Last updated: 02/17/2009

The most common type of gastroesophageal reflux surgery to correct gastroesophageal reflux disease is Nissen fundoplication. Nissen fundoplication is a specific technique that is used to help prevent the reflux of stomach contents back into the esophagus....

When Nissen fundoplication is successful, symptoms and further damage to tissue in the esophagus are significantly reduced. Prior to Nissen fundoplication, open surgery was required to gain access to the lower esophageal region. This approach required a large external incision in the abdomen of the patient.

Fundoplication involves wrapping the upper region of the stomach around the lower esophageal sphincter to increase pressure on the LES. This procedure can be understood by visualizing a bun being wrapped around a hot dog. The wrapped portion is then sewn into place so that the lower part of the esophagus passes through a small hole in the stomach muscle. When the surgeon performs the fundoplication wrap, a large rubber dilator is usually placed inside the esophagus to reduce the likelihood of an overly tight wrap. The goal of this approach is to strengthen the sphincter; to repair a hiatal hernia, if present; and to prevent or significantly reduce acid reflux.

Fundoplication was greatly improved with the development of the laparoscope. The laparoscope is a long thin flexible instrument with a camera and tiny surgical tools on the end. Laparoscopic fundoplication (sometimes called "telescopic" or "keyhole" surgery) is performed under general anesthesia and usually includes the following steps:

• Several small incisions are created in the abdomen.
• The laparoscope is passed into the abdomen through one of the incisions. The other incisions are used to admit instruments to manipulate structures within the abdomen.
• The abdomen is inflated with carbon dioxide. The contents of the abdomen can now be viewed on a video monitor that receives its picture from the laparoscopic camera.
• The stomach is freed from its attachment to the spleen.
• An esophageal dilator is passed through the mouth into the esophagus. This dilator keeps the stomach from being wrapped too tightly around the esophagus.
• The portion of the esophagus in the abdomen is freed of its attachments.
• The top portion of the stomach (the fundus) is passed behind the esophagus, wrapped around it 360°, and sutured in place.
• If a hiatal hernia is present, the hiatus (the hole in the diaphragm through which the esophagus passes) is made smaller with one to three sutures so that it fits around the esophagus snugly. The sutures keep the fundoplication from protruding into the chest cavity.
• The laparoscope and instruments are removed and the incisions are closed.