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Laparoscopic Anti-Reflux Surgery
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You May Have These Symptoms
If you have experienced heartburn, you may have gastroesophageal reflux disease (GERD). Other symptoms may include: indigestion, regurgitation, difficulty sleeping after eating, vomiting, difficulty swallowing, chronic coughing or wheezing, hoarseness or a sore throat. You may experience these symptoms at least once a month.
[back to top]What is Heartburn?
Heartburn is a symptom of GERD. Heartburn is a harsh burning sensation usually located in the center of your chest. The sensation may move through your upper abdomen, chest, throat, and/or neck.
What Causes GERD?
When you eat, food passes from your mouth, through a swallowing tube called the esophagus, and then into the stomach. Located at the lower end of the esophagus is functional valve called the lower esophageal sphincter (LES). The LES is a one-way valve that permits food to pass to the stomach. Normally, the valve closes after the food has reached the stomach and prevents stomach acids from backing up or "refluxing" back into your esophagus. Some reflux is normal and usually clears. GERD occurs when the valve fails and stomach acids flow back and burn the lower esophagus. The reflux persists over a period of time, the esophagus becomes irritated and inflamed, causing heartburn and sometimes damage to the esophagus.
What Factors Contribute to GERD?
People are sometimes born with a weak valve. Others may be affected by eating fatty or spicy foods, taking certain medications, drinking alcohol, smoking, wearing tight clothes, energetic exercising or changing body positions (lying down or bending).
Sometimes people may have a hiatal hernia. A hiatal hernia is caused when there is an opening in the diaphragm. The diaphragm is a flat muscle that separates the lungs from the abdomen. When an opening in the diaphragm enlarges, a portion of the lower esophagus and in some cases, the upper stomach moves into the opening.
What Treatments are Available?
You and your physician can work together to treat GERD through three progressive steps:
1. Lifestyle Changes - You may be instructed to: change your diet to reduce or ease symptoms. Certain foods can relax the LES or increase acid in your stomach. Avoid the following:To relieve the symptoms of GERD:
- Beverages with and without caffeine (carbonated drinks, coffee, tea)
- Chocolate
- Citrus foods
- Fatty and fried foods
- Onions
- Peppermint
- Spicy foods
- Tomatoes
2. Medical Treatment
- Eat several small-volume meals daily instead of three large meals
- After eating: avoid bending over, lying down or sleeping until 2-4 hours have passed
- Stop smoking and drinking alcohol (Both increase stomach acid and irritation) (Alcohol opens the LES)
- Maintain your recommended weight
- Lose weight if necessary
- Exercise after speaking with your physician regarding an exercise program
- Wear loose fitting clothing, belts
- Raise the head of your bed 6-8 inches with books or blocks or put a wedge under the head of your mattress or sleep over several pillows
A. Drug Therapy - If your symptoms persist after lifestyle changes, drug therapy may be discussed with your physician. The use of antacids help to neutralize stomach acids and over-the counter- antacids decrease stomach acids that are produced. These may relieve the symptoms; however, in some people, they may cause constipation or diarrhea side effects. Your physician may recommend H-2 blockers (ranitidine, cimetidine, famotidine, nizatidine). H-2 blockers can cause confusion in elderly people. Cimetidine and ranitidine may increase the effects of alcoholic beverages. Cimeditine should be taken at least one hour apart from antacids or antacids will decrease the drug's effectiveness. If you are a male and need to take H-2 blockers on a long term basis, talk with your physician about the rare possibility that your sperm count may be affected. Check with your physician about avoiding taking aspirin or anti-inflammatory drugs. These drugs can affect the protective lining of your stomach.3. Surgery - If you do not respond well to life style changes or drug therapy, require dilation procedures or need medication continually to control symptoms, or have to live with your condition, you may be asked to consider undergoing a surgical procedure. In the past, a large abdominal incision was made and resulted in significant pain after surgery. The hospital stay was 7-10 days and recovery at home was six weeks or more. With recent advances, the technique has been modified using a laparoscopic (advanced minimally invasive) approach that avoids the need for a large abdominal incision. Pain is significantly less. The length of in-hospital stay averages 2 days and return to work can occur within 2 weeks. Your physician may recommend laparoscopic anti-reflux surgery, also known as, laparoscopic nissen fundoplication.
