Laparoscopic Fundoplication For Gerd
Gastroesophageal reflux disease (GERD) is a chronic digestive disorder caused by the backflow of gastric acid into the esophagus. Patients often present with symptoms such as heartburn, regurgitation, chest discomfort, and sometimes respiratory issues like chronic cough or asthma-like symptoms. While most cases of GERD respond well to lifestyle modification and medications such as proton pump inhibitors (PPIs), a subset of patients with persistent symptoms or complications require surgical intervention. Laparoscopic fundoplication has become the gold standard surgical treatment for GERD, offering durable symptom relief through a minimally invasive approach.
Indications for Laparoscopic Fundoplication
Surgery is considered when:
Symptoms of GERD persist despite optimal medical therapy.
Patients are intolerant to or unwilling to take long-term medications.
Complications such as Barrett’s esophagus, severe esophagitis, or peptic strictures develop.
Extra-esophageal symptoms like chronic cough, aspiration, or laryngitis are linked to reflux.
Large hiatal hernia coexists with GERD.
In well-selected patients, laparoscopic fundoplication not only controls reflux but also improves quality of life significantly.
Principles of Fundoplication
Fundoplication involves reinforcing the lower esophageal sphincter (LES) by wrapping the upper part of the stomach, called the gastric fundus, around the lower esophagus. This creates a valve-like mechanism that prevents acid reflux while allowing food passage into the stomach.
The procedure can be performed in different forms:
Nissen fundoplication (360° wrap) – the most common type, providing complete encirclement of the esophagus.
Toupet fundoplication (270° posterior wrap) – partial wrap used when esophageal motility is weak, reducing the risk of postoperative dysphagia.
Dor fundoplication (anterior wrap) – less commonly performed, often in conjunction with other esophageal surgeries.
Preoperative Evaluation
Before surgery, patients undergo detailed investigations to confirm GERD and assess esophageal function:
Upper GI endoscopy – to evaluate mucosal damage, rule out malignancy, and assess hiatal hernia.
24-hour pH monitoring – to document acid exposure in the esophagus.
Esophageal manometry – to assess esophageal motility and guide the choice between full or partial fundoplication.
Barium swallow study – to evaluate esophageal anatomy and hernia size.
These tests ensure accurate diagnosis and appropriate surgical planning.
Surgical Technique
Anesthesia and Positioning
The procedure is performed under general anesthesia. The patient is positioned in the supine, lithotomy position with reverse Trendelenburg tilt to allow abdominal organs to fall away from the hiatus.
Port Placement
A five-port technique is commonly used: one for the laparoscope at the umbilicus and four additional ports for working instruments.
Key Steps of the Operation
Dissection of the hiatus – The gastrohepatic ligament is divided to expose the esophageal hiatus.
Mobilization of the esophagus – The distal esophagus is freed to ensure adequate intra-abdominal length.
Crural repair – The diaphragmatic crura are approximated with sutures to close the hiatal defect and prevent herniation.
Mobilization of the gastric fundus – Short gastric vessels are divided to create a tension-free wrap.
Fundoplication – Depending on preoperative motility studies, the gastric fundus is wrapped either completely (Nissen) or partially (Toupet/Dor) around the esophagus.
Fixation – Sutures secure the wrap to the esophagus and diaphragm.
The entire procedure usually takes 1–2 hours.
Postoperative Care
Diet – Patients start with liquids, gradually progressing to soft and then normal diet over 2–4 weeks.
Pain control – Minimal, as only small incisions are made.
Hospital stay – Typically 1–2 days.
Return to activity – Most patients resume work within 1–2 weeks.
Patients are advised to eat small, frequent meals initially and avoid carbonated beverages to reduce bloating.
Outcomes and Benefits
Laparoscopic fundoplication offers excellent results when performed by experienced surgeons:
Symptom relief – 85–90% of patients achieve long-term control of reflux symptoms.
Reduced medication dependence – Most patients no longer require daily PPIs.
Improved quality of life – Significant improvement in both physical and emotional well-being.
Correction of hiatal hernia – Prevents recurrence of reflux associated with anatomical defects.
Risks and Complications
While generally safe, the procedure carries some risks:
Dysphagia – Difficulty swallowing may occur temporarily but usually improves.
Gas-bloat syndrome – Patients may have difficulty belching, leading to bloating.
Wrap failure or herniation – Rare, but can cause recurrence of symptoms.
Injury to nearby structures – Rare complications involving the spleen, esophagus, or vagus nerve.
Overall complication rates are low, and with careful technique, outcomes are excellent.
