GERD

Robotic Anti Reflux Surgery
Overview

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Anti-reflux surgery is for the treatment of gastroesophageal reflux disease (GERD). Commonly known as “heartburn,” the disease can cause symptoms such as a burning sensation in your chest (especially after eating or at night), chest pain, difficulty swallowing, regurgitation of food or sour liquid, and/or the sensation of a lump in your throat.

This condition is attributed to stomach acid that regurgitates into the esophagus from the stomach. Treatment of this condition is important not only for symptom management but also because the chronic acid reflux into the lower esophagus causes damage that can lead to esophageal cancer in some patients.

The regurgitation is caused by the failure of the lower esophageal sphincter (LES), which acts as a valve between the esophagus and stomach, to close correctly. Some of the causes of gastroesophageal reflux disease include obesity, smoking, alcohol consumption, fatty and spicy foods. Hiatal hernias are commonly associated with the development of GERD.

Treatments for GERD and Hiatal Hernias

Lifestyle changes

This is a critical step in the treatment of GERD and often overlooked. Obesity is a major contributing factor and weight loss is often mandatory prior to consideration of surgical options. If weight loss is unsuccessful with diet and exercise, bariatric surgery (weight loss surgery) is often a better option than anti-reflux surgery. In addition to weight loss, avoiding eating before bed, and avoiding tobacco and alcohol are often successful in relieving symptoms of GERD.

Medications

Initial treatment with medications to reduce acid production in the stomach is successful in the majority of patients.

Robotic Surgical Procedures

Robotic Nissen Fundoplication

A robotic-assisted procedure that involves several small incisions in the abdomen. A tiny video camera is inserted through one incision and the surgeon uses special surgical tools through the other incisions to repair the esophagus.

Robotic Hiatal Hernia repair

A robotic-assisted procedure that inserts a laparoscope, which is a thin tube with a light and a camera through one incision and the surgeon uses special surgical tools through the other incisions in the abdomen to repair the hernia.

Robotic Surgery for Anti Reflux

djt anti reflux 2 1 1024x684Acid reflux occurs when stomach acid flows up the esophagus( food pipe), causing a burning sensation in the lower chest area (heartburn). Gastroesophageal reflux disease (GERD) is diagnosed when this occurs more than twice a week. This condition can be treated through (Nissen fundoplication), a minimally invasive surgical procedure, where the surgeon creates an effective valve mechanism at the bottom of the esophagus to prevent reflux.
The development of anti-reflux surgery from open to a minimally invasive laparoscopic approach has resulted in reduced postoperative pain and shorter procedure-related length of stay without compromising patient satisfaction. The transition to surgical treatment using robotic surgery techniques allows for superior visualization by integrating 3D visualization, enhanced dexterity by increasing maneuverability of applied instruments, and greater precision as compared to traditional laparoscopic procedures.
Robotic surgery does not call for a different preoperative workup. The procedure provides robot-assisted, anti-reflux surgery with magnetic sphincter augmentation to prevent reflux and repair hiatal hernias. The procedure helps reinforce the lower esophageal sphincter (LES) so that it prevents food and acid from rising and reinforces a hiatal hernia repair.

Patient benefits of robotic surgery include:

  • Reduced pain and discomfort
  • Less bleeding
  • Less scarring
  • Faster recovery
  • Reduced incidence of gas bloat and dysphagia
  • Symptom resolution 

Robotic anti-reflux operations have been consistently reported to be safe. The number of complications is minimal and comparable to laparoscopic surgery. Dr. Tierney has been using robotic surgical technology for many years. 

Before surgery

The steps followed before surgery are:

  • An office visit for surgical consultation where a comprehensive history and physical exam is performed.
  • Completion of clinical tests for workup and staging.
  • Multidisciplinary tumor board review for an expert recommendation regarding treatment strategy.

After surgery

The type of surgical procedure done determines the kind of post-surgery care required. Post care after a surgical operation involves:

  • A brief admission to the ICU is sometimes required for complex procedures such as a whipple procedure. Recovery then continues in the hospital ward for another three to five days. Procedures performed robotically typically have a faster recovery and can expect discharge from the hospital one or two days earlier than after open procedures. 
  • The goals of postoperative care include: monitoring for and intervening on any complications that can occur, awaiting the resumption of normal bowel function, maintaining adequate hydration and nutrition, physical and occupational rehabilitation, and providing adequate pain control. Once these measures are met, the patient will be discharged from the hospital. Post-operative follow-up will be scheduled one week from discharge with Dr. Tierney.

Frequently Asked Questions About GERD and Anti-Reflux Surgery

Gastro-oesophageal reflux disease occurs when stomach acid flows back up into the oesophagus. Most people get occasional heartburn; it is called GERD when it happens regularly, generally more than twice a week, or when it causes damage. The cause is usually a lower oesophageal sphincter, the valve between the oesophagus and the stomach, that no longer closes properly. Excess weight, smoking, alcohol, large or late meals and fatty or spicy food all contribute. A hiatal hernia, where part of the stomach slides up through the diaphragm, is commonly associated with GERD and often needs repairing at the same time. Typical symptoms are burning in the chest, especially after eating or lying down, regurgitation, chest pain, difficulty swallowing and a sensation of a lump in the throat.
Surgery is not the first step, and for most people it is never needed. Lifestyle change comes first, and it is frequently underestimated. Losing weight, stopping smoking, reducing alcohol and not eating close to bedtime resolve symptoms for a great many people. Acid-reducing medication controls symptoms in most of the rest. Surgery is considered when symptoms persist despite good medical treatment, when someone does not want to take medication indefinitely, when there is a large hiatal hernia, or when reflux is causing ongoing damage to the oesophagus. Where excess weight is the main driver, weight-loss surgery is often a better option than anti-reflux surgery, and that will be discussed honestly rather than avoided.
The commonest operation is a fundoplication, usually performed robotically or laparoscopically through several small incisions. The top of the stomach is wrapped around the lower oesophagus to reinforce the valve, and any hiatal hernia is repaired at the same time. A Nissen fundoplication wraps the stomach fully around; partial wraps such as a Toupet are used in some patients and tend to cause fewer swallowing problems. An alternative in selected cases is magnetic sphincter augmentation, a separate procedure in which a small ring of magnetic beads is placed around the lower oesophagus to support the valve while still allowing food through. Which operation suits you depends on your test results, the size of any hernia and how well your oesophagus moves.
Anti-reflux surgery is generally safe, but it changes how the valve works and the trade-offs are worth understanding beforehand. Difficulty swallowing is common in the first weeks as swelling settles; it persists long term in only a small proportion of patients, around one in fifty. Bloating and increased wind are much more common, because the wrap makes belching harder, and a substantial minority of patients still notice this years later. Some people find they cannot vomit easily afterwards. General surgical risks include bleeding, infection and injury to nearby structures. Over time the wrap can loosen, and while most patients remain off acid-reducing medication, a minority need it again or require further surgery. These trade-offs are the reason surgery follows lifestyle change and medication rather than replacing them.
Most patients go home within a day or two. Diet is advanced gradually, starting with liquids and moving through soft food over the first few weeks while swelling settles, and your team will give you specific guidance. Eating slowly, chewing well and taking smaller portions helps considerably in that period. Most people return to desk work within one to two weeks and to full activity within about a month. Heavy lifting is restricted while the hernia repair heals. Most patients are able to stop acid-reducing medication after surgery, though this is discussed rather than assumed.