Introduction
If a person is suffering from heartburn or reflux, laparoscopic anti-reflux surgery may be advised by the general practitioner or a surgeon.
This condition is known as gastro-oesophageal reflux disease. (GORD)
This brochure has been composed to provide you with additional information about the disease as well as the treatment thereof
Gastro-Oesophageal Reflux Disease is characterised by one or more of the following symptoms:
Heartburn
Heartburn is a burning sensation which extends from the upper abdomen into the thorax. The burning sensation may extend to the throat, or even to the ears.
Difficulty in Swallowing
Solid food or liquids can stick in the oesophagus. Repeated swallowing efforts must then be undertaken, or fluids must be swallowed to enable the obstructed food to descend into the stomach. Pain during swallowing can occur, particularly with acid foods, e.g. orange juice.
Reflux and Regurgitation
Reflux and regurgitation occur whenever acid or food from the stomach regurtitate into the mouth. This may occur in the upright position, during bending or in the lying down position. Some individuals feel as if they are re-chewing their food after their meal. The symptoms may arise e/g when bending over to clean one's teeth, or fastening one's shoe laces. During the night regurgitation may take place to such a degree that a feeling of obstruction occurs.
Chest Pain
Chest pain may vary from sporadic pain to severe almost constant pain. On occasion the patient may consult a heart specialist for examination of the chest pain.
Asthma, chronic bronchitis, chronic cough and hoarseness can occur as the result of GORD. In 80% of adults with asthma, the asthma is exacerbated by GORD.
After food has been chewed, it is swallowed via the oesophagus to reach the stomach. The oesophagus represents a long tube which connects the pharynx with the stomach. The inner surface of the oesophagus is lined with mucous membrane. The outer lining of the oesophagus consists of two layers of muscle, viz the circular fibres and a longitudinal layer. The muscles of the oesophagus are responsible for the contraction of the oesophagus in order to propel the food into the stomach. These contractions constitute the wave like activity of the oesophagus stoamch and intestine which is known as peristalsis.
The oesophagus extends from the throat or pharynx to the stomach. The oesophagus passes through an opening in the diaphragm. This opening is known as the diaphragmatic hiatus. Below the hiatus, the oesophagus becomes continuous with the stomach. The hiatus consists of muscle fibres which arise from the diaphragm and are arranged around the lower end of the oesophagus.
At the lower end of the oesophagus at the junction with the stomach there is a circular muscle present. The oesophagus joins the stomach at an angle . This circular muscle and the angle of the stomach , as well as the muscles around the opening in the diaphragm, are all involved in creating a valve between the oesophagus and the stomach. This valve works as a uni-directional one allowing the food to pass into the stomach. Thevlave closes after swallowing to prevent the acidic stomach contents from regurgitating into the oesophagus. In the event that the valve is not functioning properly, excessive acidic stomach contents from the stomach may regurgitate into the oesophagus. The result of such regurgitation are the symptoms of GORD with eventual damage to the distal oesophagus.
Some people are born with a poorly functioning valve between the oesophagus and the stomach. A hiatus hernia is often present in cases of GORD. GORD can also occur in the absence of an hiatus hernia.
Specific foods can produce GORD
These include fatty foods, strongly spiced foods, certain medications, tight clothes, smoking, alcohol, and coffee. Exercise or body position e.g bending or lying down may also lead to GORD. Stress also plays a role. All the above mentioned causes can cause laxness of the valve. As a result acid leaks back into the mouth and causes the symptoms.
The oesophagus extends from the mouth or pharynx to the stomach which it reaches by passing through an opening in the muscular diaphragm. This opening is known as the hiatus. The oesophagus joins the stomach below the diaphragm in the abdominal cavity. On occasion the opening in the diaphragm is larger than normal and this may cause upper portion or cardia of the stomach to move cranially and come to lie in the thorax. The connection between the oesophagus and the stomach is now situated above the diaphragm in the thorax, instead of in the abdominal cavity. This type of hernia is known as a sliding or hiatus hernia.
