Prof John Windsor

Laparoscopic Fundoplication

There are various alternative approaches to fundoplication for GORD, but the evidence now shows that an anterior partial fundoplication (ADF) is the best overall procedure. The total fundoplication (Nissen) is still commonly performed in some places but it is associated with an increased risk of swallowing problems. The anterior partial fundoplication as a very slight increased risk of recurrent reflux, but this is much easier to treat than the swallowing difficulties.

The laparoscopic APF involves several steps. The first step is to expose the gastro-oesophageal region by inflating the abdomen with carbon dioxide and elevating the left liver. In all there are five small puncture wounds to insert the camera and instruments. Dissection of the region will allow a hiatus hernia to be fixed. The rim of diaphragm (hiatus) is closed by bringing the two sides together behind the oesophagus with a series of stitches. The next step is to sew the side of the upper stomach (medial fundus) to the oesophagus to maintain 2-3 cm of oesophagus in the abdominal cavity. Then the fundus (the floppy upper part of the stomach) is folded in front of the lower oesophagus to and sutured in place. The abdomen is deflated and the small wounds are closed and dressed. (VIDEO)

The laparoscopic Nissen fundoplication is rarely required, but folds the fundus in front and behind the lower oesophagus so that it is fully encircled.

These operations are very safe and complications are rare. The biggest concern is a breakdown of the stitches and failure of the surgery. It is possible to injury adjacent organs and for bleeding, but this should be avoidable. Infection of the small wounds is rare and precautions are taken to reduce the risk of blood clots (DVT). It is not unusual for patients to experience some shoulder discomfort from irritation to the diaphragm.

Patients usually stay in hospital for 24-36 hours and are discharged when they are comfortable and able to drink freely and take a soft diet. It is important to not undertake any strenuous exercise after a fundoplication so as not to disrupt all of the suturing to the diaphragm.

Royal Australasian College of SurgeonsThe University of AucklankMercy Ascotacckuland sages isdeihbpaaasuniversity-society-of-surgeonsssatiap Royal Society Newzealand