Laparoscopic Nissen Fundoplication

What is a Laparoscopic Nissen Fundoplication?

Acid reflux occurs when acid travels the wrong way back up from the stomach into the oesophagus (gullet – food pipe). It can cause different symptoms, including burning in the chest (which is often worse at night), night time coughing and abdominal pain.

In severe cases, it can also cause damage to your teeth and gums and it can alter your voice.

A nissen fundoplication is an operation to relieve chronic acid reflux when it cannot be controlled with medication or lifestyle changes.

The operation involves wrapping the top end of the stomach around the bottom of the oesophagus to form a new valve and to stop acid travelling up into the oesophagus. After surgery, patients should be able to stop antacid medications.

The operation is carried out through a laparoscope (viewing instrument), which is inserted into your abdomen (tummy). This is also known as keyhole surgery. This means your recovery will be quicker.

Your operation will be performed under a general anaesthetic (a state of carefully controlled and supervised unconsciousness (deep sleep) that means you are unable to feel any pain.

Are there any risks or possible complications?

As with any surgical procedure, a fundoplication has some risks. These can vary according to your age and other illnesses you may have. The risks can include:

• Risks linked with anaesthesia – You will be given a leaflet which will explain in detail about anaesthesia. Your Anaesthetist (a Doctor with special training in anaesthetics) will discuss this with you. You may need to be admitted to the Critical Care Unit.

• Accidental injury during the operation to internal organs such as the stomach, spleen or oesophagus (food pipe), bowel, liver, lung and blood vessels – This is because cutting instruments need to be used during the operation.

Sometimes these may not be obvious during the operation but may be suspected later. If this happens, you will need another operation and a longer stay in hospital.

• Inability to complete the operation laparoscopically – Your Doctor may need to convert to a laparotomy. A laparotomy involves an incision being made in your abdomen (tummy) so that the surgeon can see inside.

The reasons this may be needed include; the presence of adhesions (scar tissue) from previous surgery, bleeding and accidental injury to internal organs.

If this happens, you will need to stay in hospital for a few days after the operation and may need to stay off work for up to 4 – 6 weeks.

• Difficulty in swallowing (also known as dysphagia) – Some patients may have a temporary or prolonged feeling of food sticking at the lower end of the oesophagus (gullet). You may need an endoscopy.

This is where a flexible camera (an endoscope) is passed through your mouth and down to your stomach or a further operation if this continues.

• Recurrence of reflux symptoms – The aim of this operation is to reduce symptoms of reflux. However, this is not always successful and patients may need to take antacid medications to control these symptoms.

• Gas bloat – Some patients may suffer from bloating as the wrap prevents them from burping, this can result in patients suffering from flatulence (passing wind from the back passage).

• Wound infection – This can happen to patients having this operation. If you feel feverish and your wound becomes hot, red and sticky, you should see your GP. This can be treated with antibiotics and you will not usually need to be re-admitted to hospital.

• Bleeding – You may develop bleeding inside your abdomen or from your wounds post operatively. If this happens, it will be treated accordingly. You may need a blood transfusion or another operation.

• Pain – This could be shoulder tip or abdominal pain due to irritation from the air used in your abdomen (tummy) so your surgeon can see your organs. Taking painkillers can help. You should always follow the instructions provided in the leaflet supplied with your tablets.

• Bruising – A little bruising may develop around your wound sites. This is normal and will settle over time.

• Scarring – You will have 5 – 6 small scars following surgery from the incision sites.

• Deep vein thrombosis – DVT (blood clots in the leg veins) or pulmonary embolism – PE (blood clots in the lungs).

You will be given a leaflet “Reducing the risk of a venous thromboembolism (blood clot) while you are in hospital and after you have been discharged”, which explains about this in detail.

All adult patients will have their risk of developing a blood clot assessed within 12 hours of admission. Patients who are being admitted for planned surgery may have their risk assessed at pre-assessment.

The Nurse or Doctor who carries out your assessment will discuss your risk factors with you and will advise on treatment to reduce your risk.

You will also be given information, “Your personal advice for the prevention of venous thromboembolism”, advising you on how to reduce your risk of developing a blood clot while you are in hospital and when you go home.

Some complications can develop a long time after your fundoplication surgery.

These can include:

• Port site hernia (hernia at the site of surgery) – Some patients can develop a hernia where the cuts to the abdomen were made.

What will happen at the pre-assessment clinic?

You will meet the Nurse Practitioner who will explain your operation and answer any questions you may have. The Nurse will complete your admission forms and start to discuss and plan your discharge from hospital after your operation.

Some routine health checks will be taken at the clinic, for example, blood and urine tests, ECG (heart tracing), and X-rays if required.

This reduces the length of time you will need to stay in hospital as an in-patient (see leaflet “Your pre-assessment clinic appointment”).

You can expect your appointment to last between 1 to 3 hours depending on what tests and checks need to be done.

What do I need to bring with me?

The National Institute for Health and Care Excellence (NICE) recommends that you keep warm, before, during and after your operation because it can reduce side effects, complications and help you recover from your operation faster.¹

Please make sure you bring socks and slippers, a dressing gown, a vest or other warm clothing to help you feel warm while you are in hospital. Please arrange for someone to collect your clothing and any items you will not need while you are in hospital, as storage space on the wards is limited.

Please bring in any new medicines that your Doctor has started you with after your pre-assessment visit. If doses of any other medicines change after your pre-assessment visit, you must tell your Nurse or Doctor when you are admitted.

What will happen while I am in hospital?