The appearance of the valve or sphincter as seen through the Gastroscope
The normal valve or sphincter is usually closed. It can be examined through the gastroscope which is used to examine the oesophagus and stomach. Photos can be taken of the valve.The gastroscope can be manipulated into a position in which retrograde visualisation of the junction between oesophagus can be performed.When viewed from above the valve is usually closed
The gastroscope is passed throughthe valve into the stomach. When viewed from below the valve usually closes fairly tightly around the gastroscope. The appearance of an Hiatus Hernia. With the gastroscope the oesophagus and the portion of the stomach above the opening in the diaphragm can be seen. The valve is open and a portion of the stomach is visible above the diaphragm. The hiatus hernia can also be visualised from the stomach by retroflexion of the gastroscope.
The hiatus hernia as seen through the gastroscope from above. The ulcers in the oesophagus are clearly visible. The junction between the oesophagus and stomach is visualised. The portion of the stomach which has been displaced into the thorax can also be seen.The opening in the diaphragm as seen from below as well as the portion of the stomach which has entered the thorax. The valve is wide and open. The lower end oesophagus is visualised and is recognisable by the pink mucous membrane.
With repeated exposure of the mucous membrane of the distal oesophagus to acid from the stomach, damage to the mucous membrane occurs. This is in effect a chemical burn wound of the distal oesophagus, which can vary from slight redness and inflammation to severe damage with chronic ulceration.
The damage can extend to the muscular layers of the oesophagus, and this may lead to inefficient contraction of the oesophagus. This results in weakened peristaltic contractions. The oesophagus attempts to heal, and like any other wound and particularly burn wounds, this results in scar formation. Scar formation in the oesophagus causes contraction in the length and breadth of the organ. These changes can lead to stricture and even shortening of the oesophagus.
Reflux can lead to inflammation, ulcers, and narrowing of the oesophagus.
Stricture as the consequence of chronic ulceration of the oesophagus due to an hiatus hernia with reflux.
Barrett's oesophagus
In 10 to 15% of patients with long standing and chronic reflux, the oesophageal mucous membrane undergoes such damage that the mucous membrane undergoes change in its cell structure to a form nearer to that of stomach mucous membrane in an attempt to pro-tect itself. This process is known as Barrett's oesophagus. In a small percentage of cases this abnormal mucous membrane can lead to cancer of the oesophagus. When Barrett's oesophagus is present the risk of cancer of the distal oesophagus is increased by 30 to 40 times more than the normal population. Figures as high as 10% incidence of oesophageal cancer have been reported in the medical literature. For this reason it is important to follow up cases of Barrett's oesophagus on a one or two year basis with repeated gastrosco-pies. During the examination a biopsy of the mucous membrane is taken and sent for histo-pathological examination. In this way it can be determined whether any undesirable changes have occurred. If such is the case, the Barrett's oesophagus can be treated timeously.
Certain procedures are needed to determine the cause of the symptoms of GORD and the extent of the disease, and thereby decide on the optimal treatment. It is essential to evaluate the disease to determine whether operation is needed, and whether the patient will benefit from the procedure. It must also be determined which type of operation will be of the most benefit to the patient.
The following examinations may have to be performed:
The oesophagus and stomach are examined using a long pliable tubular instrument called a gastroscope. The gastroscope may be of the fibre-optic type or the more modern version viz a video gastroscope. The video gastroscope projects the image on to a screen. A video recording or a computer may be coupled to the video gastroscope to store the visual material of the examination on either a video or digitally. Special digital video printers may be used to reproduce the images.
A Gastroscopy is usually performed in an well equipped unit or centre. The modern gastroscope is computer coupled with digital intensification. A central processing unit controls the camera function of the gastroscope.
Preparation for gastroscopy:
The patient is instructed not to drink or eat or smoke from 22.00 on the night prior to the procedure. No antacids or stomach medication are to be taken for a 24 hour period prior to the procedure.
Before the examination is performed, the patient completes an information form in which all the previous medical history is provided. Consent for the procedure and permission for the administration of sedation is signed for.
