then mobilized and the esophagus is exposed. Some small vessels between the spleen and the stomach are divided to mobilize the upper portion of the stomach known as the fundus which is subsequently used for the fundoplication. The esophagus is mobilized and any scar tissue around the esophagus is divided. The hiatal hernia is reduced back into the abdomen into its proper location. The hiatus (the hole in the diaphragm through which the esophagus passes) is partially closed if a large defect is present. The mobilized fundus of the stomach is then wrapped around the lower portion of the esophagus and sewn in place.

The entire procedure takes two to three hours. Average hospital stay is approximately 2-3 days and patients are generally back to normal activities within two to three weeks. The patients are able to stop all their reflux medications and are able to lie flat in bed, enjoy meals at late hours, etc. which they were not able to do before.