(Keyhole surgery to Treat Reflux Disease)

Reflux disease occurs as a consequence of a weak valve between the oesophagus and stomach, which allows excessive backflow of gastric juices (including acid) into the oesophagus where it causes local damage and the symptoms associated with the condition. Keyhole surgery aims to repair this valve back to normal, and restore quality of life the afflicted individuals.

The function of the valve is predominantly dependant on the structural integrity of the lower oesophageal sphincter (LOS). This has to have an adequate length, resting pressure, and be within the abdominal cavity in order to have maximal efficiency. Patients who have proven reflux disease will have some deficiency in these characteristics. Surgery therefore aims to restore these parameters back to normal limits. This most successful operation for this condition is known as a Nissen fundoplication, after the surgeon, Rudolf Nissen who first described it. This was before the era of keyhole surgery, and the operation was done through a large, open incision. Today, the same operation can be performed by keyhole surgery, which re-produces the original operation, but with much all the benefits of minimally invasive surgery.

Laparoscopic Nissen fundoplication (LNF) is the most common, and successful operation for reflux disease. In Exeter we perform this operation in close accordance with the method described by Professor Tom DeMeester MD, (University of Southern California, Los Angeles) one of the world’s leading specialists in anti-reflux surgery.

Small incisions are made in the abdomen (usually two 1cm cuts, three 0.5cm cuts) that allows entry of the operating telescope and instruments. The lower oesophagus, and junction between the oesophagus and stomach, is brought down into the abdomen where it normally belongs. The crura, two muscular pillars which line the opening in the diaphragm that the oesophagus enters the abdomen through are brought together and stitched, to prevent the oesophagus from migrating back into the chest. The upper part of the stomach, called the fundus is then mobilised by releasing its attachments to the spleen, to which it is normally connected via the short gastric vessels. This part of the stomach is then used to make a floppy wrap around the junction between the oesophagus and stomach, the location at which the LOS should normally be. This now acts as a new, efficient barrier to reflux. After the operation, most patients can go home the next day or day after. Symptomatic relief is immediate, but there can be a short-term problem with difficulty in swallowing as the oesophagus gets used to a new working valve to push food through.

The conditions of reflux disease, and hiatal hernia are closely related, and therefore surgery is similar. In many cases of hiatal hernia, the oesophagus itself is shortened (either congenitally, or a consequence of reflux disease). This causes it to migrate into the chest and create problems and the symptoms. The operation therefore may involve lengthening the oesophagus by a gastroplasty, a vertical incision along the left border of the oesophagus, in to the stomach. This creates a neo-oesophagus, as well as extra stomach fundus. The hernia sac is dissected and removed, releasing the oesophagus, which if proven to be short is lengthened. The rest of the procedure is identical to the LNF, and the same incisions are used. Recovery may take a day or so longer if avery large hernia was present.

This operation is specifically for achalasia. The abnormally high pressure LOS is completely weakened by splitting the muscle along its length (lower oesophagus, upper stomach). Left in this state, patients would automatically get reflux disease, so a partial wrap is made to create a new valve as a barrier to reflux. Because most patients with achalasia also have a poorly functioning oesophagus, a full wrap as in a LNF is avoided. Similar incisions to a LNF are made and post–operative recovery is normal two or three days.

Reflux Disease [and other benign oesophageal disease]