The procedure is performed with the patient lying on his left side on an examination couch. The examination is usually carried out under conscious sedation.
An oxymeter is attached to the patient's finger to determine the oxygen concentration of the blood as well as the pulse rate during the procedure.
It is common to spray the back of the throat with a local anaesthetic spray. The gastroscope is then placed in the back of the throat. The patient is instructed to swallow and during this swallo the gastroscope is advanced into the oesophagus, and the oesophagus, stomach and the first portion of the duodenum are examined.
During the gastroscopy biopsies may be taken from any suspicious looking area. The biopsymaterial is sent to a pathological laboratory for histological examination by a histopathologist.
The biopsies are taken via a special biopsy forceps which is passed through a channel in the gastroscope.
Trained staff assists with the procedure
Die biopsietang word deur die gastroskoop geplaas om ‘n biopsie te neem vir ontleding.
Conscious sedation
The procedure can be performed under conscious sedation. It is comparable to light anaesthesia without actually falling asleep, which makes the examination easier to perform. A short term memory loss occurs for the period of the examination. An intra-venous drip is usually put up to allow any necessary drugs to be injected during the procedure to achieve adequate sedation.
After the examination antidotes are injected to convert the effects of the conscious sedation.
After gastroscopy:
After a gastroscopy with conscious sedation, the following instructions must be obeyed;
No food or fluids for the first hour after the examination.
The throat is occasionally anaesthetised and choking can occur.
For the rest of the day:
This examination is performed in an X-Ray department by a radiologist. The patient swallows a Barium solution ( a fluid which is visible on X-ray). X-Ray pictures are taken during the examination of the oesophagus and stomach. In some cases the images may be recorded on a video tape.
The dynamic function of the oesophagus and its anatomy are recorded during the examination. Complicated hiatus hernias, anatomical abnormalities or recurrence of hiatus hernia are often also an indication for this procedure. The examination often provides additional information to that gleaned from the gastroscopy.
Barium can occasionally cause constipation and a light purgative may be taken after the examination, if indicated.
The X-ray image of a Barium Swallow
A chest X-ray showing a hernial sac filled with barium behind the heart shadow.
This examination is performed to determine the muscle strength of theoesophagus as well as the force with which the valve contracts and relaxes. The examination also determines the pressures which occur when the oesophagus contracts. The length of the oesophagus, hiatus hernia and inferior valve or sphincter can also be measured. Abnormal oesophageal contractions and abnormalities can also be identified.
The data which is obtained during oesophageal manometry is fed into a computer. Several graphs and data tables are created which provide information regarding the upper and lower oesophageal sphincters as well as the pressures. This data is used to make the further diagnosis and treatment of GORD.
The data is fed into a Computer and analysed. The manometric catheter contains sensors which measure pressures in the oesophagus and the valve. Several catheters may be used. Shown above is a "solid state" catheter with electronic sensors which are very accurate.
The examination is performed by passing a narrow tube through the nose, which has been lightly anaesthetised. The patient swallows as the tube is advanced until it is resting in the stomach. The tube is then coupled to a sensor which registers the pressures in various parts of the area examined and the data is fed into the computer. The examination is performed in the consulting rooms and takes about 40 minutes. After the examination normal daily activities can be resumed.
Die ondersoek word uitgevoer om te bepaal of daar suur teruglek vanaf die maag na die slukderm . Die ondersoek word gewoonlik na die esofageale manometrie uitgevoer aangesien die klep se posisie bepaal moet word. Die pHmetrie ondersoek strek oor 'n 24 uur tydperk.
Die ondersoek bestaan daaruit dat 'n dun plastiekbedekte draadjie ('n elektrode) deur die neus geplaas word tot in die slukderm bokant die aansluiting tussen die slukderm en die maag. Die elektrode word gekonnekteer aan 'n klein digitale opnemer wat met 'n battery werk.
Die pH word bepaal en gestoor deur hierdie mobiele reke-naartjie.’n Spesiale kateter of elektrode sensor word in die slukderm geplaas wat die pH meet.
