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Nissen Fundoplication


Nissen Fundoplication

 

What Is A Nissen Fundoplication Procedure?

Many patients develop Gastroesphageal Reflux Disease (GERD) after a Heller Myotomy. To avoid the development of the condition where contents of the stomach reflux (back up) into the esophagus, a Nissen Fundoplication may be performed at the same time the esophageal sphincter muscle is cut.

This procedure, performed laparoscopically, involves wrapping the upper part of the stomach around the lower esophageal sphincter to strengthen it.

 

 

THE PROCEDURE

Open Nissen Fundoplication was introduced by Dr Rudolph Nissen in 1951. Studies have shown that more than 90% of patients who undergo the procedure say their symptoms are cured or improved after 10 years. Many surgeons familiar with both approaches believe that the long-term results will be just as good with the laparoscopic approach because the actual fundoplication is performed in exactly the same manner.

A Nissen Fundoplication is the definitive surgical treatment for GERD where medical therapy has failed and to achieve a permanent solution to the problem of acid reflux backup into the stomach.

Nissen Fundoplication involves constructing a new "valve" between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest point of the esophagus — much the way a bun fits around a hot dog.

In the laparoscopic procedure, surgeons use a trocar (a narrow tube-like instrument) to gain access to the abdomen. A laparoscope (a tiny telescope connected to a video camera) is inserted through the trocar, giving the surgeon a magnified view of the patient's internal organs on a television monitor.

Four additional trocars are inserted to accommodate special instrumentation. The surgeon pulls the liver back to expose the junction between the stomach and the esophagus, and the vessels surrounding the stomach are sealed using an instrument such as the Endo Clip* II applier or a harmonic scalpel. After the vessels are cut, the upper portion of the stomach is then wrapped and sutured around the lower end of the esophagus. This produces a new valve. At the same time the hiatus is repaired so as to cure any associated hiatus hernia.

Following the procedure, the small incisions are closed with a dissolving stitch. Within 12 months, the incisions are barely visible.

The Nissen Fundoplication Surgery Advantages

Results are different for each procedure and each patient. Some common advantages of minimally invasive colorectal surgery are:

  • Shorter hospital stay
  • Shorter recovery time
  • Less pain from the incisions
  • Faster return to normal diet
  • Faster return to work or normal activity
  • Better cosmetic healing

PREPARATION FOR SURGERY

Before traveling to Cyprus, as part of your surgery preparation you will complete a detailed specific questionnaire, which will allow our doctors to determine your eligibility for Heller Myotomy procedure.

Ten days prior to your arrival in Cyprus, you will receive all the necessary pre operative instructions, to prepare yourself both physically and mentally for your chosen procedure.

Before your departure your records will be reviewed thoroughly by our surgeon. This includes X-rays and a complete medical and surgical history as well as your specific issues.

After traveling to Cyprus, a new set of X-rays will be taken as well as an in person physical examination. The surgeon and anesthetist will also go through you medical and surgical issues with you. During this visit, your surgeon will discuss your procedure and answer any questions.

Getting your house ready before your surgery

It is also important to get your house ready for after you come home from the hospital. At first it will be harder for you to move around, so arrange your furniture and household items ahead of time to make it easier for you during your rehabilitation.

  • Remove all your throw rugs or anything on the floor that may cause you to trip.
  • Move phone and electrical cords close to the walls.
  • Move necessary personal items you need to reach to shelves and tables that are above your waist level.

Preparation for the hospital

Here are a few things to keep in mind as you pack and prepare for the hospital and recuperation:

Clothing
Getting dressed in the morning helps you feel better, so be sure to bring some comfortable clothing to the hospital:

  • Loose shorts or pants
  • Loose tops or T-shirts
  • Underwear and socks
  • Short robe or pajamas
  • Toiletries

Before surgery

You will need to do a bowel prep to clean the stool out of your colon. Your doctor or nurse will give you more instructions based on the type of prep.

Your work up before having Heller myotomy will include an upper endoscopy to look directly at the esophagus and stomach and take any biopsies, if necessary.

 A swallowing study (x-ray study) is also needed to show if the esophagus is narrowed at its lower end and the condition of the esophagus above the area of narrowing.

You will also have a study that evaluates the ability of the esophageal muscles to push food toward the stomach, and the ability of the LES to relax when you swallow. This is called manometry and involves placing a small catheter lined with pressure sensors down your esophagus. This is done by our Gastroenterologist, specializing in gastrointestinal disease and endoscopy.

 You should not eat or drink anything after midnight the evening before your surgery.

Morning of surgery

Bring all your medicines in their original containers with you to the hospital. You will meet with the anesthesiologist. This doctor will talk to you about general anesthesia. This is a controlled sleep while the surgery is being done so you will not feel any pain or remember the surgery. You will have an IV or intravenous line put in to give you fluid and medicine during your surgery. When it is time for you to go to surgery, your family will be asked to wait in the waiting area. Your doctor will talk to your family there after your surgery is done.

