I.

INTRODUCTION Gastroesophageal reflux disease (GERD) as defined, is the excessive back-flow of gastric or duodenal contents in the esophagus where the lower esophageal sphincter loses its function to constrict thus employing a continuous opening from the esophagus to the stomach. Its exact etiology is unknown, but may be related to: a) alteration in the innervation of the pressure zone in the region of the gastroesophageal sphincter, b) displacement of the angle of the gastroesophageal junction, c) an incompetent lower esophageal sphincter. Symptoms of GERD may include heartburn, pyrosis, (burning sensation in the esophagus), dyspepsia or indigestion, regurgitation, dysphagia/odynophagia (pain on swallowing), hypersalivation, belching, flatulence and bleeding. The disease is common, with an estimated lifetime prevalence of 25% to 35% in the U.S. population and the incidence seems to increase with age. As many as 10 percent of Americans have episodes of heartburn (pyrosis) every day, and 44% have symptoms at least once a month. In Asia, the prevalence of GERD is lower than in the United States. However, rates of GERD now approach those seen in Western countries. In Japan, the incidence of esophagitis is reported to be between 14% and 16%. Diagnotic testing may include an endoscopy or barium swallow to evaluate damage on the esophageal mucosa. Ambulatory 12 to 36hour esophageal pH monitoring is used, on the other hand, to evaluate the degree of acid reflux. GERD may cause an increased pressure within the abdomen, which is a significant factor for the occurrence of hiatal hernias. Approximately 40% of people with GERD were noted to have hiatal hernias. In most cases, a hiatal, or diaphragmatic hernia occurs when the lower part of the esophagus and a portion of the stomach slide up through the esophageal hiatus, an opening in the diaphragm through which the esophagus passes before it reaches the stomach. A person with GERD and a hiatal hernia generally has more severe reflux and symptoms that are difficult to control with medication and lifestyle changes. When

lifestyle changes and/or medication fail to relieve symptoms, a surgical procedure called Nissen Fundoplication is used to correct the condition. In an article called Laparoscopic Nissen Fundoplication Procedure to Correct Acid Reflux (GERD), surgeons at the University of Maryland Medical Center provide patients with a technologically advanced option using a videoscopic surgical procedure as an alternative to traditional open surgery, in which a large incision must be made. It is thus presented that a minimally invasive surgery is now used to treat GERD where incisions are only millimeters in size. The videoscopic surgery eliminates the need for a long incision and the small incisions are made to accommodate small tubes called "trocars," creating a passageway for special surgical instruments and a laparoscope. A laparoscope, a fiber-optic instrument that is inserted in the abdominal wall, transmits images from within the body to a video monitor, allowing the surgeon to see the operative area on the screen. The most compelling advantages of this new procedure are: a) less scarring and recovery time where hospital stays are reduced and total recovery time is cut in half, and b) the risk of infection is also lower because of the smaller incisions. Videoscopic surgery usually requires only a one-day hospital stay instead of four to five days required for traditional surgery. In many cases a patient's total recovery time can be as little as one to two weeks, compared with four to six weeks for traditional surgery. The need for advance information has been credited for its helpful means of imparting new alternatives for the provision of client care. The recent developments regarding surgical procedures present limited risks and more benefits compared to the traditional ways. Physicians, most especially, nurses and other health care providers must well equipped by this kind of knowledge in so to offer the patients alternatives that will most likely assure their safety and recovery. This is in conjunction to the fulfillment of the role of becoming the patients advocate, a task that requires each health care provider to stand in behalf of the patients most effective and reasonable plan of care.

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II. CLINICAL INTERVENTIONS Description of the Surgical Treatment Nissen Procedure is usually done using the transabdominal approach where a general anesthesia through an endotracheal tube is used. A thick gastric tube is passed through the mouth and down to the esophagus into the stomach before beginning the operation, leaving it there throughout the procedure for the facilitation of identification of the esophagus, and to prevent the narrowing of the esophageal lumen and its infiltration by the sutures. The patient is positioned supine on the operating table with a sandbag placed under the lumbar spine. An incision is made, usually an upper abdominal midline from the xiphoid to the umbilicus. The abdominal cavity is explored to confirm the presence of hernia, determine its size and reducibility, and to evaluate and manage presence of coexisting intra-abdominal disorder before repairing the hernia. The avascular left triangular ligament of the liver is divided and the liver is retracted to the right to facilitate exposure of the hiatus. The stomach is manually drawn downward to evert the peritoneal reflection forming the hernia sac. The hernia sac is incised transversely immediately below the hiatus, so that the anterior wall of the esophagus is exposed. The esophagus is bared to the serosa and loose tissue around its circumference facilitated by blunt dissection and circumvented with umbilical tape or a rubber tissue. For later traction, a penrose drain will be used. Specific care is employed during these maneuvers to avoid vagus nerve injury and esophageal perforation. The lower esophagus and cardia are cleared of the

peritoneum, loose areolar tissue and vascular through the downward and outward traction on the circumventing tape, leaving the vagus nerve intact. The superior portion of the gastrohepatic ligament and the vessels above the left gastric artery are divided between ligatures, so that the intraabdominal esophagus is free of any adhesions to its whole circumference over a length of abount 10cm. The anterior and posterior aspects as well as the lesser and greater curvature of the gastric fundus are completely mobilized to allow the fundus to be wrapped around the distal esophagus. The complete mobilization of the posterior wall of the stomach from the distal pancreas is facilitated so that a fold of the posterior wall can be used for fundoplication.