Die pH metrie ondersoek meet die pH onder in die slukderm en word grafies voorgestel en ontleed volgens sekere parameters. Simptoomkorrelasie word ook uitgevoer.
Points to take note of during the 24 hour Ph measurement procedure
The following should be avoided:
The actual performance of the examination.
The time is indicated on asmall screen on the apparatus.
A form is given to the patient. The symptoms which the patient experiences must be noted along with the time at which they occurred. The notation of the time when the symptoms occurred is needed to correlate the symptoms with the pH in the oesophagus.
After 24 hours the patient reports to the consulting rooms, where the electrode is removed, and the information is fed into the computer. An analysis of the examination is done. Several graphs are created to help evaluate the degree of reflux.
Other investigations
In some cases it may be necessary to perform additional examinations to evaluate a specific problem.
We will be duty bound to inform you if such is the case.
Weight loss, cessation of smoking, the use of alcohol, a change of eating and sleeping habits can often relieve symptoms. Avoid tight clothing and elevate the top end of the bed. Reduce one's stress levels.
In many case the use of commercial antacids can control the symptoms. In the event that the symptoms of GORD persist despite the adoption of the above measures, treatment by a doctor is indicated. Treatment can vary from antacids and drugs which improve peristalsis to strong acid inhibiting medicines. Prescribed medications are more effective in the reduction of acid production than commercial products, and thus control symptoms better. These medicaments will probably have to be tn for a long period if not for life if the symptoms are to be controlled, since medications alone cannot restore the valve to its normal function. The treatment will in all likelihood produce relief of symptoms during the taking of the medicine. With return of symptoms directly medication is terminated. Or the symptoms are not entirely cured but only reduced, when the dosage must be increased to achieve relief.
Unfortunately the medication is very expensive.
Surgery offers effective relief of the symptoms of GORD. Cost implications regarding medicines, the complications of GORD and the prospect of lifelong medication, are often causes of consideration to be given to surgery. Medicines cannot make a valve function properly and the disease often flares up after cessation of therapy.The operation was previously performed either via an abdominal or trans-thoracic approach. A long vertical incision in the upper abdomen or a transverse incision through the left lower thorax was employed with considerable post operative pain and discomfort and a long period of convalescence with residual surgical scars.The operation is currently being performed by means of laparoscopic surgery. This method involves a short period of hospitalisation for approximately 48 hours, a good cosmetic result, minimal pain, rapid recovery, and a quick return to normal work and other activities.
The laparoscope is a long tubular telescope lens containing a light source for illumination of the operational field. A special long tubular lens, 10 millimeter in width is used to perform the operation. The lens is coupled to a special video camera. This lens and camera system is known as aa video laparoscope. Hene the term laparoscopic surgery.The operation is performed under general anaestthesia.
The laparascope is coupled to a special video camera which processes the information. The moderns laparoscopic image is digitally enhanced..The camera also possesses additional specialised functions.
This type of surgery is also known in the layman's literature as laser surgery, keyhole or buttonhole surgery. The abdominal cavity is distended with carbon dioxide via an insufflator, which is placed in the abdominal cavity via a special needle. The gas filled abdomen isneeded to create space in which to perform the procedure.
The insufflator is an apparatus which regulates the pressure and flow of carbon dioxide to the abdominal cavity. Several safety mechanisms are incorporated in the apparatus. The apparatus also heats the carbon dioxide gas as it passes through the instrument.
