Laparoscopic Nissen Fundoplication
1.Where are you now?
As a Reflux sufferer, you will probably agree that severe reflux
affects every aspect of your life and cripples you.
You may have been waiting for a long time for the diagnosis and felt
that the onus is on you to prove your illness. It may have made you
sad and may have affected your confidence and self esteem.
Your spouse or children may have suffered as well, as they have
watched you suffer, often for many years. You may have found
tablets, which are magical for some, help you only partially or you
get side effects from them.
You may be tossing in the bed when others are asleep or may have
woken up choking in the middle of night, being sick with burning
acidic liquid coming out of your mouth and nose.
You may be left with a permanent cough and woken up in the
morning with dry mouth, headache and feeling really grotty. You
were late at work that day and struggled to perform. You are
careful of what and when you eat and don’t want to socialise out of
embarrassment. May be friends and family hinted that you are
slightly hypochondriac and you may have been wondering about this
yourself.
Then you may have gone through a long process of having tests and
consultation before being seen by a surgeon and finally have been
told that you can have surgery.
That’s good because not everybody qualifies for surgery.
Now is the time to read this article.
2. How this operation can benefit you?
This operation is magical in curing reflux immediately and if you had
disabling reflux your life gets transformed. This can turbo charge
your relationships, work , social life, eating habits and sleep pattern.
At its best this procedure can be liberating and allows you to acheive
your full potential
3. The operation:
Laparoscopic Nissen Fundoplication is done to cure acid reflux. This
operation is also called “key hole stomach wrap “ Or Hiatus Hernia
Repair for cure of reflux.
4.What is Acid Reflux?
Reflux is backward / upward movement of acid, food and bile from
stomach into the gullet. Patients who have such a problem feel
heartburn are often sick and may develop many other difficulties.
The formal name of this condition is GastroOesophageal Reflux
Disease or GORD
We normally have a valve between gullet and stomach. This is an one
way valve. Like a gatekeeper gullet and stomach this open up when
food comes down the gullet to allow food to enter the stomach.
However, then it shuts preventing most of backward movement of
stomach contents back into gullet. Patients who have GORD tends to
have a defective valve . This valve at the lower end of gullet is called
Lower Oesophageal( gullet) Sphincter ( valve)or LOS
This operation aims at recreating this valve.
5.What is hiatus hernia ?
Stomach is supposed to be in your belly. If this goes upto your chest
then the LOS is also drawn into the chest. This is called a hiatus
hernia. Most GORD patients( but not all ) with reflux have a hiatus
hernia
97% of such hiatus hernia are small and called sliding hiatus hernias.
Operation is standard operation and you done know any difference.
3% of the hiatus hernias are very large and most of the stomach is
drawn up in the chest. The hole in the diaphragm through which
gullet enters belly is widened hugely ( very large or widened hiatus).
Such hernias are called Giant rolling (paraoesophageal) hiatus
hernia or hiat
Laparoscopic Repair of giant hiatus hernia Sometimes you may have
most of your stomach in the chest with a twist. The operation to fix
such giant hiatus hernia is similar in nature but bigger and more
complex and may involve insertion of a mesh to repair enlarged
hiatus which
6. Your Life after Surgery
Day of surgery is often a blur . However, lot of people actually feel
reasonably ok soon after. Often the biggest discomforts are due to
the tube in the nose, sore throat from anaesthetic, pain in the top of
belly and shoulder tip. On the whole you can start drinking couple of
hours after surgery in moderation.
Rarely patients may not be able to pass urine and may end up with a
catheter. On the whole you are ok but bit sore and feeling slightly
sorry for yourself.
Reflux control is usually immediate and very noticeable especially if
you had disabling symptoms.
You will go home usually on the same day or in my practice after
overnight stay. Some times longer hospital stay is needed depending
on how you are.
Do`s and Don`ts
The real restriction is around doing really strenuous activities that
can increase pressure inside your abdomen. Cough and retching
are very rare but if you have these you will need cough remedies and
anti sickness medicines.
Lifting heavy weight>5-10 kg doing weights in the Gym and certain
free hand excercises that involve working out your abdominals are
best avoided for 6-8 weeks.
However, walking and normal activities are actively encouraged.in
fact more the merrier. Naturally you will feel nervous and this may
lead you to be too careful or sedentary. Most of the time rapid
return to normal activity is preferable.
This prevents chest infection, clots in the leg ( deep Vein
thrombosis) depression and low mood.
