Laparoscopic Antireflux Surgery

What is gastroesophageal reflux?
Gastroesophageal reflux disease (GERD) is a digestive disorder that affects the lower esophageal sphincter (the muscular ring connecting the esophagus with the stomach). The sphincter normally prevents food from moving out of the stomach and back up into the esophagus.

When a person has GERD, the sphincter muscle becomes weak or fails to close tightly, causing food and stomach acids to flow back (reflux) into the esophagus. The lining of the esophagus can become inflamed or irritated from these acids, which can cause a burning chest pain and sometimes a sour taste or cough.

GERD can sometimes be managed by:

• Taking medications to reduce acid in the stomach
• Decreasing the size of portions during meals
• Losing weight, if overweight
• Quitting smoking
• Avoiding certain acidic foods that irritate the esophageal lining
• Not lying down for two to three hours after eating
• Elevating the head of the bed six inches

When is surgery necessary?
People with severe, chronic esophageal reflux might need surgery to correct the problem if their symptoms are not relieved through other medical treatments. If left untreated, chronic gastroesophageal reflux can cause complications such as esophagitis, esophageal ulcers, bleeding, or scarring of the esophagus.

Laparoscopic antireflux surgery is used in the treatment of GERD when medicines are not successful. Laparoscopic antireflux surgery is a minimally-invasive procedure that corrects gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus.

Who can have this surgery?
Laparoscopic antireflux surgery is most appropriate for people who have not had previous abdominal surgery, those who have small hiatal hernias without complications of GERD, and those who experience most symptoms of reflux when lying down.

An overview of laparoscopy
The word "laparoscopy" means to look inside the abdominal cavity with a special camera or "scope" (called a laparoscope). During laparoscopy, five or six small incisions are made in the abdomen. Then, carbon dioxide is passed into the abdominal cavity to lift the abdominal wall away from the organs below and provide more operating space in the abdomen.

The laparoscope and surgical instruments are inserted through the incisions. The surgeon is guided by the laparoscope, which transmits a picture of the internal organs on a video monitor so the procedure can be performed.

Patients who have laparoscopic antireflux surgery generally experience less pain and scarring after surgery, have a quicker recovery, and less risk of infection than those who have traditional antireflux surgery. (See the chart below)

Less risk of infection after surgery Increased bleeding and scarring after surgery

Greater risk of infection after surgery

Pre-surgical evaluation
The pre-surgical evaluation is first performed to make sure that laparoscopic antireflux surgery is the right treatment for you. The evaluation usually lasts about one day and is scheduled a few weeks before your surgery date.

During the evaluation, you will:

• Have a complete physical examination
• Have several tests to make sure you are physically ready for the surgery -- Depending on your age and general health, the tests might include a chest X-ray, blood test, electrocardiogram (EKG), or other tests as ordered.
• Meet with several health care providers, including the surgeon, who will ask you questions about your condition and your health history
• Meet with an anesthesiologist (a doctor who specializes in sedation and pain relief), who will discuss the type of pain medication (anesthesia) you will be given during surgery -- You will also discuss the type of pain control after surgery.
• Have the opportunity to ask questions about the procedure

The day of surgery

• Do not eat or drink anything after midnight the evening before surgery.
• Please do not bring valuables such as jewelry or credit cards.
• Plan to arrive at the hospital at least two hours before your surgery time.
• You will be asked to change into a hospital gown and get into bed. You will be given a bag for your clothing. The person with you will be asked to take your personal belongings.
• An intravenous tube (IV) will be placed in your arm to deliver fluids and medication
• You will be asked to remove contact lenses and dentures.
• A nurse might give you medicine through your IV to help you relax.
• Your family will wait in the family lounge. They will receive periodic reports about your progress throughout the surgery.
• Once the surgeon is ready for you, you will be taken to the operating room.

