Nissen Fundoplication

Gastroesophageal Reflux Disease (GERD)

Nissen fundoplication, also referred to as a Lap Nissen, is a laparoscopic procedure performed for patients with gastroesophageal reflux disease (GERD), to aid, support, and tighten the muscular action of the Lower esophageal sphincter (LES). The LES is the muscle that connects the esophagus to the stomach. This muscle remains closed the majority of the time, only opening to let food through to the stomach or to regurgitate stomach gas.

If a person’s LES is weak or damaged, the muscle can lose its ability to close (as with GERD), or its ability to open (as with Achalasia). When the LES fails to close, it allows stomach acid to splash up from the stomach into the esophagus, causing severe acid reflux and heartburn. On the other hand, when the LES fails to open, swallowing food becomes exceedingly difficult. Both of these conditions are very challenging and can only be cured with surgery.

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. Surgery 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 for conditions that could escalate into esophageal constriction, ulcers, or cancer.

Causes of Gastroesophageal Reflux Disease (GERD)

The problem lies at the junction of the esophagus and stomach where a muscular valve (sphincter) should prevent acid from flowing upwards. If this sphincter mechanism fails, acid is free to reflux up into the esophagus causing damage. There are a variety of reasons why the lower esophageal sphincter may weaken, and most of these are preventable.

Conditions that can increase your risk of GERD include:

  • Obesity
  • Bulging of the top of the stomach up into the diaphragm (See Hiatal Hernia)
  • Pregnancy
  • Connective tissue disorders, such as scleroderma
  • Delayed stomach emptying

Factors that can aggravate acid reflux include:

  • Smoking
  • Overeating large meals or eating late at night
  • Eating certain foods (triggers) such as fatty or fried foods
  • Drinking certain beverages, such as alcohol or coffee
  • Taking certain medications, such as aspirin or ibuprofen
Colon Cancer Development

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Symptoms of GERD & Esophageal Inflammation

GERD Symptoms

Common signs and symptoms of GERD (gastroesophageal reflux disease) include:

  • A burning sensation in your chest (heartburn), usually after eating, which might be worse at night
  • Chest pain
  • Difficulty swallowing
  • Regurgitation of food or sour liquid
  • Sensation of a lump in your throat

If you have nighttime acid reflux, you might also experience:

  • Chronic cough
  • Laryngitis
  • New or worsening asthma
  • Disrupted sleep

Over time, chronic inflammation in your esophagus can cause:

Esophageal Stricture
Esophageal Stricture (narrowing of the esophagus). Damage to the lower esophagus from stomach acid causes scar tissue to form. The scar tissue narrows the food pathway, leading to problems with swallowing.
Esophageal Ulcer
Esophageal Ulcer is an open sore in the esophagus. Stomach acid can wear away tissue in the esophagus, causing an open sore to form. An esophageal ulcer can bleed, cause pain and make swallowing difficult.
Barrett's Esophagus
Barrett's Esophagus is precancerous changes to the esophagus. Damage from acid can cause changes in the tissue lining the lower esophagus. These changes are associated with an increased risk of esophageal cancer.
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GERD & Esophageal Inflammation Treatment

As mentioned earlier, some patients, who continue to have severe symptoms of either regurgitation or incomplete healing of their esophagus despite high doses of medical therapy, should consider surgery as another option. Nissen surgery helps prevent reflux by supporting the lower esophagus with the upper stomach.

Pre-Operative Tests:

Prior to undergoing such a procedure the patients require several investigations. Dr. David W. Ford will order as the first, all or some of the following:

  • Upper Endoscopy
  • Barium Swallow X-Ray
  • Esophageal Manometry
  • A 24-hour pH Monitor

The upper endoscopy and a barium swallow x-ray are 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.

The esophageal manometry measures the pressures generated within the esophagus with swallowing. This is performed by passing a small thin catheter through the nose down the esophagus, where pressures at various points within the esophagus are measured. 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.

Occasionally, a 24-hour 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 occurring within the esophagus.

