Laparoscopic anti-reflux surgery for either hiatal hernia, Nissen fundoplication,
or paraesophageal hernia repair (PEHR), is a minimally invasive procedure
that reconstructs the malfunctioning valve where the esophagus goes into
the stomach. This procedure also repairs the defect in your diaphragm
that may be causing your stomach or other abdominal organs to protrude
into your chest. After surgery, reflux symptoms usually improve and acid
suppressing medications may no longer be needed. Chest pain or shortness
of breath symptoms may also improve..
Procedure Overview
Laparoscopic anti-reflux surgery for either hiatal hernia, Nissen fundoplication,
or paraesophageal hernia repair (PEHR) is performed under general anesthesia,
meaning you will be asleep throughout the entire surgery. Five to six
small incisions are made on your abdomen to provide your surgeon with
access to the affected organs (Figure 1). Surgery typically takes between
1 and 3 hours.
In-Hospital Recovery
Pain Management: A multi-modal pain regimen is used along with narcotic pain medications
as needed. You will receive three non-narcotic medications prior to surgery,
while in the hospital, and upon discharge home to help control your pain
post-operatively. These are: Tylenol, Gabapentin, Celebrex, and Ibuproven.
Depending on your age, you may also be given an anti-nausea patch called
Scopolamine.
A stronger narcotic pain medication may be given for any breakthrough pain
you may have.
Diet: You will be kept on a clear liquid diet the day of surgery. On the morning
after your surgery, you will be allowed a full liquid diet. Upon discharge,
you will be given specific instructions on what diet to follow at home.
At your follow-up appointment we will discuss next steps in your diet.
Typically, there are no special dietary items that need to be purchased.
Recovery at Home
Pain: As stated above, you will be given prescriptions and specific instructions
for a pain control regimen.
Activity: After discharge, your activity level should increase gradually over time.
You are to avoid heavy lifting for an INDEFINITE amount of time following
surgery. Avoid lifting anything heavier than 20 to 25 pounds. Most patients
can return to work in 1 to 2 weeks depending on occupation.
Driving: You should avoid driving for at least 5 days following surgery. You are
not cleared to drive until you are no longer taking narcotic pain medication.
Wound Care: Your incision sites will be covered with purple-colored surgical glue called
Dermabond. This glue will come off on its own with time. You may shower
normally after surgery, pat-do not rub-your incision sites and leave them
open to air. Do not soak in a bathtub or swim in a pool for at least 4
to 6 weeks following your surgery.
Pre-Operative Testing
A series of tests may be performed to determine if you are a candidate
for anti-reflux surgery. These may include upper endoscopy, barium esophagram,
ambulatory pH testing, and esophageal manometry.
New Anatomy
Following your anti-reflux surgery, your stomach will be in a new position
in the abdomen. This is because the part of your stomach called the fundus
is now acting as the valve that separates the esophagus from your stomach.
The fundus (or top part of the stomach) will now be wrapped, either 360
degrees or 270 degrees, around the esophagus. This new valve is what will
help to eliminate reflux (Figures 2 and 3).
Side Effects
Most commonly noted side effects include bloating, gassiness, and mild
dysphagia (difficulty swallowing). Dysphagia is common immediately following
the procedure and in the vast majority of patients resolves by 3-4 months.
Also, the return of symptoms is possible. There is some variability, but
the likelihood of developing chronic dysphagia is less than 5%. Gassiness
and bloating is usually self-limited and resolves by 3-4 months.
Surgical Results
Results vary depending on your exact symptoms and other factors. Long-term
observational studies of laparoscopic fundoplication performed by experienced
operators generally report that 90 to 95 percent of adult patients are
satisfied with the results of their surgery. Reference: (Dassinger MS,
Torquati A, Houston HL, Holzman MD, Sharp KW, Richards WO. Laparoscopic
fundoplication: 5-year follow-up. Nashville, TN: Am Surg.; 2004.)
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