Nissen fundoplication is a surgical procedure for severe gastroesophageal reflux disease (GERD), a condition where stomach acid frequently flows back into the esophagus. This persistent acid exposure causes discomfort and can lead to serious health issues. For those whose symptoms are not controlled by medication or lifestyle changes, surgery may be an option.
What is Nissen Fundoplication?
Nissen fundoplication addresses the anatomical problem causing chronic acid reflux. GERD often occurs when the lower esophageal sphincter (LES), a muscular valve between the esophagus and stomach, weakens or becomes dysfunctional. Normally, this sphincter relaxes to allow food into the stomach, then tightens to prevent stomach contents from flowing back up. When this mechanism fails, acid reflux occurs, causing symptoms like heartburn and regurgitation.
The procedure reinforces this compromised valve. The surgeon takes the upper part of the stomach (fundus) and wraps it 360 degrees around the lower esophagus. This creates a new, tighter valve-like structure, preventing the backward flow of stomach acid. This mechanical barrier helps keep stomach acid contained, alleviating GERD symptoms and reducing esophageal damage.
Why it’s Classified as Major Surgery
Nissen fundoplication is classified as major surgery due to its invasiveness, significant physiological impact, and potential for serious complications. Major surgery typically requires a hospital stay and carries notable risks. Patients undergo general anesthesia, meaning they are unconscious and feel no pain during the operation.
The procedure involves manipulating internal organs within the abdominal cavity, including the stomach, esophagus, and diaphragm. Whether performed through an open incision or minimally invasively, it requires careful dissection and suturing of delicate tissues. This manipulation carries risks, such as injury to the esophagus, stomach, blood vessels, or nearby organs.
Beyond immediate surgical risks, the fundoplication’s physiological changes can lead to significant post-operative adjustments. The tighter valve can alter the body’s ability to manage gas and food passage, potentially causing gas-bloat syndrome or persistent difficulty swallowing. There is also a risk of vagus nerve injury, impacting digestion, or the fundoplication loosening over time, leading to symptom recurrence.
The Surgical Process and Immediate Recovery
Nissen fundoplication is typically performed using either a laparoscopic (keyhole) or open surgical approach, with laparoscopy being more common due to its less invasive nature. In laparoscopic surgery, the surgeon makes several small abdominal incisions, usually four to six. A laparoscope, a thin tube with a camera, is inserted through one incision, providing magnified internal images. Tiny surgical instruments are then inserted through other incisions to perform the procedure.
During the operation, the surgeon mobilizes the upper stomach (fundus) and wraps it 360 degrees around the lower esophagus, securing it with stitches. If a hiatal hernia is present, it is repaired during the same procedure. The surgery usually takes one to three hours.
Immediately after the procedure, patients are monitored as they recover from general anesthesia. Most stay in the hospital for one to three days, though an open approach may require two to five days. Pain is managed with prescribed medications for surgical site discomfort and shoulder pain from laparoscopic gas. Initial dietary restrictions involve a clear liquid diet for a few days, gradually progressing as tolerated. Some patients, especially after open surgery, may have a temporary nasogastric tube to drain digestive fluids during healing.
What to Expect After Surgery
Recovery after Nissen fundoplication involves a gradual return to normal activities and careful dietary progression beyond the hospital stay. After discharge, patients transition through several dietary stages: clear liquids, then pureed or soft foods for weeks, and finally a regular diet. This phased approach allows the esophagus and stomach to heal and adjust. Patients are advised to eat small, frequent meals, chew food thoroughly, and avoid very hot or cold liquids or carbonated beverages for a period.
Activity restrictions prevent strain on the surgical site. Light activity like walking is encouraged within days of surgery. Patients should avoid heavy lifting, strenuous exercise, and activities that significantly increase abdominal pressure for four to six weeks. The exact duration depends on individual recovery and surgeon recommendations. Most people return to their normal lifestyle within two to four weeks, though this varies.
As their bodies adapt to the surgery, patients may experience long-term side effects like gas-bloat syndrome, characterized by abdominal bloating, epigastric pain, and difficulty belching, which can occur because the new valve may prevent swallowed air from escaping. This symptom often improves within weeks but can persist. Difficulty swallowing (dysphagia) is common initially due to swelling and the new structure, usually resolving within two to three months. Inability to vomit is another potential outcome, as the reinforced sphincter can make it difficult to expel stomach contents. Regular follow-up appointments are important to monitor recovery and address persistent issues.