Understanding Laparoscopic Nissen Fundoplication

What Is Laparoscopic Nissen Fundoplication?

The Nissen fundoplication is a surgery performed on the stomach and the esophagus. The stomach is the reservoir for recently consumed food and is located in the abdomen. The esophagus is the swallowing tube that connects the mouth to the stomach, thus it has three locations, the neck, the chest, and the abdomen. The diaphragm, or breathing muscle, separates the chest from the abdomen.


The esophagus passes through the diaphragm at a point called the hiatus. Some people have a "hiatal hernia" where the opening of the diaphragm is big enough to allow the stomach to pass into the chest. Most people who have this do not have symptoms from it. Although the stomach has an important role in the digestion of food, the esophagus is solely a transport structure.


The stomach contains a large amount of acid and has its own protective mechanisms to prevent injury to itself. The esophagus is not equipped to prevent injury from prolonged exposure to acid from the stomach. When acid from the stomach finds its way into the esophagus, it is usually cleared quickly by esophageal contractions. If the acid is not cleared, then the symptoms of heartburn, chest pain, cough, difficulty swallowing, or regurgitation may occur. Eventually these episodes may lead to injury of the esophagus.


These events are collectively known as gastroesophageal reflux disease (GERD). The treatment of GERD starts with life style modification and medications. If patients fail to respond to non-operative treatment or go on to develop severe esophageal injury, then they are offered operative therapy in the form of an antireflux procedure. The Nissen fundoplication is one type of operation used to treat GERD.


Before the widespread use of laparoscopic procedures, the Nissen fundoplication was performed through an incision in the middle of the abdomen, extending from just below the ribs to the umbilicus (belly button). Patients would stay in the hospital between 7-10 days, and recovery at home was between 6-12 weeks. The use of laparoscopy has reduced the in-hospital stay to an average of 3 days. Return to work usually occurs in 3 weeks.


The procedure is performed with the patient under general anesthesia in a modified sitting position. Five small incisions are made in the abdomen. One is used for the laparoscope, the other four are used to retract and manipulate structures in the abdomen. The stomach and the portion of the esophagus in the abdomen are freed from their attachments. The hiatus is tightened with 2-3 sutures to prevent the fundoplication from migrating into the chest.


The fundus (hence the term fundoplication) of the stomach which is on the left of the esophagus and main portion of the stomach is wrapped around the back of the esophagus until it is once again in front of this structure. The portion of the fundus that is now on the right side of the esophagus is sutured to the portion on the left side to keep the wrap in place.


When completed, the fundoplication resembles a buttoned shirt collar. The collar is the fundus wrap and the neck represents the esophagus imbricated into the wrap. This has the effect of creating a one way valve in the esophagus to allow food to pass into the stomach, but prevent stomach acid from flowing into the esophagus and thus prevent GERD.


Many antireflux procedures have been performed laparoscopically at the University of Washington. The majority of these have been Nissen fundoplications. The success as measured by relief of the primary symptoms is greater than 90%. Laparocopic Nissen fundoplication is a safe and effective treatment for GERD when medical management fails.


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The University of Washington Department of Surgery
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