When severe, chronic acid reflux does not improve with medication or lifestyle changes, surgical intervention is often considered. Laparoscopic fundoplication is a minimally invasive surgical procedure to treat severe gastroesophageal reflux disease (GERD). This approach reinforces the natural barrier between the esophagus and the stomach, preventing the backward flow of stomach acid and digestive enzymes. The technique utilizes small incisions and specialized instruments, resulting in less pain and a quicker recovery compared to traditional open surgery. This operation can offer lasting relief for individuals whose quality of life is severely impacted by chronic acid exposure.
Defining the Procedure and Its Goal
The procedure is primarily indicated for patients suffering from chronic GERD, particularly when symptoms persist despite maximum medical therapy. Patients often have an associated hiatal hernia, where part of the stomach pushes up through the diaphragm. GERD involves a malfunctioning lower esophageal sphincter (LES), the muscle ring that acts as a valve between the esophagus and the stomach.
When the LES is weak, stomach contents reflux back into the esophagus, causing damage and symptoms like heartburn. The core goal of fundoplication is to create a new, functional valve mechanism to reinforce this sphincter. This is achieved by taking the upper part of the stomach, the fundus, and wrapping it around the lower end of the esophagus.
The resulting “wrap” increases pressure at the junction, physically preventing reflux. By restoring the function of the LES, the surgery aims to eliminate symptoms, heal any existing esophageal injury, and allow patients to stop taking acid-suppressing medication. Repairing a hiatal hernia, if present, is an integral step that restores the normal anatomical position before the wrap is created.
The Laparoscopic Surgical Steps
Laparoscopic fundoplication is performed using three to five small incisions in the abdomen. This minimally invasive method involves inserting a laparoscope—a thin tube with a camera—and specialized surgical instruments through these ports. The surgeon watches a magnified view of the internal organs on a video monitor while performing the operation.
The first step involves repairing the hiatal hernia by pulling the stomach back down and tightening the opening in the diaphragm. Next, the surgeon mobilizes the fundus of the stomach, freeing it from surrounding attachments to ensure a tension-free wrap. The final step is the fundoplication itself, where the fundus is wrapped around the lower esophagus.
Two main variations exist:
- Nissen fundoplication: This is a complete 360-degree wrap of the fundus around the esophagus.
- Toupet fundoplication: This is a partial 270-degree posterior wrap.
The Nissen wrap provides the tightest barrier against reflux but can sometimes increase the risk of difficulty swallowing (dysphagia) or gas-bloat syndrome. A surgeon may choose the Toupet procedure for patients who have poor esophageal motility or a higher risk of post-operative dysphagia, as the partial wrap allows for a small opening for gas to escape.
Immediate Post-Operative Recovery
Following the laparoscopic procedure, patients typically spend one to three days in the hospital for monitoring. Initial pain management focuses on controlling discomfort at the incision sites and the temporary shoulder pain that can occur from the carbon dioxide gas used during the laparoscopy. Patients are encouraged to begin light activity, such as walking, soon after the surgery to aid recovery and prevent complications.
The immediate recovery requires a staged dietary progression, which is essential for proper healing of the wrap. Patients usually begin with a clear liquid diet for the first day, progressing to a full liquid and then a pureed or soft diet over the first few weeks. This slow progression is necessary because the tissues around the new valve are swollen, making it difficult to swallow solid food.
Temporary side effects are common and include dysphagia (the sensation of food getting stuck) and gas-bloat syndrome (difficulty burping or passing gas). These symptoms arise because the newly tightened LES prevents the normal release of air from the stomach. Patients are advised to eat slowly, chew thoroughly, and avoid carbonated beverages to minimize these issues, which typically resolve within four to six weeks as swelling decreases.
Long-Term Dietary and Lifestyle Adjustments
Maintaining the success of the fundoplication requires patients to adopt permanent changes to their eating habits and lifestyle. Patients must continue to eat slowly and chew their food completely to ensure it passes easily through the reinforced lower esophageal valve. Avoiding carbonated beverages permanently is strongly recommended, as trapped gas can cause painful bloating and put undue pressure on the repair.
Managing body weight is also a significant factor, as excess weight increases pressure within the abdomen, potentially stressing the fundoplication over time. Patients should avoid lying down for at least two to three hours after eating to allow gravity to assist digestion. Ongoing medical follow-up is necessary to monitor the integrity of the repair and ensure sustained symptom relief.