Then a 10 mm incision is made just above the umbilicus. A special tube containing avalve to prevent any escape of carbon dioxide is placed through the incision into the abdominal cavity. This tube is known as a trochar and cannula. The trochar is removed and the cannula left in situ. The laparo-scope is then passed through the cannula in order to view the scene. The image is displayed on a video screen which the surgeon views . The image is enlarged 10 to 20 times on the screen in front of the surgeon. Two such screens are utilised - one for the surgeon and theatre sister and another for one of the two assistant doctors who assist with opera-tion. One of the two assistant doctors control the camera. A further four small 5 mm incisions are made to introduce other trochars withtheir respec-tive cannulae. Operational instruments are then passed through these additional cannulae. The positions of the various trochars which allow access to the abdominal cavity
The operation consists of the following steps:
The valve area where the oesophagus and stomach are in continuity is opened. The stomach is loosened and replaced in the abdominal cavity. The short blood vessels between the spleen and the stomach are divided to increase mobility of the upper fundal end of the stomach. The defect in the diaphragm, the hiatus, is sewn up and reformed. ( The hiatus hernia repair). A valve is made between the oesophagus and the stomach, by utilising a portion of the somewhat redundant stomach in the form of a collar around the distal oesophagus. ( The valve repair).
The oesophagus and stomach are freed and the stomach is replaced in the abdomen. The hiatus through the diaphragm is narrowed to its correct width by pla-cing stitches through the surroun-ding muscle. The short blood vessels between the stomach and the spleen are divided to free the stomach and make it more mobile. The stomach is placed posterior to the oesophagus and stitched into position. The valve is completed by forming a 360 degree collar around the distal oesophagus with the tissues of the stomach. This valve creation procedure is known as a Nissen Fundoplasty. Dr Rudlof Nissen described the technique for the procedure which now carries his eponym. The Toupet anti-reflux procedure differs from the Nissen in that a collar of only 270 degrees is made. This type of valve creation proce-dure was described by the French-man, Toupet. The Nissen valve is visualised through a gastroscope in a back-ward view from within the stomach. The previous wide opening has now been replaced by a valve which will control the reflux.
On completion of the operation and the anaesthetic, the patient is transferred to the recovery room within the theatre complex. Directly the patient is awake he is transferred to the ward. The patient is usually in the theatre complex for about an hour.Analgesics are given after the operation when the patient is in a stable condition. Most patients experience pain in the shoulders and thorax and do not usually complain of abdominal pain. This pain is referred pain as a result of the surgical trauma to the diaphragm. It is seldom necessary to give more than one or two analgesic injections.
Booking of the operation and hospital is performed at the Consulting rooms after the physical examination had been completed. The necessary admission forms which contain all the account and medical aid information will be provided. The forms are filled in by the patient at home and on admission are taken to the hospital. The medical aid provider has usually to be informed of the planned admission and operation. The fund requires certain tariff codes for the operation. These codes can be obtained from the consulting rooms.
You must bring with you: I.D. Document, Medical Aid Society membership card, Empowerment number from the Medical Aid society, Chronic medication, Pyjamas, Toiletries, and Reading matter.
Admission to the hospital occurs at 06.00 on the morning of the procedure.
The patient is not allowed to eat, drink or smoke from 22.00 on the previous night. It is important that the patient be in a fasting condition on arrival at the hospital at 06.00 . Early arrival at the admission office is advisable in order to be prepared for the theatre in the ward, particularly in the case of those patients who are scheduled to be operated upon at the beginning of the list.
Private pateints must arrange pre payment with the hospital authorities. Quotations can be applied for. Please leave valuables and jewelry at home.
The operation is known as:
Laparoscopic Hiatus hernia repair with Nissen Fundoplasty.
The patient signs consent for the administration of a general
anaesthetic to be given and the operation to be performed.
The anaesthetic practice is Dr Gerry Brink and partners.
The anaesthetic will be rendered by one of the specialist anaesthetists from the practice.
A pre-operative information document will be given to the patient.
A form for the anaesthetist must be completed at home prior to admission which must contain all the previous medical history of the patient and former treat-ments. All the medical history as well as all the medications being used must be given to the anaesthetist. All medicines must be listed even commercial preparations such as headache pills, powders, sleeping pills, slimming aids, and obviously any heart, blood pressure and other prescribed medicines.
In the event that there may be any questions or querries about the anaesthetist regarding fees or associate anaesthetic problems, the anaesthetists should be contacted at the telephone numbers which are available in the information form. Please read the information form diligently and make yourself aware of its content.
