A hiatal hernia occurs when the upper portion of the stomach protrudes through a weakened opening in the diaphragm, known as the hiatus, and into the chest cavity. This anatomical shift can disrupt the natural barrier that prevents stomach contents from flowing backward. Nissen fundoplication is a surgical procedure designed to address this condition and its associated complications. It involves restoring the stomach to its proper position and reinforcing the lower esophageal sphincter, the muscular valve between the esophagus and the stomach, to prevent reflux.
Conditions Treated by Nissen Fundoplication
Nissen fundoplication is considered for individuals with severe gastroesophageal reflux disease (GERD) unresponsive to medical therapies or lifestyle changes. Patients often experience persistent symptoms like frequent heartburn, regurgitation of food or sour liquid, non-cardiac chest pain, and dysphagia (difficulty swallowing). These symptoms indicate a compromised lower esophageal sphincter, allowing stomach acid to irritate the esophageal lining.
Chronic acid reflux can lead to serious esophageal complications, making surgery a consideration. Conditions such as esophagitis (inflammation and damage to the esophageal lining) or Barrett’s esophagus (precancerous changes in esophageal cells) may necessitate surgery to prevent further progression. The procedure also repairs large or symptomatic hiatal hernias, even without severe GERD. For example, a paraesophageal hiatal hernia, where a significant part of the stomach slides into the chest, is a direct indication for this repair.
The Nissen Fundoplication Procedure
Modern Nissen fundoplication is commonly performed using a laparoscopic, or “keyhole,” approach. This minimally invasive technique involves several small incisions, typically four to six, in the abdomen. A laparoscope, a thin tube with a camera, is inserted through one incision, allowing the surgeon to visualize internal organs on a monitor. Specialized surgical instruments are then introduced through other small incisions to perform the operation.
The procedure begins with the surgeon returning the prolapsed portion of the stomach from the chest cavity into the abdominal cavity. The opening in the diaphragm, the hiatus, is then tightened around the esophagus using sutures to prevent the stomach from moving upward again. This step helps to correct the hiatal hernia. The final part of the operation involves the “fundoplication” itself: the upper part of the stomach, called the fundus, is wrapped completely around the lower end of the esophagus. This 360-degree wrap is stitched into place, creating a new, reinforced valve that helps prevent the backward flow of stomach acid and contents.
Life After Surgery
After Nissen fundoplication, patients typically remain in the hospital for one to three days. Pain management is provided during the immediate postoperative period, addressing discomfort around incision sites and temporary shoulder or neck pain from residual gas. A phased dietary progression begins shortly after the procedure.
Patients usually start with clear liquids the day after surgery, avoiding carbonated beverages due to difficulty burping. Over the next four to six weeks, the diet gradually advances from liquids to pureed, then soft, and eventually a more regular diet. During this period, it is important to eat small, frequent meals and chew food thoroughly to prevent discomfort or food getting stuck due to initial swelling. Adhering to these dietary guidelines helps the new wrap heal properly and reduces the risk of complications.
Common side effects include temporary dysphagia (difficulty swallowing) due to swelling around the new wrap, which typically improves over several weeks to three months. Another common side effect is gas bloat syndrome, characterized by bloating, increased flatulence, and a reduced ability to burp or vomit. These symptoms usually diminish as the body adjusts to the altered anatomy, often resolving within the first few months. Medications like simethicone and dietary adjustments can help manage these symptoms during recovery.
Surgical Variations and Alternatives
While Nissen fundoplication involves a complete 360-degree wrap of the stomach around the esophagus, other partial fundoplication techniques exist and are sometimes chosen based on specific patient needs. The Toupet fundoplication is a partial wrap where the fundus is wrapped 270 degrees around the posterior (back) side of the esophagus. This approach may be preferred for patients with pre-existing esophageal motility issues, as it places less tension on the esophagus and can reduce the risk of postoperative side effects such as dysphagia and gas bloat syndrome.
Another partial wrap option is the Dor fundoplication, which involves a 180-degree anterior (front) wrap of the stomach around the esophagus. The Dor fundoplication is often performed in conjunction with other procedures, such as a Heller myotomy for achalasia, where it helps prevent reflux after the esophageal muscle is cut. These variations offer surgeons flexibility in tailoring the procedure to the individual patient, aiming to achieve effective reflux control while minimizing potential complications. The choice of technique considers factors like the severity of GERD, the presence of a hiatal hernia, and the results of preoperative esophageal motility studies.