Laparoscopic Fundoplication for GERD

Medically reviewed by Dr Murlidhar Boob, MS, FAIS, DLS, FMAS - Laparoscopic Surgeon & Surgical Gastroenterologist

What it is

Laparoscopic fundoplication is a keyhole operation for long-standing acid reflux, or gastro-oesophageal reflux disease (GERD). The top part of the stomach, called the fundus, is wrapped around the lower end of the food pipe and stitched in place. That wrap recreates a one-way valve at the junction where the oesophagus meets the stomach - the valve that, in a person with reflux, has become slack and stopped doing its job.

There are two versions I commonly perform. A Nissen fundoplication takes the wrap the full way around, 360 degrees. A Toupet fundoplication takes it about 270 degrees, leaving the front of the oesophagus free. The choice is not a matter of preference; it depends on how well your food pipe squeezes, which we measure before surgery. In almost every case a hiatus hernia is repaired at the same sitting, because the two problems travel together far more often than not.

Who needs it

Not everybody with heartburn. Most reflux is managed perfectly well with weight loss, sensible eating and medication, and I say so to a good number of the people who come asking about surgery. The patients who genuinely benefit are these:

• Your symptoms return the moment you stop the tablets, and you are looking at taking a proton pump inhibitor every day for the next twenty or thirty years.
• The tablets are not controlling it despite a proper dose taken properly, and the endoscopy and pH study confirm that acid really is the culprit.
• What troubles you is regurgitation rather than burning - food and fluid coming back up into your throat, especially at night. Acid-suppressing medication reduces the acid, but it does not stop the volume coming up. Surgery does.
• There are complications already - inflammation of the food pipe, an ulcer, narrowing that makes swallowing difficult, bleeding and anaemia, or Barrett’s oesophagus.
• You have a large hiatus hernia, particularly one causing chest discomfort, breathlessness after meals or a feeling of food sticking.
• You cannot take the medication because of side effects, or you simply do not want to be on it for life.
• Chronic cough, hoarseness, sore throat or asthma-like wheeze that has been traced back to reflux - with the caveat that these respond less predictably than heartburn, and we confirm the diagnosis carefully before offering an operation.

“My tablets work. Why would I have surgery at all?” If they work, if you tolerate them, and you are content to keep taking them, you should. I tell patients this honestly. The conversation changes when you are 34 years old and looking at four decades of daily medication, when food is coming back into your mouth at night despite the tablets, or when there is a hernia that medicine cannot fix. Surgery is for the reflux that medicine cannot solve, not for the reflux it already has under control.

Before I agree to operate, I want three things: an upper GI endoscopy, a 24-hour pH study to prove the reflux is real and acid-related, and oesophageal manometry to see how well the food pipe pushes food down. The manometry in particular decides whether you get a full or a partial wrap. Skipping these tests is how people end up with a technically good operation for the wrong problem.

How it is done

The operation is performed through four or five small cuts in the upper abdomen, each about 5 to 10 mm.

Access. Carbon dioxide gas is used to lift the abdominal wall away from the organs, creating room to work. A camera goes in through one port, instruments through the others, and the liver is held gently aside to expose the hiatus - the opening in the diaphragm through which the food pipe passes.

Reducing the hernia. If part of the stomach has slipped up into the chest, it is drawn back down into the abdomen and the hernia sac is dissected away.

Mobilising the oesophagus. The lower food pipe is freed so that a good length of it - at least 2 to 3 cm - sits comfortably below the diaphragm without tension. This step is the one that determines whether the repair lasts. The vagus nerves are identified and protected throughout.

Repairing the diaphragm. The muscular pillars on either side of the hiatus are stitched together behind the oesophagus to narrow the widened gap. In very large hernias a mesh is occasionally added.

Making the wrap. The short vessels between the stomach and the spleen are divided where necessary so the fundus reaches without tension. The fundus is then brought behind the oesophagus and stitched to itself in front of it - the full way around for a Nissen, partly around for a Toupet. A soft tube, or bougie, is passed down the food pipe while the wrap is sewn, so the wrap is calibrated rather than guessed. The finished wrap is anchored so it cannot slip.

Closing. The instruments come out, the gas is released, and the small cuts are closed with absorbable sutures.

Anaesthesia, duration and hospital stay

Fundoplication is done under general anaesthesia. You are fully asleep, breathing is supported by the anaesthetist, and you feel and remember nothing of the procedure.

Most operations take 60 to 120 minutes. A large or long-standing hernia, previous surgery in the upper abdomen, or a revision procedure takes longer, and I would rather take the extra half hour than rush the dissection.

Expect a stay of one to two nights. You are up and walking the same evening. Sips of clear fluid start a few hours after surgery, free liquids the next morning, and you go home once you are drinking comfortably and your pain is controlled with tablets.

Recovery

Day 1. You will be sore where the ports are and, more oddly, in the shoulder tips - that is referred pain from the gas, it is very common, and it goes within a day or two. Walking helps it more than lying still does. Swallowing feels tight. Liquids only.

The first week. Soft, mashed, moist food - dal, khichdi, curd rice, soups, well-cooked vegetables, eggs. Small portions, chewed thoroughly, six times a day rather than three. No bread, no dry chapati, no rice in large mouthfuls, no red meat, no fizzy drinks, no straws. Most people stop needing painkillers by day four or five and are doing light work at home.

Weeks 2 to 4. Food gradually becomes more solid. Desk work is usually possible from the second week; if your job involves lifting, wait longer. Swallowing is still not normal and you may feel food pause for a moment at the lower chest. Bloating and a feeling of not being able to burp are at their most annoying during this period.

