Frequently asked questions about Laparoscopic fundoplication
Dr. Reju Thomas
MS; MCh (Ped.s); Dip.NB (Surg.); Dip.NB (Ped Srg); FRCS(Edin).
This is a surgical procedure done for Gastro Esophageal Reflux Disease (GERD). In this operation the fundus of the stomach which is on the left of the esophagus and main portion of the stomach is wrapped around the back of the esophagus until it is once again in front of this structure. The portion of the fundus that is now on the right side of the esophagus is sutured to the portion on the left side to keep the wrap in place. The fundoplication resembles a buttoned shirt collar. The collar is the fundus wrap and the neck represents the esophagus imbricated into the wrap. This has the effect of creating a one way valve in the esophagus to allow food to pass into the stomach, but prevent stomach acid from flowing into the esophagus and thus prevent GERD.
Gastro esophageal Refux Disease (GERD) is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a mechanical disorder which is caused by a defective lower esophageal sphincter, a gastric emptying disorder or failed esophageal peristalsis.
Medical therapy is the first line of management. Esophagitis will heal in approximately 90% of cases with intensive medical therapy. However, symptoms recur in more than 80% of cases within one year of drug withdrawal. Since it is a chronic condition, medical therapy involving acid suppression and/or pro-motility agents may be required for the rest of a patient's life. Nissen fundoplication is a safe and effective treatment for GERD when medical management fails. The expense and psychological burden of a life time of medication dependence, undesirable life style changes, uncertainty as to the long term effects of some newer medications, and the potential for persistent mucosal changes despite symptomatic control, all make surgical treatment of GERD an attractive option.
Nissen fundoplication has emerged as the most widely accepted procedure for patients with normal esophageal motility. Two surgical techniques are employed to perform Nissen fundoplication: open surgery or laparoscopic surgery. In open surgery we make a 6- to 10-inch incision in the middle of the abdomen, from just below the ribs to the umbilicus. If the patient has a hiatal hernia, that is repaired first and then the surgeon performs the procedure. In the laparoscopic procedure, we makes five small incisions in the abdomen. A telescope is inserted through one incision. This allows the surgeon to see the interior of the abdominal cavity. The surgical instruments are inserted through the other incisions. The fundoplication is performed in the same fashion as in open surgery.
The operation is ideally suited for the fat patient as the thickness of the tummy wall is immaterial when putting in the telescope and instruments. This is in contrast to an open operation where the fatter patient has a deeper and larger cut causing more bleeding, stitches, and pain.
No. Most surgeons would not recommend laparoscopy in those with pre-existing disease conditions. Patients with cardiac diseases and COPD should not be considered a good candidate for laparoscopy. Laparoscopic fundoplication may also be more difficult in patients who have had previous upper abdominal surgery. The elderly may also be at increased risk for complications with general anaesthesia combined with pneumoperitoneum. Laparoscopy does add to the surgical risk in patients with a lowered cardio-pulmonary reserve with regard to the consequences of the pneumoperitoneum and a longer operative time.
Yes; This problem is quite common in infants and child as well. Most of the time in infants it results due to faulty feeding techniques.
Babies should be kept lying on their stomach with their head propped up about 30 degrees. Lying in this position causes the stomach to fall forward, closing the connection between the stomach and the esophagus. Some infants will not lie in this position without crying, and if the baby cries all the time, they fill up their stomach with air, grunt, and strain, which tends to make their reflux worse. If babies cries in this position then it is much better to lie them down or place them in a seat that reclines a bit than to have them slumped down. Many infants will have less vomiting when they are switched from one type of milk to another or milk. Baby should take small diets. Over-feeding tends to make reflux worse. If these measures are not useful then anti reflux medicine should be tried, prescribed by a paediatrician.
Fortunately, it is extremely rare for children suffering from gastroesophageal reflux to require surgery. Commonly they respond to dietary correction and physiological correction of habits. In children who do require surgery, the most commonly performed operation is called Nissen fundoplication.
Dr. Reju Thomas
MBBS; MS; MCh (Ped.surg); Dip.NB (Gen.Surg.); Dip.NB (Ped Surg); FRCS(Edin).