Nissen fundoplication (NF) is a surgical procedure used to treat severe gastroesophageal reflux disease (GERD) and hiatal hernias that have not responded adequately to medication or lifestyle changes. This operation aims to reinforce the lower esophageal sphincter, the muscular valve between the esophagus and the stomach, to prevent the backflow of stomach acid. By physically reconstructing this barrier, the procedure provides a long-term solution for patients experiencing chronic heartburn and regurgitation.
Defining “Major” Surgery” and Nissen Fundoplication’s Classification
The medical community considers Nissen fundoplication (NF) a major surgery. Procedures are classified as major based on factors like the need for general anesthesia, entry into a significant body cavity, and a higher risk profile or prolonged recovery. NF meets these criteria because it requires general anesthesia and involves working deep within the abdominal cavity.
Even when performed minimally invasively, the operation involves manipulating and reconstructing internal organs like the stomach and esophagus, placing it firmly in the category of major abdominal surgery. The procedure is complex, requiring specific surgical skill to ensure the new valve functions correctly.
The Surgical Process: Laparoscopic vs. Open Techniques
Today, Nissen fundoplication is most commonly performed using a minimally invasive laparoscopic approach. This method uses four to six small incisions, or port sites, through the abdominal wall for specialized instruments and a camera. The abdomen is inflated with carbon dioxide gas (insufflation) to create a working space and allow the surgeon a clear view of the internal organs.
The key surgical step involves mobilizing the upper part of the stomach, called the fundus. The surgeon then wraps the fundus fully around the lower end of the esophagus. This creates a 360-degree cuff that reinforces the weakened lower esophageal sphincter, forming a new, pressure-dependent valve. The goal is to create a “short floppy” wrap that prevents reflux while still allowing food to pass easily into the stomach.
In cases involving severe scarring or complex anatomical issues, the surgeon may need to convert to a traditional open technique. The open approach requires one larger incision in the abdomen, allowing for direct visualization and manual access. Although less common, the open technique remains necessary when complications prevent the safe completion of the laparoscopic method.
Immediate Post-Operative Care and Recovery Timeline
Hospital Stay and Initial Discomfort
Following laparoscopic NF, patients typically stay in the hospital for one to three days for observation. Immediate discomfort includes soreness around the incision sites and shoulder pain. This shoulder pain is caused by residual carbon dioxide gas irritating the diaphragm, but it resolves as the body absorbs the gas.
Pain is managed using intravenous and oral medications. Patients must stop taking narcotic pain relievers before driving, as these medications impair reaction time and cause drowsiness.
Post-Operative Diet Progression
The most critical component of recovery is the strict post-operative diet progression, which prevents damage to the new wrap. Patients begin with a clear liquid diet on the day of surgery, followed by a full liquid diet for several days. This advances to a soft or pureed diet, which must be maintained for two to six weeks while swelling around the esophagus subsides.
To aid digestion, patients must take small bites, chew food thoroughly, and sit upright for at least 30 minutes after eating. Eating too quickly or failing to chew adequately can cause temporary swallowing difficulties (dysphagia). Patients must also avoid carbonated beverages, as the inability to belch can cause painful abdominal bloating.
Activity Restrictions
Physical activity is restricted to protect the internal repair and avoid increasing pressure on the abdomen. Patients are advised not to lift anything heavier than 10 pounds (4.5 kilograms) for six to eight weeks after the operation. Light activities, such as walking, are encouraged immediately. Strenuous exercise, including jogging or contact sports, is prohibited until the surgeon provides clearance.
Understanding Potential Complications and Long-Term Side Effects
Nissen fundoplication is generally safe and effective, but it carries risks common to any major surgery, such as bleeding, infection, and injury to surrounding organs. The procedure also has unique potential long-term side effects related to the new anatomical configuration.
Gas Bloat Syndrome
This syndrome is characterized by uncomfortable fullness and bloating because the reinforced valve prevents the patient from belching or vomiting. Gas normally released through burping becomes trapped in the stomach, leading to abdominal distension and increased flatulence. Although symptoms often improve over time, they can be persistent.
Dysphagia (Difficulty Swallowing)
Temporary difficulty swallowing is expected due to post-surgical swelling. However, persistent dysphagia can occur if the wrap is constructed too tightly. If swallowing problems continue past the initial recovery phase, further evaluation may be necessary.
Wrap Failure
There is a risk of the fundoplication wrap failing or migrating over time, which can cause the original GERD symptoms to return. This complication may be caused by excessive straining, violent vomiting, or natural tissue stretching. A redo operation may be required to adjust or reconstruct the wrap.