Nissen fundoplication by laparoscopy




A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. 



For GERD, it is usually performed when medical therapy has failed.



With  a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. 



The Nissen fundoplication is total at 360°, but partial fundoplications known as Thal (270° anterior), Belsey (270° anterior transthoracic), Dor (anterior 180–200°), Lind (300° posterior), and Toupet fundoplications (posterior 270°) are alternative procedures with somewhat different indications and outcomes have been reported.



Fundoplication: the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. 



The esophageal hiatus is also narrowed by sutures to prevent or treat concurrent hiatal hernia.



The Nissen fundoplication is routinely performed laparoscopically. 



When used tin  gastroesophageal reflux symptoms in patients with delayed gastric emptying, it is frequently combined with modification of the pylorus via pyloromyotomy or pyloroplasty.



Prior to fundoplication esophageal manometry should be obtained before surgery to screen for esophageal aperistalsis, as this is an absolute contraindication to the procedure. 



When the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. 



This prevents the reflux of gastric acid.



 While antacids and PPI drug therapy can reduce the effects of reflux acid, 


 surgical treatment has the advantage of eliminating drug side-effects and damaging effects from other components of reflux such as bile or gastric contents.



Nissen fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%.



Studies have shown that after 10 years, 89.5% of patients are still symptom-free.



Nissen fundoplication complications:



Bloat syndrome, dysphagia, dumping syndrome, excessive scarring, vagus nerve injury, rarely, achalasia, and 


it  can also come undone over time in about 5–10% of cases, leading to recurrence of symptoms. 



Postoperative  Nissen  fundoplication irritable bowel syndrome, which lasts for roughly 2 weeks, is possible.



Fundoplication can alter the ability of the stomach to eliminate swallowed air by belching, leading to an accumulation of gas in the stomach or small intestine, the gas bloat syndrome.



Gas bloat syndrome is usually self-limiting within 2 to 4 weeks, but in some it may persist. 



The gas-bloat syndrome may occur in as many as 41% of Nissen patients, whereas the occurrence is less with patients undergoing partial anterior fundoplication.



The accumulated gas may also come from dietary sources or the involuntary swallowing of air.



Persistence of the gas-bloat syndrome requires dietary restrictions, counselling regarding aerophagia, and correction  of 


fundoplication by endoscopic balloon dilatation or revision of  the Nissen fundoplication to a partial fundoplication.



Following fundoplication, vomiting is sometimes impossible or painful.



This complication decreases in the months after surgery.



A trial comparing laparoscopic fundoplication with esomeprazole therapy found similar remission rates after 3 years and a higher rate with esomeprazole after 5 years.


Surgical mortality about 0.2%.

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