In addition to the H-2 blockers, your physician may wish to prescribe more powerful medications called proton pump inhibitors. Some of these generic prescription drugs are metoclopramide, cisapride, and bethanechol chloride. Metoclopramide acts to empty the stomach faster. Some side effects may occur from these drugs. Metoclopramide can cause fatigue or other more serious effects. Cisapride can cause abdominal cramps, diarrhea, constipation or the jitters. If bethanechol is taken too soon after eating, nausea and vomiting may occur.
Your physician may prescribe drugs that stop the production of stomach acid. Examples include omeprazole and lansoprazole. These drugs are usually prescribed for short-term use. Side effects of omeprazole are abdominal or stomach pain. Lansoprazole can cause diarrhea and stomach pain or nausea.
B. Esophageal Dilation - If you have a narrowing in your esophagus or start to have trouble swallowing, your physician may recommend you have one or several dilatation procedures to enlarge your esophagus. Usually this procedure is performed after you have intravenous medication to keep you free of pain and comfortable. Flexible rubber tubes (bougies) of increasingly larger sizes are placed into your esophagus to make it wider.
What is Laparoscopic Anti-Reflux (Nissen Fundoplication) Surgery?
A nissen fundoplication is one surgical technique performed on the esophagus and stomach to treat GERD. The patient is given general anesthesia. As many as five (5) small incisions are made in the abdomen. One is used for the laparoscope which is attached to a camera that sends images to a video monitor. The other four incisions are used to hold or manipulate tissue in the abdomen. Carbon dioxide gas is insufflated into the abdominal cavity to allow room to work and allow the surgeon to see. Parts of the esophagus and stomach are freed from surrounding tissue. If the opening in the diaphragm is too large around the esophagus (hiatal hernia), sutures are placed to tighten it. A flexible rubber tube (bougie) is passed down the esophagus and 2-3 sutures are used to tighten the hiatus.
The fundus of the stomach (portion closest to the esophagus) is wrapped around the esophagus. A flexible rubber tube (bougie) is passed down the esophagus to prevent the wrap from being too tight. To keep the wrap in place, the fundus (now on right side of esophagus) is sutured to the portion of the stomach located on the left side. A completed fundoplication resembles a bun surrounding a hot dog or buttoned shirt collar. The result is creating a one way valve effect in the esophagus to permit food to pass into the stomach and prevent stomach acid from flowing back into the esophagus. At the end of the surgery, carbon dioxide gas is removed.
Laparoscopic nissen fundoplication is considered a safe and effective treatment for GERD when previous medical management fails.
What are Expected Results After Having Laparoscopic Anti-Reflux Surgery Versus Having Large Abdominal Surgery?
- Many studies show most patients are either free of symptoms or have significant improvement of symptoms from GERD
- Decreased post operative pain
- Shortened hospital stay
- More rapid return to work
- Minimally sized incisions with a better cosmetic result
What are the Risks of Having Laparoscopic Anti-Reflux Surgery?
Though the surgery is considered safe, complications may occur as for any surgery. Complications that may occur during surgery include:
- Bleeding
- Injury to organs such as liver, stomach, esophagus or spleen
- Adverse response to general anesthesia
Even though infrequent, complications that may occur after surgery include:
- Infection involving the wound, blood or abdomen
- Increased bloating or gas
- An inability to vomit
- Difficulty in swallowing
- Failure of surgery to eliminate GERD
You and your surgeon may wish to discuss these and whether your risks of having laparoscopic anti-reflux surgery is less than the risks of leaving the disease untreated.
What Side Effects Occur with Laparoscopic Nissen Fundoplication Surgery?
Generally, there are no long term side effects. Some patients have temporary difficulty swallowing immediately after surgery. If present, this usually lasts one to three weeks. Patients may have limited ability to belch and/or vomit after this surgery. Some patients have stomach bloating.
What Happens if Surgery Cannot be Performed by Laparoscopic Technique?