 

RECOVERY AFTER SURGERY

When you wake up after your surgery, you will be in the recovery room. You will stay there until you are awake and your pain is under control. Most patients return to their room after a few hours, but some will need to stay overnight for observation.

You will receive oxygen through a thin tube called a nasal cannula that rests below your nose. A nurse will be monitoring your body temperature, pulse, blood pressure, and oxygen levels.

You will have an analgesia pump device to deliver pain medication into your IV or epidural space (in your spine). You will also have compression boots on your lower legs to help your circulation. They will be taken off when you are able to walk.

Hospital discharge and home instructions

Your diet is slowly increased from ice chips to liquids to solid foods as your intestines start functioning. While you are recovering in the hospital, your nurse will demonstrate how to care for your stoma. You will also receive instructions and be coached through the process of managing your stoma for after your return home.

Before leaving the hospital, our surgeon and staff will help you adjust to recovery in every way possible. You will receive specific instructions and precautions from your surgeon and nursing staff and they will show you safe techniques of simple activities like getting in and out of bed, bathing, going to the bathroom, managing steps at home and getting in and out of a car.

You will be able to leave the hospital when you are:

  • Able to eat a regular diet and drink fluids
  • Passing gas or you have had a bowel movement
  • Passing urine
  • Not having a fever or other signs of infection
  • Walk for short distances
  • Most people are able to go home 2 days after their surgery.

LIFE AFTER NISSEN FUNDOPLICATION

These guidelines give you an overview of what you may expect as part of your
care after you leave the hospital. Be sure to follow your doctor’s discharge
instructions if they are different from what is listed here:

Activities

Most discomfort is in the first week after the operation.

After 48 hours, the dressings can be removed. You can shower, but please avoid submersion in a bath or pool for one week from the time of surgery. Your surgeon will discuss any specific restrictions after the surgery.

It is common to feel a lump at the sites of the operation. This lump is a combination of normal fluid and scar tissue forming in this area. It usually goes away slowly over the first month or two following surgery.

Patients are encouraged to engage in light activity while at home after surgery.

Post operative pain is generally mild although some patients may require prescription pain medication.

Anti-reflux medication is usually not required after surgery.

You will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, lifting, working and engaging in sexual intercourse.

After discharge from the hospital, avoid lifting more than 10 pounds for 2-4 weeks and excessive bending or twisting for 1-2 weeks following surgery.

Avoid driving until you no longer need narcotic pain medication and you feel you can make rapid movements unimpaired by pain. Driving while taking narcotics can impair your ability to drive safely.

You should be able to return to work in 1-2 weeks. If your job involves heavy lifting and light duty is not an option, you may need up to 4 weeks off work to recover

Medications

Your medicines: Take the medicines you were taking before surgery, unless your surgeon has made a change.

  • For pain

Your surgeon will order a prescription pain medicine for you after surgery. As your pain lessens, over the counter pain medicines such as acetaminophen or ibuprofen can be used. They can also be used instead of your prescription for mild pain.

  • For constipation

Prescription pain medicines can cause constipation. Your doctor may order a stool softener to prevent this. You should be back to your normal bowel routine in about 2 weeks. If the stool softener does not work, take Milk of Magnesia. If you still are not getting relief, call your surgeon.

  • For nausea

You may also be given nausea medication if you experience nausea or vomiting from taking your pain medication.It is very important to control any nausea you might experience after your surgery, particularly if the stomach is wrapped partially or completely around the esophagus as part of the surgery to reduce any anticipated postoperative reflux.

Diet & Bowel Care
Following Nissen Fundoplication Surgery, you will be given specific diet instructions and be seen by our nutritionist.

  • You will probably be limited to liquids for the first week after surgery.
  • Eat small and frequent meals rather than the typical three large meals a day.
  • Limit fluid intake during meals (usually only about  cup or 4oz). Between meals you may drink more fluid.
  • Do not drink any carbonated beverages.
  • Do not drink through a straw.
  • Take small bites and chew food very well to avoid “sticking” of food at the site of your reflux operation.
  • Avoid foods that cause bloating or gas (such as broccoli, beans, cabbage).
  • Avoid caffeine and alcohol.

Call your surgeon right away if you have:

  • Diarrhea that lasts more than three days
  • Nausea and vomiting that will not go away
  • Pain in your abdomen that gets worse or isn’t eased by the pain medicine
  • Pus drainage or redness around your incision
  • Fever with a temperature of 100.5 or higher

FOLLOW-UP

Follow-up after surgery is extremely important and our surgeons at SALUS are committed to providing all the post surgical care you need. In order to identify and treat any complications as they may arise, close, lifetime follow-up is essential.


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