Fundoplication Types

There are alternative partial variations to the Nissen Fundoplication, performed depending on needed anti-reflux esophageal function, and the amount or how far the gastric tissue is surgically wrapped around the LES. They can be performed using Open, Laparoscopic, and Robotically-assisted Laparoscopic Surgical methods.

Nissen fundoplication
The Nissen fundoplication is a total circumferential wrapping and suturing (360°) around the lower esophageal sphincter .
Thal fundoplication
Thal fundoplication only sutures gastric tissue 270° anteriorly around the lower esophageal sphincter.
Belsey fundoplication
Belsey fundoplication only sutures gastric tissue 270° anteriorly and transthoracic.
Dor fundoplication
Dor fundoplication only sutures gastric tissue anterior 180–200°.
Lind fundoplication
Lind fundoplication only sutures gastric tissue 300° posteriorly.
Toupet fundoplication
Toupet fundoplications only suture gastric tissue posteriorly 270°.
Fundoplication Surgery
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Nissen Fundoplication Surgical Methods

Fundoplication is a surgery that consists of folding (plicating) the stomach around the lower esophagus, thereby recreating a lower esophageal acid barrier which can restore the normal function of the gastroesophageal junction. When this procedure is performed, if a patient has a hiatal hernia, it is repaired at the same time. Fundoplications can be performed via Open, Laparoscopic, or using a Robotically-assisted Laparoscopic Surgical System.

Robotically-Assisted Nissen Fundoplication with The Da Vinci® Robotic Surgical System

Surgical robotics for minimally invasive surgery

The da Vinci Surgical System allows Dr. David W. Ford to perform minimally invasive Nissen Fundoplications with clinically supported precision and accuracy. During the robotically assisted fundoplication, Dr. David W. Ford makes two 10mm holes (ports) and three 5mm holes (ports) in the abdomen. A laparoscope (a tube with a tiny video camera) is usually inserted into your abdomen, just under the ribs, through one of the incisions. Dr. David W. Ford who is seated in the operating room operates via the Surgeon Console that controls the Patient Cart’s robotic devices, including various surgical instruments and the camera. The images gathered from the laparoscope’s camera are high-definition 3D, which are sent to a monitor that Dr. David W. Ford uses to guide the surgical system during the fundoplication. If needed, the abdomen can be inflated with a harmless gas (carbon dioxide), which creates space to allow Dr. Ford to view the inside of the body.

The 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 to 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. The average hospital stay is overnight for observation and patients are generally back to normal activities within two to three weeks. The patients can stop all their reflux medications and can lie flat in the bed, enjoy meals at late hours, etc. which they were not able to do before.

Many robotically-assisted surgical systems are FDA approved and in use today. However, many are specially designed for specific organs, procedures, or conditions, such as lung or pulmonary surgeries or knee and other extremity replacement surgeries. The da Vinci Robotic Surgical System is the premier system specialized in Nissen Fundoplications. Dr. David W. Ford is not only an expert board-certified surgeon but also certified in the use of this leading-edge technology.

This robotic platform offers Dr. David W. Ford fully wristed instruments and a 3D high-definition camera with 10x magnification. As a result, the fundoplication can be done with more precision, and complex situations can be fixed with small incisions. Furthermore, the robot doesn’t get tired and Dr. Ford sits during surgery, so there is less surgeon fatigue. For the patient, this translates into quicker recovery, less pain, and fewer complications.

Other benefits of robotic fundoplications include:

  • Access to clear three-dimensional images (unlike laparoscopic surgery’s two-dimensional images) of the inside of the esophagus for more precise surgery.
  • Dr. Ford can easily use stitches to sew tissue around the esophagus.
  • The patient is left with tiny scars rather than one large incision scar.
  • The possibility of much less pain, faster recovery, and quicker return to normal diet and activities after surgery are observed, compared to all other types of esophageal surgery.

Should robotically-assisted surgical laparoscopic surgery be recommended as part of GERD or other GI treatment, Dr. David W. Ford and his team will have the best state-of-the-art technology at their disposal to usher in your recovery.

How The Da Vinci® Robotic Surgical System works

Da Vinci surgical systems are comprised of three components: surgeon console, patient-side cart, and vision cart.