The total period of hospitalisation is usually two days. If the operation is performed on a Tuesday, the admission takes place on Tuesday morning at about 06.00.Discharge is on Thursday morning and the patient can go home by about 09.00. In the event that unforeseen incidents occur, the period of hospitalisation may have to be prolonged.
A physio-therapist will visit the patient during their stay in hospital to provide pre and post operative lung physio-therapy treatment. In this manner lung complications and post anaesthetic problems are reduced or eliminated. Early mobilisation and activity are encouraged by the physio-therapist and nursing staff in the hospital. The patient will also receive instructions on how to stand up from the lying position to the erect to avoid stress or pressure on the abdomen.
No abdominal or any other hair should be shaved off. The umbilicus is cleaned in the hospital. After admission to the ward, prior to the operation, the patient takes a bath for which anti-septic soap is provided. An intra-venous drip will be put up by the nursing staff for intra-venous fluid administration.
At the time of discharge from the hospital the patient must ensure that the following items are received from the Ward Sister:
Any home medication which was handed during admission.
Analgesics and the balance of all prescribed medicines which were being taken during the period of hospitalisation.
Any special medication which the surgeon may have prescribed.
Two weeks are normally required before return to full employment. However, if the work is more sedentary in nature or of an administrative nature, normal work may be resumed before two weeks have elapsed, provided there is no physical stress involved. A sick certificate will be issued during the early wound healing period visit to the consulting rooms after the operation.
After discharge of the patient wound care is performed every Friday morning between 08.00 and 10.00 hours at the consulting rooms. No appointments are needed. The registered nurses are on duty and waiting to assist the patients.
The patient must attend the first wound care clinic on the Friday after the operation on Tuesday. The nursing staff will change the dressings and replace the plasters. Arrangements will be made for the removal of stitches or metal clips. The stitches or metal clips are normally removed 12 to 14 days after the operation. Any abnormality redness, swelling or drainage from the wound must be immediately reported.
The patient should feel better day by day.
The following symptoms or signs must immediately be reported to the consulting rooms of the surgeon.
Fever, bleeding, increasing abdominal pain, or chest pain, discomfort or swelling, cold shivers, continuous cough, shortness of breath, inability to swallow or drainage from the wound.
A follow up consultation and evaluation follows 6 - 8 weeks after the operation. This appointment is be made by appointment during the first wound care visit at the consulting rooms or at discharge from the hospital. During the follow up consultation the oesophagus and valve are checked with oesophageal manometry and gastroscopy. The oesophageal ulcers can sometimes be healed in cases of Barrett's oesophagus.
Return to normal work can take place in the interval between discharge and the follow up consultation.
A private dietician will visit the patient in hospital and a further recovery diet will be planned for the patient's specific needs. It is important to follow the dietary instructions and in tis manner to hasten the recovery from the operation. No alcohol may be taken in the recovery period. For the first fewe days after the operation the patient is only allowed to drink liquids. Fizzy gas containing liquids are advised to encourage the patient to learn to break winds in the form of burps. Solid foods must be chewed very finely and it is very important to learn to eat slowly. Normally patients lose 5 to 10% of their body mass after the operation. It is usually regained
The patient is encouraged to return to his/her normal acitivities e.g bath, shower, driving a motor vehicle, climbing steps, picking up light objects, work and sexual intercourse. During the first three weeks after the operation no heavy objects should be lifted or picked up. During the three too six week post operative period light exercise is encouraged such as walking, cycling, and limited stretch exercises. Physical stress and contact sports must be avoided entirely in the first six post operative weeks.
Driving a motor car can be undertaken a few days after the operation directly physical movement is painless and easy.
After the 6 week post-operative visit, all normal activities can be resumed, even contact sports, gymnasium exercises etc.
Numerous studies have already demonstrated that the vast majority of patients who have undergone laparoscopic surgery for GIRS, are symptom free with amarked improvement in their quality of life.
This type of surgery is much safer than the former traditional surgery - indeed ten times safer according to published studies. However, complications do occasionally occur such as may occur with any other type of surgery.
Specialist anaesthetists are used for all the operations.
