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| Hiatus Hernia Nissen Fundoplication |
These notes give an overall guide to
your stay in hospital. You may see
some differences in the details of
your treatment, since it is tailored
to suit your own condition.
WHAT IS THE PROBLEM? THE NISSEN FUNDOPLICATION OPERATION is performed to relieve gastro-oesophageal reflux and its associated symptoms of heartburn due to regurgitation of acid stomach contents. This may be associated with an Hiatus Hernia. A hiatus (hi-ate-us) simply means a gap. A hernia is a bulge or a weakness. The hiatus is in the muscle sheet that stretches across the inside of your ribs. The hiatus allows the swallowing tube (oesophagus, ee-soff-a-guss) to pass through the diaphragm on its way to the stomach. In this case, the stomach bulges through a weakened hiatus up into your chest. Stomach acid can then leak back up your oesophagus. Sometimes it is the stomach itself that gets stuck. You can experience pain, heartburn, acid in the mouth, choking, difficulty in swallowing, shortness of breath and rarely bleeding.  WHAT DOES THE OPERATION CONSIST OF? THE NISSEN FUNDOPLICATION OPERATION may be performed either through a laparoscope or by an open surgery. If your surgery is performed laparoscopically you will have 5 or sometimes 6 very small incisions, (between 0.5 –1.0 cm each) on your abdomen, rather than one larger incision (15 cms long) vertically along the midline of your abdomen. The laparoscopic fundoplication is performed on most people. It may be necessary to change from a laparoscopic to open incision method during your surgery if difficulties arise in creating the ‘wrap’ around the lower part of the oesophagus. The operation takes between one and a half to two hours. How is the operation performed? THE AIM IS TO BRING THE STOMACH BACK DOWN from the chest and to stop acid leaking up the oesophagus. A telescope with an attached miniature TV camera (laparoscope) is inserted through a small (1 cm) incision above the tummy button (umbilicus). Four other similar incisions are made to insert the necessary instruments for the operation. The herniated stomach and the lowest part of the oesophagus are returned to their normal positions i.e. below the diaphragm. Part of the stomach (fundus) is wrapped around the oesophagus to re-create a valve. The hiatus in the diaphragm is narrowed with stitches. The interments are withdrawn and the incisions are closed.  The hiatus in the diaphragm is narrowed with stitches. The interments are withdrawn and the incisions are closed. In a small number of patients (approx. 5%) it may not be possible to operate via the laparoscope due to adhesions from previous operations, bleeding obscuring vision, awkward fatty tissue or other technical problems. It will then be necessary to revert to the standard (open) operation. How long will I spend in hospital? IF YOUR OPERATION IS PERFORMED LAPAROSCOPICALLY, with only 5 or 6 small incisions, you will usually be discharged from 2 to 4 days after the operation, and with the open incision method from 5 to 7 days after. WHAT HAPPENS BEFORE THE OPERATION? Reception When registering at reception your medical aid details will be required. Your medical aid may require that you obtain an authority number from them for the hospital. Please check this. If you are not on a member of a medical aid you will be required to pay a deposit or to sign an indemnity form. As far as possible we will try to advise you about hospital costs before your admission. Welcome to the ward You will be welcomed to the ward by the nurses or the receptionist and will have your details checked. Some basic tests will be done such as pulse, temperature, blood pressure and urine examination. You will be asked to hand in any medicines or drugs you may be taking, so that your drug treatment in hospital will be correct. Please tell the nurses of any allergies to drugs or dressings. The surgeon will have explained the operation and you will be asked to sign your consent for the operation. If you are not clear about any part of the operation then read this again and then ask for more details from the surgeon or from the nurses. Visit by the anaesthetist The anaesthetist who will be giving your anaesthetic will interview and examine you. He will be especially interested in chest troubles, dental treatment and any previous anaesthetics you have had. He may want to use a spinal or epidural anaesthetic. This helps with pain control after the operation. He will talk to you about this Diet You will have your usual diet until 6 hours before the operation when you will be asked to take nothing by mouth. This will let your stomach empty to prevent vomiting during the operation. Shaving The operation area will be shaved to remove excess hair. Timing of the operation The timing of your operation is pre-arranged so that the nurses will tell you when to expect to go to the operating theatre. Do not be surprised, however, if there are changes to the exact timing. Premedication You may be given a sedative about one hour before the operation. Transfer to theatre You will be taken on a trolley to the operating suite by the staff. You will be wearing a cotton gown, rings will be fastened with tape and removable dentures will be left on the ward. There will be several checks on your details on the way to the operating theatre where your anaesthetic will begin. Are there any risks involved? Any operation is associated with some potential risks, either from the procedure itself or from the anaesthetic. Your surgeon and anaesthetist will explain these to you beforehand. Problems which can arise in the early stages, particularly after the open fundoplication operation include:
Special preventative measures will
be taken tin order to minimise the
risks of complications, which are
very uncommon after the laparoscopic
operation. WHAT HAPPENS AFTER THE OPERATION? WHAT YOU CAN EXPECT AFTER the operation will vary depending on whether your surgery is performed by the laparoscopic or open method. This will also influence the length of your hospital stay after the operation, your overall recovery time and the instructions you will follow after your discharge from hospital. Coming round after the anaesthetic Immediately after your operation you will be transferred to the recovery area until you are awake. Although you will be conscious a minute or two after the operation ends, you are unlikely to remember anything until you are back in your bed on the ward. Some patients feel a bit sick for up to 24 hours after operation, but this feeling passes. You will be given medication to prevent nausea as it is important not to vomit as this might disrupt the repair. You may be given oxygen through a facemask for a few hours. There will be an intravenous drip in your arm to give you fluids. If you have the Laparoscopic Fundoplication you will have:
