Operation

Reflux—GERD—Heartburn

A surgical rehabilitation with a fundoplication is a very efficient, sustainable and the only causal therapy with closure of the diaphragmatic hernia (= hiatal hernia) and reconstruction of the closure apparatus 4 between the esophagus and Stomach. This technique treats reflux and reflux-associated symptoms equally well and implements the efficient and sustainable treatment of all therapy goals described above.

Indications for the operation—fundoplication are:

  • Incompetent locking mechanism,
  • alkaline gall reflux,
  • young patients with lifelong use of PPIs,
  • higher grade reflux diseases - GERD & nbsp; stage II-IV
  • extraesophageal manifestations
  • Regurgitations
  • large diaphragmatic hernia / upside down stomach
  • Insufficient treatment success (persistence of heartburn) with sufficient dosage or predominance of drug side effects
  • voluminous refluxes
  • Barrett without dysplasia
  • Patient's request

Endoscopic measures have not shown the desired success in long-term follow-up examinations. It has therefore only been able to establish itself as a sensible method over the last few years and still represents the gold standard in the treatment of reflux disease in the case of diaphragmatic hernia (hiatal hernia). - the fundoplication according to Nissen (360 degree cuff) or fundoplication according to & nbsp; Toupet (270 Degree cuff). The great advantage over newer techniques such as the implantation of a magnetic ring (Linxring) or a pacemaker from Medtronik is that only the body's own material is used for reconstruction in fundoplication and, apart from the sutures, foreign material can be completely dispensed with. The laparoscopic fundoplication according to Nissen or Toupet tries to come as close as possible in terms of function to the original state and reconstructs the occluding apparatus in three dimensions.

The technique is a minimally invasive and minimally traumatizing method with a good chance of success for sustainable healing (& gt; 90%) with a very good acceptance and high satisfaction rate. The operation is almost exclusively performed laparoscopically and the diaphragmatic hernia is closed again, a cuff is formed from the upper part of the stomach and placed around the esophagus like a scarf. The length (sphincter augmentation) and the width of the lower esophageal sphincter are reconstructed (3D reconstruction) in order to restore the original as functionally as realistic as possible. Thus the reflux and also the heartburn & nbsp; causal and completely treated 4.

Surgical steps

Under undisturbed general anesthesia, after sterile washing and covering, under antibiotic protection, the navel is entered openly and a pneumoperitoneum is applied. Place the remaining trocars under view. Exposure of the left lobe of the liver, cutting of the small mesh, exposure of the right diaphragmatic limb, blunt dissection of the esophagus, sparing the anterior and posterior branches of the vagus. The transition from the right to the left gastro-epiploic system is now discussed, the great curvature is skeletonized, the left diaphragmatic limb is shown, the preparation of the esophagus is completed, while protecting the anterior and posterior branches of the vagus. The diaphragmatic hernia is closed with a V-Loc suture, non-resorbable, using a continuous suture technique by approximating the diaphragm, then the fundus tip is pulled through from left to right 3. The first suture encompasses the cuff, diaphragm and esophagus, the second and third suture each encompasses the cuff and esophagus. To pex the right part of the cuff, another suture is placed between the cuff and the diaphragm. The corresponding left part is pulled up so that an approximate cuff closure is created. The first suture encompasses the cuff, diaphragm, esophagus, the second and third sutures, analogous to the Nissen fundoplication, both cuff parts and the esophagus 4. The reconstruction can be done easily and without resistance with the thick stomach tube. Removal of all trocars under sight, draining the pneumoperitoneum, fascia sutures, skin sutures, steristrips, dry bandages.

The procedure—the fundoplication—takes place under inpatient conditions under anesthesia and is in the vast majority of cases so well tolerated that the discharge usually takes place on the next day or the day after Operation can be done.

A swallowing disorder after fundoplication, if it occurs at all, is limited in time and can be estimated at around 5%. Sustained swallowing disorders are very rare and, in percentage terms, are significantly lower. In the beginning, care must be taken to eat slowly, to chew well, to bite well and to take small portions several times a day. After a few days/weeks the esophagus has adapted again and can perform its intended task again. Normal eating is then possible again without any problems.

It is essential for sustainable, ideally lifelong success that, within the first 6 weeks after the operation, as far as possible all actions are avoided that negatively influence or disrupt the healing of the fundoplication: All actions that involve pressing and/or pressure increase suddenly or chronically or persistently in the abdominal cavity such as coughing, sneezing, vomiting, tight pressure during bowel movements, lifting and carrying loads of more than 4kg, sport—especially weight training. … But—don't worry—6 weeks after the operation you can go back to your normal routine. You will receive a compilation of the "recommendations for behavior after a fundoplication" for better planning of a suitable appointment for the procedure after our conversation in my ordination, directly after the operation in the hospital or you can download it here (PDF) like to print.

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