Fundoplication ‘Anti-Reflux’ Surgery | Hiatal Hernia Repair

Acid reflux is a common condition than affects around 40% of the adult population in Western societies. It is often caused by a range of underlying structural issues, but most commonly a hiatal hernia plays a significant role, as well as a dysfunction lower oesophageal sphyncter.

A hiatal hernia occurs when the upper part of your stomach bulges through the large muscle separating your abdomen and chest (diaphragm).

Your diaphragm has a small opening (hiatus) through which your oesophagus passes before connecting to your stomach. In a hiatal hernia, the stomach pushes up through that opening and into your chest.

A small hiatal hernia usually doesn’t cause problems. You may never know you have one unless your doctor discovers it when checking for another condition.

But a large hiatal hernia can allow food and acid to back-up into your oesophagus, leading to heartburn.

Types of Hiatal Hernia

There are two main types of hiatal hernias: sliding and paraesophageal.

In a sliding hiatal hernia, your stomach and the lower part of your oesophagus slide up into your chest through the diaphragm. Most people with hiatal hernias have this type.

A paraesophageal hernia is more dangerous. Your oesophagus and stomach stay where they should be, but part of your stomach squeezes through the hiatus to sit next to your oesophagus. Your stomach can become squeezed and lose its blood supply.

The broad term used to define the set of conditions that arise from a hiatal hernia is common referred to as Gastro-oesophageal reflux disease (GORD).

What is Acid Reflux (GORD)?

Acid reflux is the result of stomach acid (often combined with bile) refluxing back into the oesophagous and typically causing a sensation known as “heartburn” (lower to mid-chest pain, burping and food regurgitation). Sometimes, patients may also complain of change of voice, swallowing or breathing difficulty, nausea, sore throat, night-time coughing or recurrent chest infection.

This disorder is also called gastro-oesophageal reflux disease (GORD) and is caused by a weakness of the circular lower oesophageal sphincter (LOS). The LOS is normally situated below the diaphragm and acts like a valve preventing stomach content from moving back into the oesophagous. When a hiatal hernia (HH) is present, the LOS is progressively displaced upwards into the chest, as the stomach bulges through a hole in the diaphragm. With time the HH increases in size thus exacerbating reflux symptoms, as the LOS becomes unable to fulfill its role as an anti-reflux flap valve mechanism. Additionally, certain factors such as obesity, pregnancy, smoking, alcohol, or food (chocolate, garlic, caffeine, spicy food, citrus) may impair even further its function thus aggravating GORD.

How is GORD diagnosed?

Clinical symptoms are quite typical of GORD and often no further test are initially required before progressing to treating patients with antacid medications (eg: proton pump inhibitor (PPI), H2 antagonist, etc).

When considering GORD surgery, additional tests are performed to assess the severity of the disease and to discover any possible complications that might arise from surgery.

  • Gastroscopy (“endoscopy”)
  • Barium swallow
  • Oesophageal manometry
  • Abdominal/Chest CT-scan
  • 24 hour pH-testing

How is GORD treated?

  • Most patients can be successfully treated by the combination of dietary and lifestyle measures (stop smoking, decrease caffeine and alcohol intake, weight loss, small meals and no meals within 2 hours from bedtime, raise head of bed) as well as antacid medications.
  • Anti-reflux surgery may become an option when GORD persists or worsen despite adequate conservative measures and optimal antacid medications.

Who needs anti-reflux surgery?

  • Patients with severe symptomatic GORD despite optimal treatment;
  • Patients with large paraoesophageal Hiatal Hernia;
  • Young patients who need lifelong PPI treatment;
  • Non-compliance or serious adverse event associated with PPI;
  • Patient choice.

Laparoscopic (keyhole) fundoplication is the operation of choice where all or part of the stomach is wrapped around the end of the oesophagous and Lower-eosophageal-sphyncter (LOS), and sutured into place.

How is anti-reflux surgery performed?

  1. The procedure is performed under general anasthaesia and the patient stays in hospital 24-48 hours.
  2. Laparoscopic surgery entails five (5) small incisions in the upper part of the abdomen to perform the surgery.
  3. The aim of this procedure is to safely relocate the entire stomach and lower part of the oesophagous (LOS) back into the abdominal cavity, to tighten with sutures the hole in the diaphragm through which the oesophagous passes, and to create an anti-reflux mechanism with the upper part of the stomach (fundus) that is sutured around the lower oesophagous.
  4. The wrap (or fundoplication) can be complete (360o; Nissen fundoplication) or partial (270o Toupet fundoplication, or 180o Dor fundoplication)
  5. Prof Berney’s is an advocate of the Toupet or Dor fundoplication method, as it reduces the risk of post-operative complication. However, when indicated, he will perform a nissen fundoplication.
  6. In the presence of a large paraoesophageal hiatal hernia, the hernia sac is dissected out from the chest and totally excised. Furthermore, the diaphragmatic repair is reinforced with placement of a prosthetic mesh that is fixed with fibrin glue.
  7. Once the repair is satisfactory, a small drain (plastic tube) is left overnight to ensure that no blood collects in the abdomen.
  8. The patient may start drinking only few hours after surgery and will be discharged home on a soft (puree) diet for 1-2 weeks.
  9. Once discharged home, the small waterproof dressings covering the wounds can be safely removed 5 days later and there is no need to remove the stiches as they spontaneously dissolve within few weeks.
  10. Follow-up appointment is made for 2 weeks after surgery.

Differnt types of fundoplication procedures.

About Prof Chris Berney

MB, MD, PhD, FMH, FRACS

Specialist Hernia & Gastrointestinal Surgeon with 30+ Years of Experience.

Prof Berney specialises in advanced laparoscopic (‚Äúkeyhole‚ÄĚ) surgery and is recognised for his considerable surgical research and high case volume in hernia surgery.

Prof Chris Berney completed his medical and surgical training in Switzerland before coming to Australia over 25+ years ago. He has dedicated his professional career to the research and development of many pioneering laparoscopic procedures, such as the use of mesh in hernia surgery, and now has one of the largest series of patients of any surgeons in Australia for this specific approach to hernia repair.

He consults in Hurstville and Bankstown and treats both Private and Public patients.

Learn more here.

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