GERD and Acid reflux is a very common problem affecting patients of all age. The problem is also on a rise due to the current westernized lifestyle. Although most of the patients will need diet and lifestyle modifications along with medications, some may eventually need surgery. Having a hiatus hernia is one important factor that may make surgery mandatory in patients with acid reflux. For all such patients who need this surgery, here is our attempt to help them understand the whole process of surgery. I hope this will help reduce their anxiety and help in making proper preparations for the surgery.
All the patients who are considered for surgery for Acid reflux are scheduled for esophageal manometry and 24 hr pH Impedance study. These investigations are needed to give us all the detailed information regarding the functioning of your food pipe and the lower esophageal sphincter (the LES valve). It will also confirm the diagnosis of GERD, will give us the details of its severity. Thus it will ensure us about the results of the surgery. Some modifications in the surgery are also done based on these tests to give you the best outcomes after surgery.
Once the test is complete, the surgeon will discuss the results with you in detail. He will also give his opinion on whether to go ahead with surgery or make any changes to the treatment plan. He will talk about the outcome of surgery, the need for medications after surgery, and possible difficulties with diet in the early stages of post-surgery. Ultimately, you and your surgeon will have to make a joint decision about surgery. Surgery for GERD and hiatus hernia is called laparoscopic fundoplication surgery.
Once a decision is made regarding your surgery for GERD/Acid reflux/Hiatus hernia is made, its date and time, the surgical team contacts the Operation Theatre incharge to fix the timing of surgery. The OT incharge also updates the anesthetist doctor regarding the date and time of surgery. The surgeon will also give a call to the anesthetist to discuss what surgery is planned, what is expected during the surgery. The anesthetist would like to know at this stage whether the patient is having any medication condition, which would need further investigation or optimization with medications prior to surgery. In a situation where such is the case, your surgeon will advise you to do so and that may need to delay the surgery if needed.
The OT incharge will make sure that the instruments are properly sterilized prior to your surgery, all the devices are working properly and all the materials needed for surgery are available in the OT during the surgery.
Once you are admitted to the hospital, the doctor on duty will see the reports of all your tests and follow the instructions of the surgeon. The doctor will also make sure that you have not taken food and water for 6 hours before the scheduled time of surgery. The doctor will then speak to your surgeon and inform him about your admission and all your prior tests. Your surgeon is also told about your temperature, pulse, blood pressure, sugar. As per your surgeon’s advice, the doctor on duty will complete other tests like ECG, blood tests, and X-rays.
The anesthetist doctor is also informed about your admission, your previous and recent test reports. The surgical site of the body is prepared for surgery by shaving that part of the body if needed. At this time your consent form will be signed for your consent to the surgery. While doing all this, the doctors on duty will try to boost your spirits by reducing the apprehensions of you and your loved ones. Everyone in the hospital understands your pre-surgery concerns.
You are shifted to the OT recovery room 10-15 minutes before the scheduled time of surgery. Again the nursing staff will see all your reports. They will also ensure that all the preparation is done properly. Your surgeon or anesthetist or both will come and visit you with the aim of relieving your anxiety. Finally, before being shifted to the operation theatre, you will be asked to go to the washroom to pass urine.
When you enter the operation theatre, you will see some of the OT staff preparing various instruments and equipment. You will be made to lie on the OT table. An intravenous line (IV line) is placed in your arm to give you the medicines. ECG lead, blood pressure cuff, and pulse-oxygen sensor are also attached to you at this time. They will monitor your pulse, BP, oxygen level, and heart activity throughout the surgery. The anesthetist, doctor, OT staff, and your surgeon will continue to talk to you throughout this procedure.
Once all these preparations are done, then the anesthetist doctor will put a mask on your face and ask you to breathe through the mask. Anesthetic gas will come from this mask, which will make you feel a little sleepy. Further medicines will be given to you through the IV line, so that you can get complete sleep. After you go into deep sleep, the anesthetist will put a tube through your mouth into your windpipe. You will continue to breathe through this tube and a ventilator throughout the surgery. The anesthetist will monitor your sleep and depth of breath, and keep a watchful eye on the monitor. The monitor shows your pulse, BP, oxygen level, and heart activity. So now is your time to relax and sleep. After the surgery is over, the anesthetist will slowly bring you back to your senses.
