Treating GERD and hiatal hernias with minimally invasive surgery
Nissen fundoplication is a surgical procedure used to treat gastroesophageal reflux disease, or GERD, and hiatal hernia. It tightens and reinforces the sphincter at the top of the stomach to prevent stomach acid from rising into the esophagus.
A hiatal hernia (paraesophageal/diaphragmatic hernia) is when part of the stomach extends up through the diaphragm and into the chest. This condition can cause severe acid reflux or GERD symptoms. Often, these symptoms can be treated with medications, but if those don’t work, your doctor may offer surgery as an option.
Nissen fundoplications and paraesophageal hernia repairs are often done together. Hiatal hernia surgery corrects the hernia by pulling the stomach back into the abdomen and making the opening in the diaphragm smaller, while the fundoplication tightens the lower esophageal sphincter. Our surgeons use minimally invasive techniques, including robotics, to perform the procedure. The type of method chosen will vary according to the particular health condition.
Do you need a Nissen fundoplication/paraesophageal hernia repair?
To determine whether you need this procedure, your doctor might perform a variety of diagnostic tests and procedures including:
- Endoscopy
- X-rays (barium swallow test)
- Ambulatory acid (pH) probe test
- Esophageal manometry test
How to prepare for fundoplication/paraesophageal hernia repair surgery
Prior to the procedure, your doctor and treatment team will explain to you what to expect before, during and after the procedure and potential risks of the procedure.
Talk to your doctor about:
- All medications, herbal products and dietary supplements you are currently taking and ask for their recommendations about each
- Radiation exposure, especially for those that are pregnant
- Any allergies to medicines, latex, tape, iodine, and anesthetic agents
- Any history of bleeding disorders
- Any body piercings on your chest or abdomen
Checklist of things to do before surgery
- Eat a normal meal the evening before the procedure. However, do not eat, drink or chew anything after midnight before your procedure. If you must take medications, only take them with sips of water.
- Leave all jewelry at home.
- Remove all makeup and nail polish.
- Wear comfortable clothing when you come to the hospital.
- If you normally wear dentures, glasses, or hearing devices at home, plan to wear them during the procedure.
What to expect during a Nissen fundoplication procedure/paraesophageal repair
The surgery will typically take between 2 to 3 hours to complete. It is typically performed in the cardiothoracic operating room. Check with your doctor about the details of your procedure. In general:
- You will change into a hospital gown.
- A nurse will start the intravenous (IV) line in your arm which will administer medications and fluids during the procedure.
- Usually, your doctor will administer anesthesia (will make you feel sleepy).
- Once you are sedated, your doctor may insert a breathing tube through your throat into your lungs and connect you to a ventilator. This will breathe for you during surgery.
- The doctor makes a few tiny incisions in the abdomen.
- The doctor inserts a laparoscope (thin tube with a light and a camera) to help repair the hernia and tighten the stomach opening to prevent the hernia from coming back.
- The doctor will close up the incision(s) with stitches or staples, and you will be moved to the recovery area.
What to expect after fundoplication/paraesophageal hernia repair
After the surgery, patients usually stay in the hospital for 1 to 2 days. In general:
- The breathing tube is removed when you wake up from anesthesia. A small tube in the nose drains fluid and gas from the stomach. When the tube is removed (usually same day or surgery if early or the next day), you may have liquids.
- Urine catheters and drainage tubes (chest tubes) are removed after 24 hours.
- You are encouraged to be out of bed and to walk as much as possible.
- You will need to follow a specific diet after a Nissen fundoplication. Your doctor will talk with you about it, and provide any other postsurgery instructions before you go home.
Toupet fundoplication is a surgical procedure to provide a barrier between the esophagus and stomach. It can be used alone for the treatment of GERD or in conjunction with hiatal hernia repair.
Operation
We use the most advanced robotic system called Da Vinci Xi to perform Toupet fundoplication. The procedure is called “Robot-assisted laparoscopic Toupet fundoplication.” We perform the procedure through five small incisions in the abdomen. We separate the esophagus away from the diaphragm, close the diaphragm with sutures reinforced with pledgets, and parially wrap the esophagus with the upper portion of the stomach or fundus of the stomach.
In order to ensure that the closure of the diaphragm and the wrap around the esophagus is not too tight, we use a balloon called an Endoflip to tailor the fundoplication during the operation. The balloon catheter is placed through the mouth into the stomach and the esophagus and removed at the end of the operation.
Overall, the risks of the operation are very low. With any operation, there is a risk of injuring any structure that we operate around including the esophagus, stomach, liver, spleen, vagus nerve, diaphragm and the pleura. Other risks include bleeding and infection at the site of surgery. There is always a risk of needing to convert from a small incision to a larger incision.
Hospital Stay: 1 Day
After the operation, the patient goes to a recovery area called PACU or post-anesthesia care unit. Once the patient recovers from anesthesia, the patient is admitted under observation on the floor. On average, patients are in the hospital for one night. Patients start a liquid diet during the night of the surgery along with pre-emptive pain control with around the clock pain medication. If patients can tolerate a liquid diet with good pain control, they are ready to continue the recovery at home.
Diet
At home, we ask patients to have a liquid diet for two weeks to prevent any vomiting episodes that would cause complications with the surgical repair. After two weeks, patients are asked to start a soft diet avoiding breads and tough meat such as steaks. When taking in a solid diet, it is very important to chew well and let the food pass down into the stomach before taking the next bite. If patients have too much difficulty with solid food, we advise patients to stay on a liquid diet for an additional week. You should be able to resume a regular diet about four weeks after surgery.
Pain Management
We also advise our patients to stay ahead of the pain with pre-emptive pain control. Instead of taking pain medication after having pain, we ask patients to take pain medication in regular intervals. The typical regimen for post-operative pain medication is:
3 days of Aleve (Naprosyn) 1 tab two times a day
5 days of Tylenol (Acetaminophen) 1 g three times a day
After 5 days, take Tylenol as needed. If this regimen is not adequate to control pain, we ask patients to call our office.
Activity
In order to further help with recovery from surgery, we advise patients to walk at least three times a day, work on the incentive spirometer, and sit in a chair for at least 6 hours a day for about a week after the surgery. We advise patients to avoid heavy lifting for 6 weeks. As long as the patient is not on narcotic pain medication, it is safe to drive.
Constipation
One of the things that we want patients to avoid during the recovery period is being constipated. Constipation can cause an increase in intra-abdominal pressure that can put a strain on the repair. We recommend taking over the counter stool softener such as Dulcolex or Colace to make sure they have normal bowel movements.
Bloating
A common side effect of this operation is bloating. This is caused when patients swallow air and it gets trapped in the stomach with a new barrier between the esophagus and the stomach. This usually gets better over time but in order to minimize discomfort, we ask patients to take Gas-X four times a day for 1 month.