Surgeon Console

Surgeon Console

The surgeon console is where I sit during the procedure, have a crystal-clear 3DHD view of your anatomy, and controls the robotic instruments. Through a few small incisions, the tiny instruments are "wristed" and move like a human hand, but with a far greater range of motion.
Patient Cart

Patient Cart

The patient-side cart is positioned near the patient on the operating table. It is where the instruments used during the operation move in real time in response to your surgeon’s hand movements at the surgeon console.

A camera provides a high-definition, 3D magnified view inside your body. Every hand movement your surgeon makes is translated by the da Vinci system in real time to bend and rotate the instruments with precision.

Vision Cart

Vision Cart

The vision cart makes communication possible between the components of the system possible, and supports the 3D High Definition vision system.

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Robotic-Assisted Surgery

"The da Vinci Surgical System allows me to make smaller incisions, resulting in reduced risk of infection, minimize scarring, reduce pain, and accelerate recovery time, allowing my patients to return to normal activities more quickly."
David W. Ford, MD, FACS
da Vinci Surgical System

Traditional (Open) Nissen Fundoplication

If complications arise with the location or size of lining disruptions in both esophagus or stomach, a complex hiatal hernia is present, or other complications arise, an Open Fundoplication may be used. The most common reasons to convert during surgery to an open operation include signs of cancer, unexpected findings, difficult anatomy, an unexpected tumor that may be invading into surrounding organs.

During an Open Nissen fundoplication, Dr. David W. Ford will make a 20-25 cm incision in the abdomen, and the gastric fundus (upper part) of the stomach is wrapped, or plicated, fully 360° around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus (the hole in the diaphragm through which the esophagus passes) is also narrowed down by sutures to prevent or treat a hiatal hernia, in which the fundus of the stomach slides up through the enlarged esophageal hiatus of the diaphragm.

If one of the partial fundoplication variations is necessary, the fundus may be laid over the top of the esophagus or wrapped around the back of the esophagus, less than 360°. When used to alleviate gastroesophageal reflux symptoms in patients with delayed gastric emptying, it is frequently combined with a modification of the pylorus via pyloromyotomy or pyloroplasty. If necessary, a drain may be placed at the incision site, with a few days in the hospital recovering. Once home, it may take four to six weeks to fully recover.

open nissen fundoplication surgery
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Post-Operative Treatment of Nissen Fundoplication

With open Nissen Fundoplication, the body must heal from the large incision in the abdomen that cuts through tissue and muscle, so recovery in the hospital is usually at a minimum of four to five days. In five to eight weeks, you'll be able to return to some of your normal activities. By comparison, people who have a robotic fundoplication reduce hospital stay to about 1 day, with returned normal eating and bowel movements, and are back to work in 2 weeks with less pain.

As a preventative measure to assist in healing, patients are usually requested to continue acid-reducing medications for one week after surgery, with first clear foods followed by a soft, easy-to-chew and swallow diet. There may be some initial resistance to the passage of food, causing more air to be swallowed, causing episodes of a gas-bloat syndrome, where abdominal distention, nausea, flatulence, and difficulty in belching or vomiting occurs. Also, dysphagia or difficulty swallowing may last for 6 weeks or longer, usually temporary, due to post-surgical swelling at the wrapped site. Patients are encouraged to eat small, frequent meals that are chewed well, and to avoid using straws, gum, caffeine, tobacco alcohol, or carbonation (to reduce air swallow), or eating foods that cause stomach gas or stomach distention, such as corn, beans, peas, onions, broccoli, cauliflower, cabbages, dried fruit, seeds or coarse foods.

