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Category Dr.Chirag Thakkar

GERD/Hiatus hernia/Acid reflux surgery: Know what happens before, during and after surgery

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.

Final decision to go ahead for GERD/Hiatus hernia/Acid reflux 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.

Your surgery is not performed just by your surgeon. There is a whole team at work during the surgery. Any surgery, even when they are routinely done is a complex set of multiple tasks done by many people in the team. Minimal post-surgery pain and fast recovery may make this process simple, but actually, it is not so.

There are 6-7 people in the OT during the surgery actively working to make it a success. This includes an anesthetist and a support staff with him for the anesthesia part.

About four people including the surgeon perform the surgery. The surgeon is accompanied by a camera person, an assistant, and a trolly staff. The camera person is in charge of the camera and guides the vision of the surgeon during the entire surgery. The assistant helps the surgeon during the surgery as and when needed, mainly to help make the working space. The trolly person helps in the exchange of instruments and getting the necessary material on the trolly as needed during the surgery.

Apart from this, there is a runner staff as a stand-by, in case something is needed unexpectedly during the surgery. Good and coordinated teamwork is needed to give you the desired results.

How will your GERD/Hiatus hernia surgery progress

Anesthesia and preparation for surgery

Once you are completely put to sleep and the anesthetist doctor says all in 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 whole your 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.

Gas insufflation of tummy, local anesthetic injection, and port placement

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 in filled in your tummy to create space, the needle is removed and the first port is inserted into your tummy through the same cut. This 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.

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Actual surgery

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 glue and covered with bandages. Now you are ready to be awakened.

Watch this short video of the surgery to understand it better.

What happens once the surgery is over

Once the surgery is done, the anesthetic doctor will change the medications such that you will start to awake. 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 relieve you and your relatives from the anxiety of surgery.

What happens once you are back to the room

Recovery: Initial few hours

Once you are reasonably awake you would be shifter back to your room. You would be allowed to rest for a couple of hours. On duty, the 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.

Further recovery and discharge

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. Any 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.

Follow up visit at the clinic after GERD/Hiatus hernia 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. Any other questions of yours 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 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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