Driving is allowed when you can do an emergency stop without
being in discomfort. You also need to be off any opioid ( morphine
like e.g tramadol, codeine solpadol,oromorph) pain killer as they can
affect your performance
Main restrictions are around eating and drinking
Your food pipe is slightly wider than base of your great toe so it’s a
fairly narrow pipe. However, it is fairly elastic and can distend up if
needed to accommodate large food bolus. Imagine the soft tube is
now has a large rubber band around I at the lower end where gullet
joins with stomach . This resistance naturally prevents acid from
stomach to go up the gullet.
However, this also provides a resistance to food trying to enter
stomach from the gullet. This is the reason for developing dysphagia
or difficulty in swalllowing after this operation. Moreover if the wrap
is too loose then the reflux control is not good and hence short term
dysphagia is accepted for long term reflux control
What to eat?
First week:
In short you can eat anything and everything provided the food has
been liquidised by blender. What Joy! Majority of patients will
become quite expert on soups and smoothies and liquid yogurts!
However, lot of them will have normal food ( veg,casseroled
chicken,ricee , pasta, curries, noodles) after putting them through
blender. I must admit that I have not enquired how they taste. Some
patients will buy babyfoods and other really soft stuff viz. icecream ,
mousse etc. It is amazing how inventive you can be.
Avoid fizzy drinks as you can not burp easily and may end up feeling
quite bloated.
If you had any restriction due to diabetes, kidney problem or any
other diseases needing dietary restrictions then those restrictions
will continue
Week 2-8:
During this period , your eating will undergo slow and gradual
normalisation. Most people can initiate semisolid Puree like food
from 5th day and you will start getting better from day 7. However, it
is crucial that you avoid hard food and especially bread , sausage
various meats and steak. Certain food that can stick to your gullet
viz. mash can be problematic even if they are soft.
On the other hand, food that brought on reflux attacks in the past
viz. wine, coffee, citrus fruits, spicy food, curries, onion and late
meals are no longer a problem and on the whole you start feeling lot
better.
You miss your sandwiches and large portions remain a problem. You
notice dysphagia ( food sticking in the gullet) especially with certain
food. Bread and meat are difficult, flaky fish and soft chicken, cake
and biscuits are ok .
Avoid fizzy drinks as you can not burp easily and may end up feeling
quite bloated.
How to eat?
Sounds patronising? Wrong. You really need to be aware of this
aspect.
1.
2.
3.
4.
5.
Eat sitting upright
Take small mouthfuls, bitesize only
Chew very very well
Eat slowly and swallow small amount at a time.
Wash food down with liquids
Problems and complications
Soon after operation
1. Pain: usually minimal rare after key hole surgery and will need
pain killers for first few days
2. Bruising can be an eyesore but harmless lasts about 6-8 weeks
3. Infection: very rare rare after key hole surgery
4. Minor bleeding from skin wound is of no concern but may lead
to anxiety
5. Clots in the leg are rare after key hole surgery . They can be
prevented by being mobile and keeping yourself well
hydrated. You may need to have clot prevention injections if
you had an open operation or had clots in the past. For the
same reasons long flights are usually best avoided in first few
weeks.
6. Anesthetic complications: they are rare and general to all
operations
7. Injuries bleeding and open operation: In a specialist practice
these are extremely rare.They are largely preventable .
However, injury to blood vessels, bowel, oesophagus and
spleen have all been reported
8. Total dysphagia: If you can not or have major difficulty in
swallowing straight after operation there is a problem and the
wrap or repair of hiatus may be too tight. This may mean a
reoperation
extremely rare
9. Sudden sever chest pain usually needs to be taken seriously.
If a heart attack and lung clot ( Pulmonary embolus ) has been
ruled out then failure of the operation is a possibility.
However , more commonly this may be due to accumulated
gas or wind in the stomach ( gas bloat) or spasms in your
gullet Extremely Rare
Intermediate and Long term problems:
1.Hiccups, chest pain and persistent shoulder tip pain
These can happen and can be prblematic especially if you had a
giant hiatus hernia repair
2.Gas bloat : sensation of discomfort and fullness in the stomach
be due to accumulated gas or wind in the stomach
3.Diarrhoea: Minor diarrhoea is common but severe disabling
diarrhoea is very very rare and usually results from bruising of vagus
nerve and recovers. Extremely rarely this may be permanent.
4.Permanent Dysphagia can happen in 1% patients and if this is
significant may need treatment with a stretch using endoscopy
but even a reoperation may be needed
5.Flatulence : is almost invariable and will happen in most
patients
6.Recurrence or return of reflux symptom does occur and usually
needs top up with PPI medicines. Rarely redo surgery may be
needed.
Message :
Information is power. Knowledge allows you to make an informed
choice for yourself. Please weigh up the pros and cons. No operation
is perfect and quest to improve results of this procedure goes on.
However, if you are the correct person to have this operation and if
it is executed expertly this operation can transform your life. Thank
you for reading this article.