Sometimes it is not possible for the surgeon to use the laparoscopic technique because it may be difficult to see or handle organs safely. The surgeon decides to perform an open procedure either before or during the surgery. The surgeon may decide to convert the laparoscopic surgery to an open procedure in certain situations and for patient safety. Though very infrequent, when conversion to an open technique occurs, it should not be considered a failure of the procedure. Factors that might increase the possibility of changing to an "open" procedure are obesity, previous abdominal surgery causing dense scar tissue or bleeding during surgery.
What can I Expect to Happen Before Having Laparoscopic Surgery?
- A thorough medical evaluation will be made by your physician. Several diagnostic tests may be needed. You may have blood tests, an electrocardiogram (ECG or EKG) or chest x-ray to check your heart and lungs. You and your physician will discuss whether or not this surgery will help you.
- Taking no food of liquids after midnight the night before the surgery. This decreases the risk of vomiting after you receive anesthesia.
- If taking medications daily, discuss the need to take them with your doctor prior to the morning of surgery (with a sip of water). If taking blood thinners, aspirin or arthritis medications, discuss the proper time to stop these before the surgery date (day).
- Speak with the anesthesiologist before surgery to discuss anesthesia and keeping you free of pain during surgery and pain management postoperatively.
- Arrange for someone to drive you to the hospital the day of surgery and take you home when you are discharged to go home from the hospital.
What can I Expect the Day of Surgery?
- Arrive at the hospital on the day and time you are instructed.
- Sign a written consent authorizing your physician to perform surgery.
- Receive a small needle/catheter in your vein to provide medication before, during and after your surgery.
- Receive preoperative medications as necessary.
- Undergo general anesthesia (asleep) prior to your surgery.
- Understand the procedure may last several hours.
- Going to the recovery room after surgery and having your blood pressure, pulse, and respirations closely monitored until you are fully awake.
- Having your blood pressure, pulse, and respirations closely monitored.
- Going back to your room.
- Staying in the hospital the night of surgery and additional days as needed.
What can I Expect After Surgery?
- Engage in light activity at home.
- Experience mild post operative pain and having pain medication available as needed.
- Feeling some tightness from swelling of the esophagus and some difficulty swallowing may happen. This should gradually go away within 2 months.
- Not having to take anti-reflux medications after surgery.
- Having a modified diet starting with liquids followed by gradually taking solid foods. Eat small meals frequently and chew food well. Ask your physician about dietary restrictions after surgery. You may be asked to eat foods such as soup, gelatin, bananas, pudding, or yogurt because they are easy to swallow and digest. Don't gulp to avoid gas bloat and make it easier for swallowing. You may be asked to avoid carbonated drinks for 3-4 weeks.
- Resume normal activities such as showering, stair climbing, working, lifting, driving and having sexual intercourse after discussing these with your physician.
- Call and schedule a follow-up appointment within one to two weeks after surgery. Schedule any additional follow-up appointments.
- Have any stitches removed depending upon the type your physician uses.
- Increase in frequency of passing gas.
When Should I Call My Physician?
Make certain that you call your physician if you have any of the following symptoms:
- Redness around or significant drainage from incisions
- Persistent fever over 101 degrees Fahrenheit or chills
- Persistent and/or productive cough
- Persistent nausea or vomiting
- Prolonged soreness or no relief from prescribed pain medication
- Difficulty swallowing that persists longer than a few weeks
- Any problems that may be related to your surgery or problems you are not sure of
If you have any questions about the need for laparoscopic hernia repair surgery, alternatives, procedure cost, insurance or billing, physician training and experience, or have questions about surgery, you are encouraged to ask office staff or your physician.
Written by:
Horatio Asbun, M.D.
Director of Minimally Invasive Surgery Programs
John Muir Health
Jacklyn J. Schuchardt, RN, MSN, CNOR
Clinical Nurse Specialist, Surgery
John Muir Medical Center, Walnut Creek Campus
Walnut Creek, California
Diane M.Graham, RN, MSN, CNOR
Perioperative Clinical Nurse Specialist, John Muir Medical Center, Concord Campus, Concord, CA