This video demonstrate Nissen fundoplication, also referred to as a Lap Nissen, is a laparoscopic procedure performed for patients with gastroesophageal reflux disease (GERD). Many patients with reflux can be treated with medicines to decrease acid production in the stomach.

Laparoscopic fundoplication is a minimally invasive surgical procedure performed to treat gastroesophageal reflux disease (GERD) and related conditions such as hiatal hernia. It is considered the gold standard surgical treatment for patients with severe reflux symptoms who do not respond adequately to medical therapy or who develop complications from long-term reflux. The procedure involves wrapping the upper part of the stomach (fundus) around the lower end of the esophagus to strengthen the lower esophageal sphincter (LES), thereby preventing acid reflux into the esophagus.

GERD is a chronic disorder in which stomach acid flows back into the esophagus, leading to symptoms such as heartburn, regurgitation, chest discomfort, chronic cough, and difficulty swallowing. While most patients respond to lifestyle modification and medications such as proton pump inhibitors (PPIs), some patients require surgical correction to address the underlying mechanical defect of the LES. Laparoscopic fundoplication provides long-term symptom relief by restoring the barrier function of the LES.

Types of Fundoplication

There are different variations of fundoplication based on the degree of gastric wrap around the esophagus:

1. Nissen Fundoplication (360° wrap) – Most commonly performed procedure.

2. Toupet Fundoplication (270° posterior wrap) – Used in patients with poor esophageal motility.

3. Dor Fundoplication (anterior partial wrap) – Often used in selected clinical conditions.

These variations are chosen based on patient physiology and esophageal motility findings.

Indications

Laparoscopic fundoplication is recommended in the following situations:

• Severe or refractory GERD not responding to medical therapy

• Complications such as esophagitis, Barrett’s esophagus, or strictures

• Patient intolerance or side effects from long-term PPI therapy

• Hiatal hernia associated with reflux

• Objective evidence of reflux on investigations such as pH monitoring

Proper patient selection based on objective testing is essential for successful outcomes.

Preoperative Evaluation

Patients usually undergo:

• Upper GI endoscopy

• Esophageal manometry

• 24-hour pH monitoring

• Barium swallow study

These tests confirm diagnosis and guide surgical planning.

Step-by-Step Surgical Procedure (General Overview)

1. Patient Positioning and Anesthesia – General anesthesia is administered.

2. Port Placement – 4–5 small ports are inserted in the abdomen.

3. Hiatal Dissection – Esophagus is mobilized and crura are exposed.

4. Hiatal Hernia Repair – If present, diaphragmatic crura are approximated.

5. Fundus Mobilization – Short gastric vessels may be divided to mobilize stomach.

6. Creation of Wrap – Fundus is wrapped around distal esophagus (usually 360° in Nissen).

7. Fixation and Calibration – Wrap is created loosely (“floppy”) to prevent dysphagia.

Consensus exists regarding the importance of crural closure and proper wrap calibration for optimal outcomes.

Advantages of Laparoscopic Approach

Compared to open surgery, laparoscopic fundoplication offers:

• Less postoperative pain

• Shorter hospital stay

• Faster recovery

• Lower morbidity

• Better cosmetic results

Most patients return to normal activity within 1–2 weeks.

Outcomes and Success Rate

Laparoscopic fundoplication shows excellent long-term results:

• Good to excellent outcomes reported in 85–95% of patients

• Long-term symptom relief in majority of patients

• Patient satisfaction over 90% in long-term follow-up studies

• Around 80% success even at 20-year follow-up

Recurrence of reflux is relatively low.

Complications

Although generally safe, possible complications include:

• Dysphagia

• Gas-bloat syndrome

• Wrap migration or herniation

• Bleeding or perforation (rare)

• Pneumothorax or infection

Overall complication rate ranges approximately 5–10% in most series.

Postoperative Care

Patients typically:

• Start with liquid diet

• Progress to soft diet

• Return to normal diet in 2–3 weeks

• Resume routine activities gradually

Temporary swallowing difficulty is common but usually improves over weeks.

Conclusion

Laparoscopic fundoplication is a safe, effective, and durable surgical treatment for GERD and related conditions. With proper patient selection, standardized surgical technique, and experienced surgeons, the procedure provides long-term symptom relief and improved quality of life. As minimally invasive surgery continues to evolve, laparoscopic fundoplication remains a cornerstone in the surgical management of reflux disease worldwide.