Nissen Fundoplication: Procedure, Recovery, Risks and Alternatives

Nissen fundoplication is the best-known anti-reflux operation. It treats gastroesophageal reflux disease (GERD) by rebuilding the barrier between the stomach and the esophagus. It is often combined with repair of a hiatal hernia, where part of the stomach has slipped up into the chest.

How Nissen fundoplication works

At the bottom of the esophagus is a ring of muscle called the lower esophageal sphincter (LES), which acts like a valve. In GERD, the valve is weak or opens too often, and a hiatal hernia can make this worse. In the operation, the surgeon:

1. Brings the stomach back below the diaphragm if a hiatal hernia is present
2. Tightens the opening in the diaphragm (hiatal repair), sometimes with mesh
3. Wraps the upper part of the stomach (the fundus) around the lower esophagus and stitches it in place

The wrap adds pressure at the bottom of the esophagus, so stomach contents are less likely to flow upwards.

Types of fundoplication

Procedure	Wrap	Notes
Nissen	Complete, 360 degrees, around the esophagus	The standard operation, strongest barrier
Toupet	Partial, about 270 degrees, at the back	Often used if esophageal muscle movement is weak; fewer swallowing problems
Dor	Partial, about 180 degrees, at the front	Commonly used after surgery for achalasia

For a short esophagus, a lengthening procedure (Collis gastroplasty) may be added.

Who might need anti-reflux surgery?

Surgery is considered when GERD is proven with objective tests and:

• Symptoms continue despite the best medical treatment
• Someone has good response to medicines but does not want lifelong tablets, or has side effects from them
• There is a large hiatal hernia, or regurgitation of food or liquid that medicines do not control
• GERD is causing complications such as strictures or repeated aspiration

Surgery is less suitable if GERD has not been confirmed with tests, if the esophagus does not move food well (a partial wrap may be chosen), or in people with severe obesity, who may do better with gastric bypass.

Tests before surgery

• Upper endoscopy to look at the esophagus and stomach
• pH monitoring (or pH-impedance) to measure acid reflux
• Esophageal manometry to check how well the esophagus squeezes
• Barium swallow to show a hiatal hernia and the shape of the esophagus
• Gastric emptying test if slow stomach emptying is suspected

See our guide on how to prepare for surgery.

What happens during the operation

Nissen fundoplication is usually done laparoscopically (keyhole) under general anesthetic. The surgeon makes several small cuts, inserts a camera and instruments, and carries out the steps above. It typically takes about 1.5 to 3 hours. Open surgery is used less often, for example after previous operations or complications.

Recovery

• Hospital stay: usually 1 to 2 nights
• First weeks: sore throat, discomfort, bloating and difficulty swallowing are common, and usually improve
• Diet: a staged plan, typically clear liquids, then full liquids, then pureed or soft foods for a few weeks, then a gradual return to normal foods by about 4 to 6 weeks. Your team will give exact instructions.
• Eating tips: small, frequent meals, chewing thoroughly, eating slowly, avoiding fizzy drinks, chewing gum and drinking through straws. Bread, dry meat and rice can stick early on, so introduce them slowly.
• Activity: walk daily. Avoid heavy lifting and straining for about 4 to 6 weeks. Desk work is possible after 1 to 2 weeks.
• Medicines: your surgeon will advise when to stop acid-reducing tablets and what pain relief and anti-sickness medicine to use.

Results

In studies, most people have good control of heartburn and regurgitation, and many stop daily reflux medicines. Trials comparing surgery with long-term acid-reducing medicines have found similar reflux control, but surgery spares you from daily tablets and carries its own risks. Over the years the wrap can loosen, and some people restart medicines. A small number need a repeat operation.

Surgery does not remove Barrett's esophagus, so people with it still need endoscopic surveillance.

Side effects and risks

• Difficulty swallowing (dysphagia): common early on, and usually settles. Persistent problems may need a dilation procedure or revision.
• Gas-bloat syndrome: trouble belching, causing bloating, fullness and flatulence. It often improves over time but can persist in a minority. See gas and bloating.
• Inability to vomit: the wrap makes vomiting difficult
• Early fullness, nausea and diarrhea: sometimes from irritation of the vagus nerve
• Wrap problems: too tight, loose, or slipping, or the hernia returning
• Surgical risks: infection, bleeding, injury to the esophagus, stomach, spleen or liver (uncommon), blood clots, and anesthetic complications

Other anti-reflux treatments

• Lifestyle changes and medicines: see GERD treatment
• LINX magnetic sphincter augmentation: a ring of small magnetic beads placed around the lower esophagus that opens when you swallow. It usually allows burping and vomiting, but is not suited to large hiatal hernias or severe esophagitis.
• Transoral incisionless fundoplication (TIF): an endoscopic procedure that creates a partial wrap through the mouth, for people with small or no hiatal hernia
• Stretta: radiofrequency energy applied to the lower esophageal sphincter, with limited evidence
• Gastric bypass: the preferred operation for people with obesity and GERD, since sleeve gastrectomy can worsen reflux

Hiatal hernia repair

A large or paraesophageal hiatal hernia that causes symptoms is usually repaired by pulling the stomach back into the abdomen and tightening the diaphragm opening, often with a fundoplication. Small sliding hiatal hernias without troublesome reflux do not usually need surgery. For more on hernia types, see our guide to the types of hernia.

When to call your surgeon

Contact your surgical team or seek urgent care if you cannot swallow liquids or saliva, have persistent vomiting or retching, severe chest or abdominal pain, fever, black stools, or wound redness or discharge, or breathlessness or a swollen calf.