Conclusion
Laparoscopic fundoplication for GERD is a safe and effective surgical option for patients with persistent reflux symptoms or complications unresponsive to medication. By restoring the barrier function of the lower esophageal sphincter, it provides long-lasting relief, reduces dependence on drugs, and significantly improves quality of life. With advancements in minimally invasive techniques, this procedure continues to be the gold standard surgical treatment for GERD, combining efficacy with minimal discomfort and rapid recovery.
Indications for Laparoscopic Fundoplication
Surgery is considered when:
Symptoms of GERD persist despite optimal medical therapy.
Patients are intolerant to or unwilling to take long-term medications.
Complications such as Barrett’s esophagus, severe esophagitis, or peptic strictures develop.
Extra-esophageal symptoms like chronic cough, aspiration, or laryngitis are linked to reflux.
Large hiatal hernia coexists with GERD.
In well-selected patients, laparoscopic fundoplication not only controls reflux but also improves quality of life significantly.
Principles of Fundoplication
Fundoplication involves reinforcing the lower esophageal sphincter (LES) by wrapping the upper part of the stomach, called the gastric fundus, around the lower esophagus. This creates a valve-like mechanism that prevents acid reflux while allowing food passage into the stomach.
The procedure can be performed in different forms:
Nissen fundoplication (360° wrap) – the most common type, providing complete encirclement of the esophagus.
Toupet fundoplication (270° posterior wrap) – partial wrap used when esophageal motility is weak, reducing the risk of postoperative dysphagia.
Dor fundoplication (anterior wrap) – less commonly performed, often in conjunction with other esophageal surgeries.
Preoperative Evaluation
Before surgery, patients undergo detailed investigations to confirm GERD and assess esophageal function:
Upper GI endoscopy – to evaluate mucosal damage, rule out malignancy, and assess hiatal hernia.
24-hour pH monitoring – to document acid exposure in the esophagus.
Esophageal manometry – to assess esophageal motility and guide the choice between full or partial fundoplication.
Barium swallow study – to evaluate esophageal anatomy and hernia size.
These tests ensure accurate diagnosis and appropriate surgical planning.
Surgical Technique
Anesthesia and Positioning
The procedure is performed under general anesthesia. The patient is positioned in the supine, lithotomy position with reverse Trendelenburg tilt to allow abdominal organs to fall away from the hiatus.
Port Placement
A five-port technique is commonly used: one for the laparoscope at the umbilicus and four additional ports for working instruments.
Key Steps of the Operation
Dissection of the hiatus – The gastrohepatic ligament is divided to expose the esophageal hiatus.
Mobilization of the esophagus – The distal esophagus is freed to ensure adequate intra-abdominal length.
Crural repair – The diaphragmatic crura are approximated with sutures to close the hiatal defect and prevent herniation.
Mobilization of the gastric fundus – Short gastric vessels are divided to create a tension-free wrap.
Fundoplication – Depending on preoperative motility studies, the gastric fundus is wrapped either completely (Nissen) or partially (Toupet/Dor) around the esophagus.
Fixation – Sutures secure the wrap to the esophagus and diaphragm.
The entire procedure usually takes 1–2 hours.
Postoperative Care
Diet – Patients start with liquids, gradually progressing to soft and then normal diet over 2–4 weeks.
Pain control – Minimal, as only small incisions are made.
Hospital stay – Typically 1–2 days.
Return to activity – Most patients resume work within 1–2 weeks.
Patients are advised to eat small, frequent meals initially and avoid carbonated beverages to reduce bloating.
Outcomes and Benefits
Laparoscopic fundoplication offers excellent results when performed by experienced surgeons:
Symptom relief – 85–90% of patients achieve long-term control of reflux symptoms.
Reduced medication dependence – Most patients no longer require daily PPIs.
Improved quality of life – Significant improvement in both physical and emotional well-being.
Correction of hiatal hernia – Prevents recurrence of reflux associated with anatomical defects.
Risks and Complications
While generally safe, the procedure carries some risks:
Dysphagia – Difficulty swallowing may occur temporarily but usually improves.
Gas-bloat syndrome – Patients may have difficulty belching, leading to bloating.
Wrap failure or herniation – Rare, but can cause recurrence of symptoms.
Injury to nearby structures – Rare complications involving the spleen, esophagus, or vagus nerve.
Overall complication rates are low, and with careful technique, outcomes are excellent.
Conclusion
Laparoscopic fundoplication for GERD is a safe and effective surgical option for patients with persistent reflux symptoms or complications unresponsive to medication. By restoring the barrier function of the lower esophageal sphincter, it provides long-lasting relief, reduces dependence on drugs, and significantly improves quality of life. With advancements in minimally invasive techniques, this procedure continues to be the gold standard surgical treatment for GERD, combining efficacy with minimal discomfort and rapid recovery.
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