In the event that the patient has experienced previous problems associated with anaesthesia, it is imperative that the anaesthetist be informed thereof. Anaesthetics are only given after mature consideration and are performed with the utmost degree of safety for the patient.
Some patients experience nausea from the administration of post-operative analgesics. Allergic reactions to specific analgesics can also occur, but are not common. Routine injections to prevent such nausea are routine given to prevent or inhibit this problem.
Bleeding and damage to other organs in the vicinity of the oesophagus and stomach
As is the case with all forms of surgery, these complications are always a factor. With laparoscopic surgery the operative field image is enlarged 20 times on the video screen. Special preventative measures are taken during laparoscopic surgery to limit or eliminate these complications. Blood loss during laparoscopic surgery is very little and it is uncommon for a patient to require a blood transfusion after or during normal laparoscopic surgery. This type of surgery is thus particularly useful in the event that the patient's religious beliefs offer opposition to blood transfusions. Slight bleeding does occasionally occur in the small surgical incisions which occasionally require drainage.
With surgery, infection of the wound or the abdominal cavity is an ever present danger. Specific wound care is always performed to avoid any risk of infection. Wound infection in laparoscopic surgery cases is unusual and rare.
Deep venous thrombosis or blood clots in the calf veins are an ever present risk in all forms of surgery. Pre-operative preventative measures are taken by giving sub-cutaneous injections of heparin. This injection is given on a daily basis while in the hospital. Physio-therapy to maintain good lung function is given and early ambulation or activity is encouraged to prevent possible deep vein thrombosis. Patients at risk are provided with special anti-thrombotic stockings to reduce the chance of developing deep calf vein thrombosis.
Conversion of a laparoscopic procedure to a traditional open surgical operation
In a very small percentage of cases it has been found that it is not possible or safe to perform laparoscopic surgery. If the surgeon decides that to complete the procedure or to revert to traditional open surgery, it should notbe considered as a complication, but as a sound surgical decision since there is never a good reason to subject a patient to a hazardous operation. Factors which may contribute to such a decision include previous abdominal operations resultant scar formation or adhesions, previous infections of the abdominal cavity which have produced adhesions, previous diaphragmatic hernia operations, and other complications such as bleeding , or where in other cases the completion of the operation laparoscopically is not safe because of technical problems encountered. The decision to revert to traditional surgery is based on the procedure which is safest for the patient.
Side-effects of the operation
Long term side effects after the operation are unusual.
Some patients complain of difficulty in swallowing in the immediate post operative period. The normal swallowing mechanism returns to normal within a one to three month period after the operation. It is seldom necessary to resort to post operative dilatation of the oesophagus after the operation.
In the event that a stricture of the oesophagus was present prior to the operation, it may on occasion be necessary to perform dilatation of the oesophagus after healing of the oesophagus. It is very rare to have to resort to further operation.
Most patients find that they can break winds after the operation but there is a small percentage of patients who find difficulty in doing so. This may lead to abdominal discomfort and distension and increased passage of flatus. In rare cases there isaninability to vomit after the operation.
It is unusual that the symptoms of Gastro intestianl reflux do not improve after the operation.
Further questions
In the event that there are any other questions concerning gastro-intestinal reflux disease, please do not hesitate to make enquiries from the personnel at the consulting rooms, nursing staff or the surgeon himself. All questions will be answered to the best of their ability.
Laparoscopic Hiatus Hernia repair and Nissen Fundoplasty
A Private Dietician will visit you in the hospital on the day after the operation. It is important to obey the dietary instructions to hasten you recovery as well as to ensure the success of the operative procedure. No alcohol may be consumed during the recovery period.
A follow up appointment is made for a date 6 weeks after the operation. This is for evaluation and examination. You may return to your normal work after 2 weeks.
You must ensure that at the time of your discharge from the hospital you are in possession of the following items which must be obtained from the Nursing staff.
1. Medications which you were taking prior to admission and which you handed in prior to admission
2. Analgesics and the balance of all prescribed medicines which were prescribed during you period of hospitalisation.