Introduction
Hiatal hernia repair, fundoplication, and Heller myotomy are the most common benign foregut surgeries performed. Surgery performed on benign lesions (groups of cells that are not cancerous) in the foregut is called benign foregut surgery. These surgeries are performed only when medication and lifestyle modifications are less effective or produce no results.
What Is Benign Foregut Surgery?
Hiatal hernia repair, fundoplication, and Heller myotomy are the most common benign foregut surgeries performed. In addition, surgery done on benign lesions in the foregut involves benign foregut surgery. The foregut includes the stomach, the initial part of the duodenum, the liver, the gallbladder, the pancreas, and the spleen.
When the upper portion of the stomach bulges into the diaphragm, this condition is called a hiatal hernia. The diaphragm has a small opening called the hiatus, through which the esophagus passes before reaching the stomach. A hiatal hernia is usually asymptomatic, though it may be associated with heartburn and abdominal discomfort in some cases. A surgical procedure used to treat gastroesophageal acid reflux is called fundoplication. It can be done laparoscopically and has a faster recovery. Heller myotomy is a laparoscopic procedure that is used to treat achalasia.
What Is Hiatus Hernia Repair?
Everyone with a hiatus hernia may not require a surgical procedure. It is resolved in some cases by medication and lifestyle modification. However, many surgical procedures are available for those who may require surgery to resolve the condition. The following conditions might require surgical resolution:
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The symptoms are severe, affecting the quality of life.
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The symptoms are not relieved by other treatments.
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When a hernia is at risk of strangulation (increased chance of the blood supply to the herniated organ being cut off).
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Bleeding, ulcers, narrowing of the esophagus, etc., occur.
What Are the Surgeries for Hiatus Hernia Repair?
There are three types of surgeries for hiatus hernias:
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Open repairs.
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Endoluminal fundoplication.
1. Nissen Fundoplication: This is the most common form of surgery for a hiatus hernia and is done using laparoscopic repair. It is a minimally invasive procedure. A laparoscope consists of a thin tube fitted with a camera. It is inserted into the abdomen to repair the hernia. The hiatus (the opening in the diaphragm where the stomach herniated) may also be tightened to prevent the hernia from occurring again. This procedure has several advantages over others, including less pain, a lower risk of infection, minimal scarring, shorter hospital stay, and a typically quick recovery.
2. Open Surgery: The surgeon would need to make large incisions in the abdomen for open surgery to correct the hernia. The fundus, the upper part of the stomach, is put around the esophagus after pulling back the stomach. This helps to create a tight sphincter and prevent regurgitation. A tube might be inserted to keep the stomach in place, which will be removed after a few weeks.
3. Endoluminal Fundoplication (ELF): This is a less invasive procedure than laparoscopy and is uncommon. This does not require incisions, as they insert an endoscope through the mouth into the esophagus, and the opening between the stomach and esophagus is tightened. Though this procedure is minimally invasive, it has many limitations: Many endoluminal devices available are not fully reliable, and many people have complaints of hernias recurring.
4. Transoral Incisionless Fundoplication (TIF): The TIF is another minimally invasive non-surgical procedure to treat hernias and acid reflux. TIF 2.0, the most advanced version, does not require any incision. An endoscope is inserted through the mouth to tighten the esophagus. The cardia and fundus (parts of the stomach) are wrapped rotationally and secured using polypropylene fasteners.
5. Endoscopic Anterior Fundoplication with Medigus Ultrasonic Surgical Endostapler (MUSE): This involves a surgical stapler that attaches the fundus to the esophagus.
A Nissen fundoplication is the most successful treatment for relieving the symptoms of GERD (gastroesophageal reflux syndrome), with a success rate ranging from 90 to 95 percent.
What Is Fundoplication?
A surgical procedure used to treat gastrointestinal diseases is called fundoplication. The surgery can be laparoscopic or open, with laparoscopic being minimally invasive and having fewer complications. The different types of fundoplication include:
1. Nissen 360-Degree Wrap: In this procedure, the fundus is wrapped around the esophagus to tighten the sphincter. This prevents regurgitation.
2. Toupet 270-Degree Posterior Wrap: This does not wrap completely around the esophagus - posteriorly, the fundus is wrapped only two-thirds of the way at the bottom of the esophagus. This creates a valve-like structure that allows you to release gas through burps or vomit if necessary.
3. Watson 180-Degree Anterior Wrap (Dor Fundoplication): This covers an even lesser part of the esophagus. The procedure involves reconstructing the portion of the esophagus close to the diaphragm. The fundus is wrapped halfway around the front of the esophagus and attached to a portion of the diaphragm.
Although fundoplication is successful in controlling acid reflux and its symptoms, there can be side effects associated with it. For example, the 360-degree wrap can make it difficult for the sphincter to open up to release pressure, causing abdominal gas, abdominal pain, bloating, increased flatulence, etc.
What Is Heller Myotomy?
Heller myotomy is a minimally invasive procedure to treat achalasia, a disorder of the esophagus that makes it hard for food to pass to the stomach. It is a kind of esophagostomy (cutting the esophageal sphincter using a laparoscope). The procedure is usually permanent and has a high success rate.
Many incisions are made in the abdomen to pass the scope and instruments. The lower esophagus and upper part of the stomach are exposed to cut the muscle. The exact location of the lower sphincter is identified, and myotomy (cutting of the muscle) is done to open the lower esophageal sphincter. To prevent reflux from the stomach to the esophagus, Dor fundoplication is done. This covers the myotomy and creates a low-pressure valve. The advantages of Heller myotomy include the following:
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Lesser post-operative pain.
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Lesser hospital stays when compared to open surgery.
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Faster recovery.
Conclusion
The esophagus, the stomach, and the upper part of the small intestine constitute the foregut. Any disorder or disease of these organs is called foregut disorder. A disease that is not cancerous is called a benign one. Benign tumors do not invade the nearby tissues and organs and are considered safer. They usually have a good prognosis. Benign foregut surgeries are usually minimally invasive and have a higher recovery rate. These surgeries are performed only when medication and lifestyle modifications are less effective or produce no results.
