Laparoscopic anti-reflux surgery

What are the advantages of laparoscopic surgery?

Surgery minimises reflux of gastric contents back into the oesophagus, rather than just decreasing the acid content of the fluid that flows back up. This can alleviate regurgitation, as well as heartburn, and minimises the potentially carcinogenic effects of reflux (although it is not clear if this is enough to prevent oesophageal cancer from developing). It also removes the need for life-long acid suppression; the stomach is meant to have a certain level of acid production, and the long-term effects of acid suppression have not been proven to be safe, osteoporosis being a particular concern.

The advantage of the laparoscopic approach to surgery is that it usually provides:

• Reduced postoperative pain
  
• Shorter hospital stay
  
• A faster return to work
  
• Improved cosmetic result

Are you a candidate for the laparoscopic method?

Although laparoscopic anti-reflux surgery has many benefits, it may not be appropriate for some patients. Obtain a thorough medical evaluation by our surgeons in consultation with your GP or Gastroenterologist to find out if the technique is appropriate for you.

What to expect before laparoscopic anti-reflux surgery

After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery. Preoperative preparation includes blood work, medical evaluation, chest x-ray and an ECG depending on your age and medical condition.

You may be requested to drink clear liquids, only, for one or several days prior to surgery. It is recommended that you shower the night before or morning of the operation. After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.

Drugs such as clopidogrel (Iscover, Plavix), warfarin (Coumadin, Marevan), blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery. Diet medication, Ginko biloba or St. John’s Wort should not be used for the two weeks prior to surgery.

Quit smoking and arrange for any help you may need at home.

What to expect the day of surgery

• You usually arrive at the hospital the morning of the operation.
  
• The anaesthetist will place a small needle/catheter in your vein to dispense medication during surgery.
  
• Often pre-operative medications are necessary.
  
• You will be under general anaesthesia—asleep—during the operation which may last several hours.
  
• Following the operation you will be sent to the recovery room until you are fully awake.
  
• Most patients stay in the hospital the night of surgery and may require additional days in the hospital.

How is laparoscopic anti-reflux surgery performed?

Laparoscopic anti-reflux surgery (commonly referred to as Laparoscopic Nissen Fundoplication, although other types of fundoplication can also be performed) involves reinforcing the “valve” between the oesophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the oesophagus – much the way a bun wraps around a hot dog.

In a laparoscopic procedure, surgeons use small incisions (5mm to 12mm) to enter the abdomen through cannulas or ports (narrow tube-like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the ports, giving the surgeon a magnified view of the patient’s internal organs on a high-definition video monitor.

The entire operation is performed “inside” after the abdomen is expanded by inflating gas into it.

What happens if the operation cannot be performed or completed by the laparoscopic method?

In a small number of patients the laparoscopic method is not feasible because of the inability to visualise or handle the organs effectively. Factors that may increase the possibility of converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

What should I expect after surgery?

• Patients are encouraged to engage in light activity while at home after surgery.
  
• Post operative pain is generally mild after the first three or so days. Some shoulder discomfort (“referred pain” from the diaphragm) is common during the first few days. Most patients require prescription pain medication for three to seven days after surgery.
  
• Anti-reflux medication is usually not required after surgery.
  
• Diet after surgery generally begins with two weeks of liquids, followed by two weeks of puréed food, followed by gradual introduction of soft solids. You should ask your surgeon about dietary restrictions immediately after the operation.
  
• 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.
  
• Heavy work or heavy lifting should be avoided for six weeks or so (longer if a large hiatus hernia was repaired).
  
• Call and schedule a follow-up appointment within 2 weeks after your operation.

Are there side effects to this operation?

Studies have shown that the vast majority of patients who undergo the procedure are either symptom-free or have significant improvement in their GORD symptoms. Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves within one to three months after surgery.

Occasionally, patients may require a procedure to stretch the oesophagus (endoscopic dilation) or rarely re-operation.
The ability to belch and or vomit may be limited following this procedure. Some patients report stomach bloating.

Rarely, some patients report no improvement in their symptoms, or a recurrence of symptoms after some time.

What complications can occur?

Although the operation is considered safe, complications may occur as they may occur with any operation.
Complications may include but are not limited to:

• Adverse reaction to general anaesthesia
  
• Bleeding
  
• Injury to the oesophagus, spleen, stomach or internal organs
  
• Infection of the wound, abdomen, or blood

Other less common complications may also occur. Your surgeon may wish to discuss these with you to help you decide how the risks and benefits of laparoscopic anti-reflux surgery compare to non-operative management.