What is a fundoplication?
In this article, one of RefluxUK’s consultant surgeons and a leading specialist in reflux surgery, Mr Paul Super, discusses a range of topics around the traditional anti-reflux surgery - the laparoscopic fundoplication, including the difference between a total and partial fundoplication and why his preference is the Lind fundoplication.
Written by Mr Paul Super
What is a fundoplication?
Patients with reflux often have a loose valve at the top of their stomach called the lower oesophageal sphincter, or LES. When this valve becomes loose, often referred to as a hiatus hernia, it allows contents in the stomach such as food, acid and other irritating components to come up into the food pipe, causing symptoms such as heartburn and regurgitation among many others.
A fundoplication is the term to describe the adaptation of the LES, using a loose area of the top of the stomach called the fundus. In its simplest form, the fundus is wrapped around the bottom of the oesophagus to create a stronger valve. When the LES is tightened there is better prevention of reflux as less stomach contents are able to come back up into the oesophagus.
Fundoplication surgery has been around for 60 years, having been initially established as an open operation (large tummy cut), then adopted by chest surgeons through the ribs, to keyhole, or laparoscopic, surgery which nowadays is the standard way of repairing this area. Laparoscopic fundoplication surgery for reflux was started in 1993.
Nissen vs Partial Fundoplications
When it was first designed, nearly all fundoplications used a total wrap of the oesophagus (also called a 360-degree wrap). The most common type was the Nissen fundoplication. This can often be too tight, and patients experience trouble swallowing solid food after the surgery which can be permanent and requires further treatment (such as dilatation) to stretch the area of the anti-reflux surgery.
There are now multiple other types of fundoplication, each varying in the degree of oesophagus wrapped up, mainly to reduce the chances of the wrap being too tight. These are called partial fundoplications and common types used include Toupet, Watson and Lind fundoplications. All types of fundoplication do work but reliability of the surgery in the years after repair are dependent on surgical expertise at the time of the surgery and the type of fundoplication performed.
The more complete the wrap (closer to 360 degrees), the less chance of the wrap failing, but this carries increased chance of being too tight. For this reason, many experienced surgeons in the field are adopting partial fundoplications where there is a large amount of oesophagus wrapped, but at the same time leaving a gap so as not to be too tight.
The Lind Fundoplication: My Choice
The Lind is my personal preference since it is a 300 degree, posterior wrap of the oesophagus, and each side of the wrap is stitched to the corresponding side of the oesophagus to make it less likely to come undone. At the same time there is a gap of 60 degrees (about 1cm) of the circumference of the oespohagus not wrapped, which gives room for expansion when food goes past. Trouble swallowing is rare other than for the first few weeks due to post operative tissue swelling. Another important part of the Lind is that the anterior vagus nerve is identified and left free in the unwrapped oesophagus, so as not to become trapped in any of the stitches which can cause considerable pain on eating afterwards if trapped.