Major complications can include:

  • Bleeding
  • Perforation of the esophagus
  • Perforation of the stomach
  • Splenic injury

You may call with any problems, questions, or concerns at 843-797-5151

Prescription Refill Hours:
Monday – Thursday 8:30 AM – 4:30 PM
Friday before 2:00 PM

Please call if you experience any of the following:
  • Temperature greater than 101 degrees
  • Incisions with increasing areas of redness, thick or colored discharge, worsening tenderness
  • Nausea and vomiting or an inability to tolerate anything by mouth
  • Progressively worsening pain

Here’s an outline of what to expect over the first few months as well as how your diet may change permanently:

  • 2 weeks after surgery. Eat soft or liquid foods, including yogurt, soup, and pudding. Only drink beverages like water, milk, and juice — don’t drink soda or carbonated beverages that can increase gas buildup in your stomach.
  • 3 to 4 weeks after surgery. Slowly introduce solid — yet still softened — foods back into your diet. Try pasta, bread, mashed potatoes, peanut butter, and cheese.
  • 1 to 3 months after surgery and beyond. You’ll be able to gradually return to the diet you had before. You may want to stop eating foods that can get stuck in your esophagus, such as steak, chicken, or nuts.

Pain

Pain management efforts are more successful if you take the medication as soon as you start to feel uncomfortable, rather than waiting until the pain is severe. Should you require a refill, please plan ahead, as we do not call in prescriptions after hours. Scheduled medication, such as narcotics, cannot be called in and must be written in-person.
Acetaminophen (Tylenol)
  • 650mg to 1000mg every 6 – 8 hours for first 3 days, scheduled
  • After 3 days, may continue as needed for pain
  • Do not exceed 4000mg in 24 hours
  • Avoid if history of hepatic (liver) impairment, alcohol abuse
Non-Steroidal Anti-Inflammatories (NSAIDs), choose one:
  • Ibuprofen (Advil, Motrin) 400mg by mouth every 6 – 8 hours, as needed
  • Naproxen (Aleve) 440mg by mouth every 12 hours, as needed. Avoid if history of renal (kidney) impairment, or a history of coronary artery disease (CAD), hypertension. Avoid multiple NSAIDs at once (e.g. Ibuprofen + Naproxen)
Narcotics and Opioids
  • Oxycodone, Hydrocodone & combo pills are for severe breakthrough pain ONLY
  • If a combo pill (e.g. Percocet, Lortab, Vicodin, Norco), do NOT take with Tylenol.
  • Do not drive or operate machinery while taking narcotic pain medication.
  • Narcotics can be habit-forming, have addiction potential, and cause constipation, so be careful – and use sparingly.
Tramadol
  • Tramadol (Ultram) is for severe breakthrough pain & often used in place of opioids
  • It is not a true narcotic but can be habit-forming with long-term use.
  • Avoid if history of seizures
Simethicone
  • Simethicone (GasX) 40 to 125 mg every 8 hours as needed for gas pain & bloating
  • Do not exceed 500mg in 24 hours; this is sold over-the-counter

Hygiene

  • You may shower and use soap and water on surgical site incisions, the day after surgery
  • Keep dressing clean and dry for 24 hours, you may replace as needed for drainage
  • Do not swim or soak; no hot tub, pool, beach, lake, etc. for at least 7 days

Constipation

  • Post-operatively & within 2 days, should be having regular, soft bowel movements (BMs)
  • Hydrate & drink plenty of water (8 –10 glasses per day)
  • PEG 3350 (Miralax) 17g by mouth each day for BMs each day

Other alternative recommendations, as needed – Use at least one if have not had a BM for 2 days:

  • Magnesium Hydroxide (Milk of Magnesia) 15 – 30 mL by mouth once a day, as needed
  • Magnesium Citrate 200 – 300 mL by mouth once a day, as needed
  • Docusate (Colace) 100mg by mouth twice a day, as needed

Activity

  • Ambulate and increase activity as tolerated post-operatively
  • Simply walking often improves mentation, decreases pain & bloating, and improves BMs
  • Avoid heavy lifting (greater than 20 pounds) until follow-up after laparoscopic and open surgeries
  • Avoid prolonged straining and strenuous activity until follow-up
  • Wear your abdominal binder after hernia repair
  • Resume all home medication as directed

Wound Care

  • The raised, firm area called a healing ridge is normal, and should resolve over time
  • Remove your dressings/bandages 2 days after surgery, unless told otherwise by Dr. Ford himself
  • You may shower and use soap & water on surgical site incisions, the day after surgery
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