Your intravenous drip will stay in for a short time after the operation, until you are able to drink enough. It may be removed the evening of your operation or the next morning. If you have the open incision Fundoplication you will have:
Opening bowels It is quite normal for the bowels not to open for a day or so after the operation. If you have not opened your bowels after 2 days and you feel uncomfortable, ask the nurses for a laxative. Sometimes diarrhoea follows the operation at first but this settles down in time. Ask the surgeon if you are troubled by it. Passing urine It is important that you pass urine and empty your bladder within 6-12 hours of the operation. If you find using a bedpan or a bottle difficult, the nurses will assist you on to a commode or the toilet. If you still cannot pass urine let the nurses know and steps will be taken to correct the problem. Sometimes a tube (catheter) is passed into the bladder to drain urine out into a bag at operation. This tube is removed 3 or 4 days after operation. Sleeping You will be offered painkillers instead of sleeping pills to help you to sleep. If you cannot sleep despite the painkillers please let the nurses know. Pain relief after Laparoscopic Fundoplication If you have any pain you will be given injections to make you comfortable. You may experience some pain in the shoulder tip, which is quite normal and due to irritation of the diaphragm nerves. After the first day or two pain tablets will normally be quite sufficient. Pain relief after Open Fundoplication For the fist couple of days after the operation you will probably have a patient controlled analgesia machine to give you pain relief via your intravenous drip. This is a pain relief, (usually morphine), which you self-administer by pressing a button. Occasionally an epidural catheter may have been inserted before the operation. If you have either of the above you may need to have an oxygen mask as well. It is important that your pain is well controlled allowing you to move around in bed, do deep breathing, coughing and leg exercises. If you are not comfortable please tell the nursing staff. Complications COMPLICATIONS ARE SELDOM SERIOUS AND ARE WELL KNOWN. The main complication, which can be serious, is damage to the oesophagus. This will usually be recognized at the time of surgery and may require an open operation to repair it. Most patients have a good result from the fundoplication operation without any complications. However, a small number of patients who have the laparoscopic fundoplication may develop problems either due to the wrap being too tight or the wrap slipping into the chest. The likelihood of this is reduced by the surgical technique but unfortunately complications can still occur. These can sometimes be corrected by early laparoscopic re-operation lengthening the recovery time by a few days. To detect complications after laparoscopic fundoplication and early enough for laparoscopic repair, a barium xray will usually be performed in the first 1-3 days after operation, which allows the position and construction of the wrap to be checked. It is quite normal for there to be some difficulty in the passage of food through the oesophagus into the stomach after this type of surgery. This is generally due to the swelling and bruising at the site of the operation, and while this will gradually resolve, it may take 3-6 months for swallowing to return completely to normal. A small number of patients need to avoid lumpy food and if more severe, it may be necessary to stretch the lower end of the oesophagus. This is usually done in our rooms with a flexible scope rather than in theatre. Sometimes there is a delay in the recovery of the gut after the operation, which means that you do not start drinking so soon. This will settle down. Sometimes there is infection in the wound and this is treated appropriately. You will also pass significantly more flatus per rectum. The next few days There are no restrictions on your activity level after the operation. Once your anaesthetic has worn off after the laparoscopic operation you will be able to get up and move about. You will however be too sleepy to do much till the next morning. It is important that you do your breathing, coughing and leg exercises as instructed by the nursing staff. Dietary Advice Dietary modifications will be required during the first 4-6 weeks after your surgery. This will involve:
Return to usual activities and work You will probably feel rather run down when you get home. You can commence regular gentle activities and gradually return to your normal activity level as you feel able. After laparoscopic fundoplication your energy level will return after a week or two. You should be able to return to light duties after about a week and progress to your usual activities and work about two weeks after surgery. You will find it uncomfortable to lift heavy objects for about four weeks and you should refrain from doing so. After the open fundoplication it will take longer before you can resume your normal activity level, up to 4-6 weeks. It is important not to strain or lift heavy objects for 8 weeks after the operation. You should discuss increasing activity level and return to work with your surgeon. Driving You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about 2 weeks. What about sex? You can resume sexual activity as soon as wound is comfortable enough. Generally speaking The operation is a major one but you may well be surprised how quickly you get over the effects and experience relief from your old symptoms (such as heartburn and reflux). You may still experience some breathlessness temporarily. In prospective studies over 90% of patients are very satisfied with the outcome and would have had the operation having been aware of the consequences, i.e. all the information above. This compares favourably with almost any other operation in any discipline of surgery. |
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