Your surgery isn’t performed just by your surgeon. An entire team is working during the surgery. Each surgery is a complex combination of multiple tasks performed by multiple team members, even if it is a very commonly performed surgery. Because of the minimal pain and rapid recovery after laparoscopic surgery, the procedure may seem simple, but in reality, it is not. During surgery, in OT, 6-7 people are actively working to make the surgery successful. It includes an anesthetist doctor and a support staff for work related to anesthesia.
About four people are involved in the surgery process, including the surgeon. One person to control the camera, one assistant, and one person accompanies the surgeon to deliver the essential instruments from the trolley.The person assigned to control the camera is in charge of the camera and guides the surgeon’s vision throughout the surgery. The second assistant assists the surgeon during the surgery whenever and wherever there is a need to make room for the surgery. The assistant assigned to the trolley helps in the exchange of equipment and providing essential items during surgery from the trolley.
In addition, a runner staff is kept on stand-by, who assists in providing any extra equipment or medications in case need arises during surgery. In order to give you the results you want, good and coordinated teamwork is required.
Once you are completely put to sleep and the anesthetist doctor says all is under control, the surgical team starts their action.
At first, they start preparing the part where the surgery is to be done, that is your tummy. It is made germ-free by applying betadine solution methodically. This is called “painting”, that is painting the part with betadine. Then your whole body except your tummy is covered with sterile drapes. This is called “draping”, that is separating the germ-free part of surgery from the rest of the body with sterile drapes (germ-free cotton sheets).
Then, the team prepares all the gadgets. This includes the laparoscopic system and the energy source. The laparoscopic system includes the camera, a laparoscope, a light source cable, and an insufflating tube to fill Co2 gas in your tummy. All this is pre-sterilized by a special method called ETO sterilization. The energy source is the device that will help in doing the surgery in a bloodless manner.
Once all the setup is ready, the surgeon will inject a small amount of local anesthetic solution at the place where the first cut is to be made. This will help the surgeon in keeping you pain-free once you are awake after surgery. Then a small cut is made a bit above your navel and a special needle is inserted in your tummy through this cut. After confirming that it is in the proper place the insufflating tube is attached to this needle and CO2 gas insufflation is started. Once adequate gas is filled in your tummy to create space, the needle is removed and the first port is inserted into your tummy through the same cut. The port is a hollow metal tube, through which the laparoscope and instrument can go inside your tummy. Gas is also continuously filled to maintain the space throughout the surgery.
Now is the time to insert the laparoscope inside your tummy, and the live images are seen on the monitor in front of the surgical team. The surgeon now inspects the inside of your tummy before proceeding with the surgery. Once that is done, four more ports are placed after injecting the anesthetic solution before giving cuts. These four new ports are placed under laparoscopic vision. This means when they are placed the surgeon can exactly see them coming inside the tummy through a laparoscope. Hence the surgeon can place them exactly at the site where needed in your case.
Now the actual surgery starts. The camera person shows the exact area of surgery with a clear focus. The assistant inserts one instrument through one of the ports and holds the fundus (top part) of the stomach and pushes it towards your left shoulder. Now your surgeon has clear access and vision to the area of surgery. He cuts the thin tissue over the hiatus and esophagus with the help of an energy device. By doing this he clearly identifies the muscles of the diaphragmatic hiatus and mobilises the lower part of your food pipe all around.
The surgeon then takes stitches at the muscles of the hiatus and closed the enlarged hiatus, and makes is of the normal size. Of the size that will just allow the esophagus to pass. Futher the fundus of the stomach is pulled behind the lower part of the foodpipe and wraped around the LES valve. This wrap is kept in palce by taking few stiches.