During the surgery

• An anesthesiologist will inject medication into your IV that will put you to sleep.
• After you are asleep, the nurses will clean your abdomen with antibacterial soap and cover you with sterile drapes.
• The surgeon will place a small needle just below your bellybutton (umbilicus) and insert it into your abdominal cavity. The needle is connected to sterile tubing. Through the tubing, carbon dioxide is passed into the abdominal cavity to lift the abdominal wall away from the organs below. This space provides your surgeon a better view and more operating space.
• A small incision will be made near your bellybutton. The laparoscope, which is connected to a video camera, is placed through this incision. The image your surgeon sees in the laparoscope is projected onto video monitors placed near the operating table.
• Before starting the surgery, your surgeon will take a thorough look at your abdominal cavity to make sure that laparoscopy will be safe for you. Some reasons why laparoscopy might not be done include multiple adhesions (scar tissue), infection, or any widespread abdominal disease.
• If your surgeon decides that laparoscopic surgery can be safely performed, additional small incisions will be made using instruments called trocars and cannulas. These incisions will give your surgeon access to the abdominal cavity in order to perform the surgery. These incisions are usually located as shown in Figure 1.
• To correct GERD, the surgeon wraps the upper part of the stomach (called the fundus) around the lower portion of the esophagus. This creates a permanently tight sphincter so that food will not reflux back into the esophagus.
• Finally, your surgeon will check that there are no areas of bleeding, rinse out the abdominal cavity, and close the small incisions.

After the surgery
When you wake up from surgery you will be in a recovery room. You will have an oxygen mask covering your nose and mouth. This mask delivers a cool mist of oxygen, which helps eliminate the remaining anesthesia from your system and soothes your throat. Your throat might be sore from the breathing tube that was present during your surgery. This soreness usually subsides after one or two days.

Once you are more alert, the nurse in recovery room will switch your oxygen delivery device to a nasal cannula, a small plastic tube that hooks over your ears and lies beneath your nose. Your nurse will frequently check your blood oxygen level. Depending on the percentage of oxygen measured in your blood, you night need to keep the oxygen in place after you are transferred to your hospital room.

Some patients experience bloating and cramping from the carbon dioxide that was placed in the abdomen during surgery. You will be given pain medicine to relieve your discomfort. Bloating will subside during your hospital stay.

Recovering from surgery
Once you have recovered from anesthesia, you will be transferred to your hospital room. After your surgery, the nurses will measure your "intake and output." They will document all the fluids that enter your body, and measure and collect any urine or fluids you produce, including those from tubes or drains placed during surgery.

A tube that was passed from a nostril into your stomach (a nasogastric tube) during surgery will be removed in the recovery room.

• Diet -- You may begin to drink clear liquids the morning after surgery. Once you have passed gas (flatus) from the rectal area or have had a bowel movement, you will gradually be able to eat solid foods (within three to four days after surgery).
• Activity -- You will be encouraged to get out of bed, starting the first day after surgery. The more you move, the less chance for complications such as pneumonia or blood clots in the veins in your legs.

Your recovery at home
Normally, you will be discharged from the hospital the day after surgery.

• Activity -- For six weeks after surgery do not lift or push anything heavier than 5 pounds. Avoid activities that increase abdominal pressure, especially sit-ups.

However, you are encouraged to gradually increase your activity level. Walking is great exercise. Walking will help your general recovery by strengthening your muscles, keeping your blood circulating to prevent blood clots, and helping your lungs remain clear.

• Diet -- A registered dietitian will visit you on your day of discharge to review your dietary instructions. You will be following a soft diet. Follow this diet until your next appointment. Also avoid caffeine, carbonated beverages, and citrus drinks.
• Incision Care -- You might notice some minor swelling around the incision. This is normal. However, call your health care provider if you have a fever, excessive swelling, redness, bleeding, or increasing pain. The small pieces of tape covering your incisions (called steri-strips) will gradually fall off on their own. Do not pull these strips off yourself. If the strips do not fall off on their own, your health care provider will remove them at your follow-up appointment.

Follow-up appointment
A follow-up appointment will be scheduled about one week after your surgery. You will have a chest X-ray, and your surgeon will assess the wound site and your recovery. The surgeon will provide guidelines about your activity and diet at this time.