By 6 weeks. Almost everyone is eating a normal diet, back at full work, and driving and exercising freely. The tightness at the wrap has settled and the tablets have usually been stopped.

“Will I ever be able to eat normally again?” Yes - but give it time, and be patient with the early weeks. The commonest mistake I see is a patient who feels well at day ten, eats a full chapati and a mouthful of meat, gets a frightening episode of food sticking, and decides the operation has failed. It has not. Follow the diet stages in order, and your swallowing will look after itself.

Why keyhole rather than open surgery

Fundoplication was an open operation for decades, and it can still be done that way if it has to be. Very few patients need that now. Through keyhole surgery:

• The pain is far less, because the upper abdominal muscles are not cut across.
• The stay is one to two nights instead of five to seven.
• The camera gives a magnified, well-lit view right up at the hiatus - a deep, awkward corner that is genuinely easier to see laparoscopically than through an open incision.
• Chest infections and wound infections are less common, which matters most in older patients and in smokers.
• You are back at work in weeks rather than months, and the scars are a few marks rather than a long one.

The results of the repair itself are comparable. What changes is what you go through to get them. Occasionally, because of dense adhesions from earlier surgery or unexpected bleeding, the safest thing is to convert to an open operation - that is a judgement made for your safety, not a failure.

Risks and complications

I would rather you hear these from me beforehand than discover them afterwards.

• Difficulty swallowing in the early weeks - expected, and it settles in the great majority. In a small number it persists and needs an endoscopic dilatation.
• Gas-bloat syndrome - a full, distended feeling and more wind than before, because belching is harder. It usually improves over some months.
• Difficulty belching or vomiting, particularly after a full 360 degree wrap.
• Wrap slippage or herniation into the chest, which can bring the symptoms back and occasionally needs a revision operation.
• Recurrence of reflux over the years, in a minority of patients.
• Vagus nerve injury, which can cause diarrhoea or slow stomach emptying.
• Injury to the oesophagus, stomach or spleen during dissection - uncommon, but serious when it happens.
• Bleeding, port-site infection, or a port-site hernia.
• Conversion to open surgery.
• Clots in the leg veins, which is why you are walked early and given stockings or injections when indicated.
• The usual risks of general anaesthesia, which the anaesthetist will go through with you.

Alternatives

Lifestyle change first, always. Losing weight is the single most effective non-surgical measure there is - reflux and abdominal weight are tightly linked. Smaller meals, no food for three hours before lying down, raising the head end of the bed, cutting down on smoking, alcohol, very spicy and very fatty food. These are not throwaway advice; done properly they settle a lot of reflux.

Medication. Proton pump inhibitors, H2 blockers and alginates control symptoms in most people. Long-term use is safe for the majority, and a reasonable lifelong plan.

Endoscopic procedures. Several endoscopic anti-reflux techniques exist. They suit selected patients, mainly those without a significant hernia, and their long-term durability is less well established than surgery.

Bariatric surgery. If your body weight is the main driver and you are significantly obese, a gastric bypass often treats the reflux and the weight together, and is a better operation than a fundoplication in that situation.

Watchful waiting. Mild, occasional reflux that responds to an antacid does not need an operation, and never will. Our general surgery and gastroenterology team sees a great many people for whom the honest answer is reassurance and a diet plan. If you are still working out whether your symptoms are ordinary heartburn or something more, this is worth reading: when heartburn is not just heartburn. You can also see all the procedures we perform.

What it costs

We have not published a fixed price for laparoscopic fundoplication, because the cost varies more than it does for a routine keyhole operation. What moves the figure is:

• The size and type of hernia, and whether a mesh is needed to reinforce the repair.
• How long the operation takes - a straightforward primary repair and a large para-oesophageal hernia are different operations.
• Whether it is a first operation or a revision of a previous fundoplication.
• The pre-operative tests - endoscopy, 24-hour pH study and manometry are an essential part of the workup and are billed separately.
• Your room category and how many nights you stay.
• Consumables - staplers, energy devices, sutures and mesh.
• Whether another procedure is done at the same sitting, such as gallbladder removal.
• Your insurance or TPA cover, and whether the admission is pre-authorised.

Call us on +91-8668954915 and we will give you a written, itemised estimate for your own case before you commit to anything.

Preparing for your surgery

• Bring all your reports - endoscopy, pH study, manometry, barium swallow, CT if you have had one, and the list of every acid medicine you have tried and for how long.
• Stop smoking, even a few weeks helps your lungs and your healing.
• Blood thinners such as aspirin or clopidogrel need to be discussed well in advance - never stop a heart medicine on your own.
• Tell us about your other conditions - diabetes, blood pressure, heart or lung disease - so the anaesthetist can plan.
• Fasting. Nothing to eat for six hours and nothing to drink for two hours before surgery, or as the anaesthetist instructs.
• Shop for the first two weeks in advance. Dal, curd, soups, khichdi, soft fruit, protein drinks. Come home to a kitchen that is ready for a liquid and soft diet.
• Arrange someone at home for the first week, and do not plan to lift anything heavy for a month.
• Ask your questions before the day of surgery - especially about the diet stages, which is what most people wish they had understood better.

---

If you have been on acid tablets for years and are wondering whether that is simply your life now, it is worth having the question properly examined. The surgical gastroenterology team at Shubham Hi-Tech Hospital and Test Tube Baby Centre, Amravati, will look at your reports, arrange the tests that are actually needed, and tell you plainly whether an operation would help you or whether it would not. Call +91-8668954915 or get in touch here.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.