The surgeon will finally inspect the whole area of surgery. This is to recheck that the hiatus is reduced to adequate size, the wrap is not too tight and there is no bleeding. Now all the instruments and ports are removed under laparoscopic vision. The gas is emptied out of the tummy. The muscles of the tummy wall at the site of 10 mm ports (the larger ports) are closed with one stitch. This stitch is self-dissolving and will dissolve after a few months. The 5 mm ports do not need such stitch around the muscles. The skin cuts are then closed with self-dissolving stitches and glue and covered with bandages. Now you are ready to be awakened.
Once the surgery is done, the anesthetic doctor will change the medications such that you gradually regain consciousness. Once he is sure you are awake enough to breathe yourself and gulp the saliva, he will remove the tube from your windpipe. He will make sure you are comfortable, pain-free, and breathing well. Once he is convinced about your wellbeing, we will shift you to a shifting bed. You are then taken to the recovery room on this bed itself.
In the recovery room, your pulse, BP, and oxygen will be monitored for about 10 minutes. This is the time when you would be still very sleepy. Hence, one staff will be there to comfort you and monitor your condition. The surgeon and anesthetist will also visit you to make sure you are doing well. They will also talk to the relatives and update them about your condition and will allow them to meet you. All this is done to make you and your relatives comfortable and reduce the stress of surgery.
Once you are reasonably awake, you would be shifter back to your room. You would be allowed to rest for a couple of hours. The on-duty doctor will be there in case you need any help. After 2 hours, the staff will check your pulse, BP, and oxygen levels. And once they make sure you are well awake, you would be advised to sit. Gradually, as you feel comfortable water and then other liquids will be started orally. You would be advised to get out of bed, walk a few steps in the room under the observation of staff. At his point in time, all the IV drip and medications are stopped.
Once all this goes well, you would be advised to go to the washroom and pass urine. Initially, there may be a little bit pain, but that reduces once you start moving around. In case the pain is more, further medications will be given by the doctor after a telephonic talk with your surgeon. All the medications are given orally once liquids are started and you do not have vomiting. Even if all is well, your progress will be updated to your surgeon by the on-duty doctor.
After about 4-5 hours of surgery, once you have tolerated liquids, a soft diet will be started. The surgeon also will make a visit to ensure all is processing well. All of your apprehensions about going home will be addressed by him during this visit. You can have a shower the next morning, as the bandages are wash-proof. Once you are relatively pain-free, tolerating liquids and food, have passed urine, you are ready for discharge. The discharge can be done on the same day for young patients with no other medical problems and coming from the same city. For all the rest, discharge is generally done the next day of surgery.
You will be called for a follow-up visit in a couple of days after discharge. The main aim is to ensure that you are doing well and check your wounds. The surgeon will check your wounds, clean it, and reapply the bandages. He will discuss how to progress with your diet and resuming activities after surgery. All of your questions would be answered at this time.
Generally, a soft diet is advised for a couple of days. There can be a little difficulty in swallowing food for the initial few days. All you have to do is eat slowly and chew properly. This should settle in about a week. Once you are able to eat a soft diet reasonably well, we can gradually start all other food as per your normal diet. In the initial few weeks, you should eat a small quantity at a time, as you may feel full with less amount of food. This is a temporary phenomenon and should gradually improve in a few weeks.
The bandages are now to be removed by yourself, at home while bathing after 5 days. If for any specific reason, your wounds need to be rechecked, then your surgeon would specify.
The next visit would be a month, two months, and three months later, just to make sure you are doing well. If you are coming from another city, this follow-up can be done by a telephonic call. It is mainly to ensure you are progressing well with your diet and if any medications need to be continued. In between, if you have any issues you can schedule an appointment as per need. We recommend patients to come for an in-clinic follow-up at least once after 6 months for a thorough check-up.
ADROIT centre for Digestive and Obesity surgery is performing all kinds of the esophagus, stomach, and other advanced laparoscopic surgery routinely. Our outcomes are par with international standards and our patient satisfaction level is great. We have all the facilities for a thorough evaluation of GERD, Acid reflux, Hiatus hernia, and Achalasia cardia problems at our clinic. We have a huge experience in the treatment of GERD and a large number of happy patients. Click the below links to listen to our patient’s feedback.
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