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Name: Laparoscopic Nissen Fundoplication

Description: What is Nissen fundoplication?this is an operation used for The treatment of gastro esophageal reflux. During the fundoplication surgery, the surgeon reproduces the natural barrier between the stomach and the esophagus by wrapping a part of the stomach known as the fundus around the lower esophagus. This reduces the flow of acids from the stomach into the esophagus, and strengthens the valve between the esophagus and stomach. This procedure is often done using laparoscopic surgical technique. It can also be done as (open) surgery.

Indications: Who is a good candidate for the procedure? Surgical candidates are those whose heartburn is not well controlled with medicine, those who are tired of taking medications, and those who are having complications from reflux, including ulcers, strictures, hernias or Barrett’s esophagus.

Preoperative Evaluation: Preparation may include endoscopy, PH monitoring, manometry and blood tests as deemed necessary.

Method: How is the laparoscopic technique performed? A laparoscopic surgical procedure is an alternative to open surgery, in which a large incision must be made. Now, minimally invasive surgery is used to treat GERD. Our surgeons use laparoscopic surgery to make incisions only millimeters in size. Laparoscopic surgery eliminates the need for a long incision. Small incisions are made to accommodate small tubes called "trocars." These create a passageway for small special surgical instruments and a laparoscope. A laparoscope is a fiber-optic instrument that is inserted in the abdominal wall. This device transmits images from within the body to a video monitor, allowing the surgeon to see the operative area on the screen. During the laparoscopic Nissen fundoplication procedure, surgeons use small surgical tools and a laparoscope to recreate the valve that separates the stomach and esophagus.

Benefits: The success rate for the Nissen Fundoplication is 90 to 95 percent for patients who have the typical symptoms of GERD, such as heartburn, regurgitation, or belching. For those whose with less typical symptoms, including hoarseness, asthma and chronic cough, the surgery is about 60 to 70 percent effective at relieving their symptoms.

Risks: The risks of minor complication is 2%. The risk of major complication is less than 1%. Rate of recurrent symptoms is 5%.

Options: Treatment can include lifestyle changes, such as weight reduction, avoiding certain types of food and taking medications to alleviate symptoms. Surgery may be an option when treatment with medications does not completely relieve symptoms. It’s also a good option for patients whose symptoms are well controlled but who don’t want to take medication, and for patients with complications of reflux disease, such as ulcers, strictures or Barrett’s esophagus. Anti-reflux operations (Nissen fundoplication) may help patients who have persistent symptoms despite medical treatment.

Hospitalization: Hospitalization is usually less than 48 hours.

Post Op: The parents are usually started on a liquid diet and gradually advanced to soft foods. The patients are asked to avoid carbonated beverages, drinking with a straw or chewing gum.

Recovery: Most people return to normal activities including physical excercise in one or two weeks The postoperative pain is usually short term. The scars are frequently small and in a few marsh barely noticeable. Sutures are rarely used on the outside of the incisions.

Follow Up: The patients are usually seen, in the office at intervals until deemed asymptomatic and fully recovered.

Additional Resources: References 1. Duranceau A, Jamieson GG. Hiatal Hernia and Gastroesophageal Reflux. In: Sabiston DC Jr, Lyerly HK, eds. Textbook of surgery: the biologic basis of modern surgical practice, 15th ed. Philadelphia. WB Saunders, 1997:767-783 2. Hinder RA, Filipi CJ. Laparoscopic Nissen Fundoplication. In: Cameron, JL ed. Current Surgical Therapy, 5th ed. St. Louis. Mosby, 1995:1063-1069 3. Hinder RA, Filipi CJ, Wetscher G, et al. Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 1994;220:472-481 4. Hinder RA, Libbey JS, Gorecki P, Bammer, T. Antireflux surgery - indications, preoperative evaluation, and outcome. Gastrointest Clin N Am 1999;28:987-1005 5. Castell DO, Brunton SA, Earnest DL, Fogel R, Hinder RA, Liss D, Peters JH, Siegel MM. GERD: Management algorithms for the primary care physician and the specialist. Practical Gastroenterol 1998;4:18-46 6. Glaser, K; Wetscher, GJ; Klingler, A; Klingler, PJ; Eltschka, B; Hollinsky, C; et al. Selection of patients for laparoscopic antireflux surgery. Dig Dis 2000;18:129-137 7. Bammer T, Hinder RA, Klaus A, Klingler PJ. Five to eight year outcome of the first laparoscopic Nissen fundoplications. J Gastrointest Surg 2001;5:42-47 8. Perdikis G, Hinder RA, Lund RJ, Raiser F, Katada N. Laparoscopic Nissen fundoplication: where do we stand? Surg Lap Endosc 1997;7:17-21 9. Carlson MA, Frantzides CT. Complications and results of primary minimally invasive antireflux procedures: a review of 10,735 reported cases. J Am Coll Surg 2001;193:428-39 10 Malhi-Chowla N, Gorecki PJ, Bammer T, Achem SR, Hinder RA, DeVault KR. Dilation after fundoplication: timing, frequency, indications and outcomes. Gastrointest Endosc 2002;55:219-23 11. Klaus A, Hinder RA, DeVault KR, Achem SR. Bowel dysfunction after laparoscopic antireflux surgery: incidence, severity, and clinical course. Am J Med 2003;114:6-9

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