Since the evolution of Laparoscopic Cholecystectomy, surgery has been revolutionized by the development and popularization of many other advanced laparoscopic procedures.  The invention of many new instruments for the performance of advanced laparoscopic procedures has aided the ability of surgeons to undertake many highly complex operations through the laparoscope with results equal to the open techniques, yet with much more rapid recovery and lower postoperative morbidity.  Laparoscopic Anti-Reflux Surgery is one of these procedures.

This is not a new operation.  Anti-Reflux Surgery has been around with several variations for many years utilizing standard open surgical techniques.   The development of the ability to perform these procedures with the laparoscope has resulted in a more clear definition of indications for surgery and the ability to perform this surgery with lower morbidity and a much more rapid return to normal post-operative function following surgery.

A complete description of Gastroesophageal Reflux Disease, including X-ray and laboratory work-up, indications and contra-indications to surgery is located elsewhere on this site and I encourage those interested to visit that page.  This discussion will be confined to a description of the procedure as well as what to expect during the post-operative period.  Risks and benefits of the procedure will also be discussed.

The patient selected for Laparoscopic Anti-Reflux Surgery will generally be admitted to the hospital the morning of surgery.  The operation requires general anesthesia. A foley catheter and venous compression devices are usually utilized.  Generally 4 or 5, ¾” incisions are made on the abdomen for trocars which allow passage and easy exchange of specialized laparoscopic instruments.  The camera is inserted through the trocar near the umbilicus after the abdomen is insufflated with CO2.  Special instruments are used to retract the liver while the esophageal hiatus is dissected and a window created around the esophagus.  The attachments of the stomach to the colon and spleen are divided with cautery or ultrasonic scalpel.   The crura of the diaphragm are then sutured to close any diaphragmatic hernia.  A large diaphragmatic hernia may require placement of a mesh and possible use of relaxing incisions in the diaphragm so that this repair is without tension. 

The anesthesiologist then inserts an esophageal bougie dilator through the patients mouth and down through the esophagus and into the stomach.  This is to assure that the wrap (to be done next) is not too tight.  Finally, the fundus of the stomach, which has now been completely mobilized, is wrapped around the esophageal hiatus in a counter-clockwise fashion.  3 or 4 sutures are placed, the top-most incorporating the wall of the esophagus and the bottom-most, the stomach.  This diminishes the likelihood of the wrap slipping.  The bougie is then removed and a naso-gastric tube inserted. 

Occasionally, a patient is encountered who has a markedly shortened esophagus with the stomach pulled partially into the chest.  Though modifications of this technique exist which allow staplers to be used through the laparoscope for creation of a gastric tube to artificially elongate the esophagus, this frequently requires conversion to an open procedure and may occasionally require thoracotomy for exposure via the chest.

Following surgery the patient is kept without food or water overnight and the naso-gastric tube is kept to suction to avoid distension of the stomach.  The following morning an X-Ray with swallowed contrast is obtained to assure that there is no leak.  The naso-gastric tube may then be removed and the patient is started on a liquid diet.  Generally, patients are sent home on post-op day 2 or 3 on a full liquid diet, which is maintained for 3 or 4 weeks.  Repeat endoscopy is performed at 3 months post-op to determine the state of healing of any esophagitis that was present pre-op, and then at appropriate intervals thereafter.

Finally, a discussion of risks versus benefits of this procedure is in order.  Following laparoscopic anti-reflux surgery 70% to 80% of patients achieve immediate relief of symptoms of esophageal reflux without medications.  The rest may require some medication to obtain complete relief.  Rarely are patients unrelieved of symptoms.  For those patients who have mucosal changes of Barret’s Esophagus the risk of degeneration to esophageal cancer is markedly diminished. 

The most common side effect experienced following this type of surgery is difficulty in belching.  This is particularly true if the wrap is made too tight.  To minimize the risk of this complication the bougie is used as described above to assure that the wrap is not too tight.  Nevertheless, most patients do notice a change in their ability to belch. 

The most feared and dangerous complication of this procedure is esophageal perforation.  This is fortunately very uncommon, however, when it occurs it must be promptly recognized and treated.  It occurs most frequently during dissection of the esophageal hiatus and is usually small.  A small hole will usually heal on its own as long as the patient is not fed.  This is why a contrast study is done prior to feeding the patient.  If a perforation is found, the patient is kept NPO and continued on antibiotics and intravenous fluids for several days until a repeat study shows no leak.  Occasionally, a return to the operating room will be necessary to repair a leak and drain the area. 

Other potential complications include inadvertent entry into the chest cavity during dissection of the diaphragm resulting in a pneumothorax.  This is usually recognized in the operating room since the gas being used to insufflate the abdomen will leak into the chest and result in difficulties with the anesthesia ventilator.  If any such difficulties are encountered during surgery they are easily controlled with placement of a chest tube to allow the gas to escape and the lungs to expand.  The chest tube is then removed a day or two after surgery.  This also is an uncommon complication.

This procedure has been criticized for it’s delayed failure rate.  Early, during the development of this procedure, it was found that a significant percentage of patients had failure of the wrap, that is, the wrap came apart or slipped several years after surgery.  Though many of these patients experienced a return of symptoms some did not, and did not require repeat surgery.  With the present technique of incorporating part of the esophageal wall and stomach wall in the sutures used to hold the wrap the incidence of slippage or wrap failure is much diminished but not completely absent.

I have tried to describe this procedure in some degree of technical detail so the reader may understand the potential complications, how they occur, and how they are avoided.  It should be understood that the vast majority of patients experience immediate, long-term relief with minimal side effects. 

I encourage all interested to E-mail me with any questions or comments.