Gastroesophageal reflux disease (GERD), commonly called chronic heartburn, can significantly impair a person's quality of life. Heartburn has nothing to do with the heart; symptoms are caused by stomach acid that backs up (refluxes) into the esophagus, the tube that carries food from the mouth to the stomach. The muscle that separates the stomach and esophagus (called the lower esophageal sphincter, or LES) acts like a one-way valve: it remains closed until swallowing forces it to open and it contracts as soon as the food empties into the stomach. When it does not work properly, stomach acid can reflux into the esophagus and cause the burning sensation of heartburn.
GERD can increase pressure within the abdomen, which may be a factor in the occurrence of hiatal hernias. Approximately 40 percent of people with GERD also have a hiatal hernia. In most cases, a hiatal, or diaphragmatic, hernia occurs when the lower part of the esophagus and a portion of the stomach slide up through the esophageal hiatus, an opening in the diaphragm through which the esophagus passes before it reaches the stomach. In a small percentage of cases, the junction of the esophagus and stomach remains in place, but a portion of the stomach rolls up and through the esophageal hiatus alongside the esophagus.
A person with GERD and a hiatal hernia generally has more severe reflux and symptoms that are difficult to control with medication and lifestyle changes. When lifestyle changes and/or medication fail to relieve symptoms, a surgical procedure called Nissen fundoplication is used to correct the condition.
Nissen Fundoplication Surgical Procedures
Two surgical techniques are employed to perform Nissen fundoplication: open surgery or laparoscopic surgery.
General anesthesia is used to render the patient unconscious. Once the anesthesia has taken effect, the upper abdomen is cleaned with an antiseptic solution to lessen the risk for infection.
In open surgery, the surgeon makes a 6- to 10-inch incision in the middle of the abdomen, from just below the ribs to the umbilicus (belly button). If the patient has a hiatal hernia, that is repaired first. The esophageal hiatus is tightened with a couple of stitches to prevent herniation of the fundoplication and then the surgeon performs the procedure.
The upper portion of the stomach (the fundus), which is on the left side of the esophagus, is pulled behind and wrapped around the lower portion of the esophagus and then sutured to the portion of the stomach that has moved into the fundus's original position. This creates a "valve" that acts like the LES to prevent stomach acid from refluxing into the esophagus.
In the laparoscopic procedure, the surgeon makes five small incisions in the abdomen. A laparoscope, a miniature telescope attached to a video camera, is inserted through one incision. This allows the surgeon to see the interior of the abdominal cavity. The surgical instruments are inserted through the other incisions. If the patient has a hiatal hernia, that is repaired first. The esophageal hiatus is tightened with a couple of stitches to prevent herniation of the fundoplication and then the surgeon performs the procedure. The fundoplication is performed in the same fashion as in open surgery.
Laparoscopic surgery allows for a faster recovery period, less postoperative pain, a shorter hospital stay, and a much smaller scar. Whether or not a patient is eligible for laparoscopy depends on several factors and is made on an individual basis. In some circumstances, open surgery is safer.