Laparoscopic fundoplication is a minimally invasive surgical procedure designed to treat gastroesophageal reflux disease (GERD) and certain hiatal hernias. GERD occurs when stomach acid and digestive juices repeatedly flow back into the esophagus, causing symptoms such as heartburn, regurgitation, chest pain, and in severe cases, damage to the esophageal lining. When lifestyle changes and medications fail to control symptoms effectively, fundoplication offers a long-term solution. By reinforcing the valve between the stomach and esophagus, the surgery prevents acid reflux, improves quality of life, and reduces dependence on medications.

Understanding Fundoplication

The procedure involves wrapping the upper part of the stomach, called the fundus, around the lower end of the esophagus. This reinforces the lower esophageal sphincter (LES), which acts as a valve to prevent stomach contents from refluxing into the esophagus. Depending on the technique, the wrap can be complete (360 degrees) or partial.

Nissen fundoplication (360° wrap): The most common form, offering strong reflux control.

Toupet fundoplication (270° posterior wrap): Used when esophageal motility is weak.

Dor fundoplication (180–200° anterior wrap): Sometimes performed along with other procedures such as Heller myotomy.

The choice of technique depends on patient factors, esophageal motility studies, and surgeon expertise.

Indications for Laparoscopic Fundoplication

The surgery is recommended for patients who:

Suffer from chronic GERD unresponsive to lifestyle changes and medication.

Experience esophagitis, strictures, or Barrett’s esophagus due to ongoing acid damage.

Have a hiatal hernia associated with reflux.

Do not wish to continue lifelong proton pump inhibitor (PPI) therapy.

Develop complications such as recurrent aspiration, chronic cough, or asthma triggered by reflux.

Advantages of Laparoscopic Approach

Traditional open fundoplication required a large abdominal or thoracic incision, which was associated with pain, longer recovery, and visible scarring. The laparoscopic approach has transformed this surgery by offering:

Small incisions (5–10 mm) instead of a long cut.

Reduced postoperative pain and faster mobilization.

Shorter hospital stay, often just 1–2 days.

Quicker return to normal activities and work.

Cosmetic benefits due to minimal scarring.

Comparable or better outcomes compared to open surgery.

Surgical Technique
Anesthesia and Positioning

The patient is placed under general anesthesia and positioned in a supine orientation with legs slightly apart (French position). A nasogastric tube may be inserted to decompress the stomach.

Port Placement

Typically, five laparoscopic ports are inserted: one for the laparoscope and others for instruments. Carbon dioxide insufflation creates a pneumoperitoneum, providing space for safe dissection.

Steps of the Procedure

Hiatal dissection: The surgeon carefully dissects around the esophageal hiatus to expose the lower esophagus and stomach.

Reduction of hernia (if present): The stomach and esophagus are repositioned into the abdominal cavity.

Hiatal repair: If the hiatus is enlarged, sutures are placed to tighten the opening and prevent future herniation.

Fundoplication: The gastric fundus is wrapped around the esophagus and sutured in place.

In a Nissen fundoplication, the wrap is complete (360°).

In partial fundoplication, the wrap is tailored according to esophageal function.

Final check: The surgeon ensures that the wrap is secure but not too tight to allow normal swallowing.

The entire surgery usually lasts 1–2 hours.

Postoperative Care

After surgery, patients are monitored closely. Postoperative care includes:

Hospital stay: Usually 24–48 hours.

Diet: Initially liquids, gradually progressing to soft foods, and eventually a normal diet after a few weeks.

Pain management: Mild analgesics are sufficient.

Activity: Walking is encouraged early to reduce the risk of blood clots. Heavy lifting is avoided for 4–6 weeks.

Patients are advised to chew food thoroughly and avoid carbonated beverages in the early recovery period.

Outcomes and Benefits

Laparoscopic fundoplication has high success rates, with 80–90% of patients achieving long-term relief from reflux symptoms. Other benefits include:

Elimination or significant reduction in the need for acid-suppressing medications.

Healing of esophagitis and prevention of further complications.

Improvement in extra-esophageal symptoms like chronic cough, hoarseness, or asthma related to reflux.

Overall improvement in quality of life.

Risks and Complications

While generally safe, potential complications may include:

Dysphagia (difficulty swallowing): Usually temporary, caused by swelling or tight wrap.

Gas-bloat syndrome: Inability to belch or vomit easily, leading to bloating.

Slippage or loosening of the wrap: May require revision surgery.

Injury to nearby structures such as the esophagus, stomach, or spleen (rare).

Careful patient selection, preoperative investigations, and surgical expertise minimize these risks.

Conclusion

Laparoscopic fundoplication is a highly effective and minimally invasive solution for patients suffering from severe GERD or hiatal hernias unresponsive to medical therapy. By reinforcing the natural barrier between the stomach and esophagus, it offers durable symptom control, reduces medication dependence, and prevents reflux-related complications. With its excellent success rates, quicker recovery, and long-term benefits, laparoscopic fundoplication has become the gold standard surgical treatment for GERD, significantly improving patients’ health and quality of life.