General and Gastrointestinal Surgery

Anti-Reflux Surgery

Anti-reflux operations are procedures performed on the stomach that recreate a high pressure area at the junction of the esophagus and stomach. This high pressure prevents the reflux of food and fluid from the stomach into the esophagus. This surgery has been performed successfully since the 1950s.

All the operations performed involve wrapping a part of the stomach (the fundus) around the esophagus to create a partial or complete ring. Since the fundus, the highest and floppiest part of the stomach, is used, this procedure is called a fundoplication. 

Illustrations of after and before antireflux surgery
Illustrations of (A) after anti-reflux surgery and (B) before anti-reflux surgery.

Two basic types of fundoplications are commonly performed through the abdomen:

  • Nissen fundoplication: Full, 360°  wrap
  • Toupet fundoplication: Partial, 270° wrap

The Nissen and Toupet fundoplications can be performed either via a traditional abdominal incision that goes from the breastbone to the belly button, or via laparoscopy, in which five ¼ to ½ inch incisions are made on the abdomen, the abdomen  is insufflated (expanded) with gas (carbon dioxide) and the operation is performed while it is viewed on a television monitor. The major advantage of the laparoscopic approach is that the small incisions result in much less pain, less time in the hospital and less time to reach full recovery, compared to the open approach.  Both approaches have the same results and complications, and in both approaches, the operation on the stomach is the same.  It is our policy to attempt all anti-reflux procedures via the laparoscopic approach.

What actually happens during the operation?

After the abdomen is entered by either laparoscopy or an abdominal incision, the liver is retracted out of the way so that the esophageal hiatus and/or hiatal hernia can be identified. The esophagus is freed from surrounding tissues at the hiatus, so that a space is created behind it. Next, the edges of the esophageal hiatus, the hole in the diaphragm, are freed from tissues. These are then sutured together to tighten up this area so the stomach will not to go into the chest.  If we make it too tight, the patient will have difficulty swallowing, but if we make it too loose, the patient may get reflux. To make it just right, we take measurements.

Next the blood vessels are divided to the fundus of the stomach in preparation for the wrap. The stomach is brought behind the esophagus. In a Nissen wrap, we suture the stomach to the esophagus, and also to itself, with three individual sutures. In a Toupet wrap, the stomach is sutured to the esophagus, but not to itself. The stomach is sutured to the diaphragm.

How do these operations work?

No one knows for sure. Three elements appear important in making the operation work:

  • A zone of high pressure is created partially or completely around the esophagus by wrapping the stomach around the esophagus. As the pressure in the stomach increases, the wrapped stomach pinches off the esophagus preventing regurgitation of liquids, solids and gases into the esophagus.
  • The angulation of the esophagus, produced not only by the stomach being behind it but also by the closing of the opening (the hiatus) in the diaphragm below the esophagus, contributes. This angulation creates a hump over which fluids and solids must go in order to reflux back into the esophagus from the stomach.
  • Fundoplication keeps the esophagus in the abdomen, so that the lower part is exposed to intra-abdominal pressures rather than intra-thoracic pressures. This means that the primary pressure on the lower esophagus is similar to that on the stomach, thereby reducing or eliminating the pressure gradient.

Possible complications 

Reflux Disease