Laparoscopic Anti-Reflux Surgery
Anti-reflux surgery or Fundoplication (folding of the stomach) surgery is a procedure to treat gastroesophageal reflux disease (GORD). It is also incorporated in to hiatus hernia operation. GORD occurs when stomach contents reflux and enter the lower end of the oesophagus (LES) due to a relaxed or weakened sphincter or hiatus hernia. GORD is treatable disease and can have serious complications may occur if left untreated.
In most cases GORD is a chronic condition where the stomach contents or acids reflux into the oesophagus. Everybody gets some reflux symptoms from time to time, but can be troublesome if is experienced regularly or is very severe.
The main symptom of GORD is heartburn or indigestion. It is usually felt as a burning pain in the centre of the chest. Other symptoms can include:
- An acid, sour taste in the mouth
- Burning pain in the throat
- Difficulty in eating
- Bloating and belching
- Stomach pains
- Regurgitating food (when food comes out of your stomach and back up your oesophagus)
- Nausea and vomiting
- Vomiting blood
- Dark tarry stools
Symptoms tend to get worse after eating, especially after a large fatty or spicy meal.
Your doctor usually diagnoses based on your medical history alone, but may ask you to undertake the following tests:
- Endoscopy- A thin endoscope with a camera on the end is passed down the oesophagus towards the stomach. It enables doctors to see the inside of your oesophagus on a television monitor.
- Barium x-rays: These are diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract. The patient drinks a liquid that contains barium, which will coat the walls of the oesophagus and stomach. X-rays are then taken, which can then show if there are strictures, ulcers, hiatal hernias, erosions, or other abnormalities.
- Oesophageal manometry: This is a test that measures the function of the lower oesophageal sphincter and the motor function of the oesophagus.
- PH Study or Acidity test: This is done on the inside of the oesophagus by passing a thin wire through your mouth or nose and into your oesophagus. The wire will measure how acidic your oesophagus is and record the results electronically.
- Ambulatory 24 hr PH Probe Study: This study measures the acid that refluxes back up from the stomach. A very thin tube is inserted up through the nostril and then down the throat and oesophagus until it reaches just above the stomach. The tube has a very small probe at the end that will register any acids that are refluxed from the stomach. An x-ray is taken to make sure that the probe has been positioned correctly. The other end of the thin tube is attached to a small computer (small black box) for 12 or 24 hours. During this period, you are given a diary sheet to complete, on which you should record the time of each activity that takes place, basically a running history.
- PH Capsule: This is a new type of pH probe which requires no tube though the nose. It is a sensor that is attached to the lining of the oesophagus, with an endoscope. Often this procedure is carried out at the same time as having an endoscopy (upper GI) performed. The pH sensor sends signals to a portable computer which collects the data about the acid exposure over the usual 24 hrs. There is no removal procedure, the sensor will slowly detach itself from the oesophagus with time and is then passed through a normal stool.
- Impedance Study: Like a standard pH test, but with two probes. One sits in the stomach and the other just above the stomach. The advantage of the dual sensor is that it can detect both acid and alkaline reflux travels. The tube is inserted through the nostril (this can be placed whilst still sedated after an endoscopy), and the other end is attached to a small computer, no bigger than a Walkman.
If non-surgical treatment options (medications) fail to resolve your GORD, your doctor may recommend a anti reflux procedure called laparoscopic fundoplication (Nissen Fundoplication or partial fundoplication). Fundoplication surgery reinforces the lower oesophageal sphincter’s ability to prevent gastroesophageal reflux from occurring. The surgery involves wrapping the top part of the stomach (the fundus) around the lower end of the oesophagus and suturing it in place. Sutures are also placed to narrow the hiatus, the (opening in the diaphragm) that the oesophagus passes through, to prevent or treat concurrent hiatal hernia. Hiatal hernia is a condition that occurs when the upper part of the stomach slides up into the oesophagus.
Anti-reflux surgery can be performed laparoscopically through tiny (Keyhole) incisions in the abdomen as opposed to an “open” approach with a large abdominal incision. A laparoscope is a long, narrow telescope with a light source and video camera at the end. The scope is passed through a tiny incision into the abdomen where images from the camera are projected onto a large high definition monitor for the surgeon to view. The surgical field is very small but appears much larger when viewed through a laparoscope, helping the surgeon perform surgery precisely.
Laparoscopic anti-reflux surgery is performed under general anaesthesia and requires 1-2 nights stay in hospital.
- The surgeon makes a small incision in the upper abdomen and inserts a tube called a port through which the laparoscope is introduced into the abdomen.
- The surgeon introduces carbon dioxide into the abdominal cavity near the belly button to expand the viewing area of the abdomen giving the surgeon a clear view and room to work.
- Additional small incisions (3 or 4) may be made for a variety of surgical instruments to be used during the procedure.
- After the critical structures are identified, the hole in the diaphragm, through which the oesophagus passes, is then tightened with sutures.
- With the images from the laparoscope as a guide, your surgeon wraps the upper part of the stomach, the fundus, around the lower oesophagus to create a valve, suturing it in place.
- The laparoscope and other instruments are removed and the gas released.
- The tiny incisions are closed and covered with small waterproof dressings.
Laparoscopy is much less traumatic to the muscles and soft tissues than the traditional method of surgically opening the abdomen with long incisions (open techniques).