On admission to the ward, you will be introduced to your ‘named Nurse’ who is responsible for planning your nursing care with you. Your named Nurse is part of a team of Nurses who are there to help and advise you on a day-to-day basis and to make your stay as comfortable as possible.

What will happen before my operation?

When you arrive, one of the Nurses who will care for you will welcome you to the Access Lounge. They will re-check your details taken at the pre-assessment clinic, to make sure nothing has changed.

You will be seen later in the day by one of your Doctors, who will tell you the time of your operation and answer any questions you may have.

Before your operation, one of your Doctors will again explain the reasons for your operation, the operation itself, and the precautions we take to avoid any risks or complications. When you fully understand the operation, you will be asked to sign a consent form, if you have not already done so.

You will be asked to remove any jewellery you are wearing (except your wedding ring), contact lenses, make-up and nail varnish and also not to use any body lotions, deodorants and perfumes. You will be asked to put on a theatre gown.

False teeth, glasses and hearing aids may be removed in the operating theatre.

You may be given a ‘pre-med’ (some tablets to help you relax).

Just before the time of your operation, one of your Nurses from the ward will go with you and transfer your care to a theatre Nurse.

If you have any worries or concerns, you should tell the staff, they are there to help and support you.

Your theatre Nurse will check your details again before taking you into the anaesthetic room. In the anaesthetic room, you will meet your Anaesthetist again.

They will give you your anaesthetic before you are taken to the operating theatre and will stay with you throughout your operation.

Your Nurse will take your temperature before you are taken to the operating theatre. If it is below 36°C (96.8°F), the operation will not start until you are warm. A warm air blanket or jacket may be used to raise your temperature.

When you are in the operating theatre and the recovery room, your Nurse will take your temperature regularly. If it falls below 36°C (96.8°F), you will be placed under a warm air blanket or jacket.

Please tell your Nurse or Doctor if you feel cold during your stay in hospital.

Before and during your operation:

• a cannula (fine needle) will be placed in the back of your hand or arm so we can inject drugs. Sometimes, when drugs are injected they may feel cold and sting a little.

• an intravenous drip may be attached to your cannula, but this usually takes place when you are asleep.

• you may be asked to breathe oxygen through a face mask before you are given the anaesthetic.

• your blood pressure will be measured.

• your pulse will be taken and the amount of oxygen in your blood will be measured by attaching a special clip to your finger. This does not hurt.

• your heart rate will be monitored by placing sticky pads on your chest. These are attached to some leads to show a tracing of your heart on a monitor. This is routine and is nothing to worry about.

Why am I asked not to eat or drink before my operation?

Your Nurse will tell you when you must stop eating and drinking before your operation. This is very important. You must follow the instructions. Nothing means nothing at all, including water and chewing gum.

If you forget and you do eat or drink something, you must tell your Doctor or Nurse, as your operation may need to be postponed for your safety. This is because when you are unconscious, if your stomach contains food or drink, you may be sick and it could get into your lungs, affect your breathing and cause an infection.

What will happen during my operation?

You will have 5 to 6 small incisions (cuts) on your abdomen (tummy).

Your abdomen will be filled with air so that the laparoscope can be inserted safely and the organs can be seen clearly. The laparoscope allows the Surgeon to see the inside of your abdomen.

It is also possible to pass instruments through the small cuts

in your abdomen to carry out the surgical procedure. When the Surgeon is finished, the air is released.

The small wounds are closed either by using dissolvable sutures (stitches) or by sutures which need to be removed by the practice Nurses at your GP’s practice. Your Nurse will tell you which type you have.

The operation can take around 2 hours. This will depend on what needs to be done. Your Doctor will discuss this with you before your operation.

What will happen after my operation?

After your operation, you will be taken to the recovery room, where specially trained staff will look after you until you are ready to return to your ward. Most people do not remember waking up in the recovery room or returning to their ward.

The Nurses in the Operating Department will transfer your care back to your ward or unit Nurse.

You will be made comfortable in bed. Apart from Nurses checking your pulse, blood pressure, pain level and wound regularly, you will be allowed to rest.

You will have surgical stockings on your legs as well as pumping devices on to prevent blood clots.

The Doctor will instruct you when you are able to drink fluids, which is normally after your operation. You will not be able to eat until the Doctor is satisfied it is safe for you to do so. This is normally the next day.

If at any time you are in pain or feel sick, please let one of your Nurses know and they will give you medication to relieve it.

A little bruising may develop around your wound sites, but this will clear.

You may have:

• some discomfort in your upper abdomen (tummy) and shoulders. This is due to the air which was pumped into your abdomen. This should get better in 2 to 3 days.

• colic type abdominal pain for a few days after your laparoscopy or laparotomy. It is important to walk around to help get rid of the air.

• discomfort from your wound sites. Taking painkillers at regular intervals works best, rather than waiting until you are in pain. It will also reduce the need to take stronger painkillers. Always follow the instructions provided in the leaflet supplied with your tablets.

• some nausea (feeling sick) or vomiting (being sick) due to the effects of the anaesthetic. These will usually settle within 24 to 48 hours. It is important to drink plenty of fluids, but not alcohol to avoid dehydration.

It is normal to feel tired for 24 to 48 hours after your operation.

You will be encouraged to get out of bed as soon as possible on the day of surgery. This helps to reduce the chance of complications after your operation, such as blood clots in the legs or chest infections.

The day after your operation, the amount and types of fluids you can drink will be increased. Your drip will be removed when you are drinking enough fluids to be hydrated.

On the day after your surgery, you may be allowed to eat a pureed diet. If you do not have any problems with eating, you will be able to go home.

After your surgery, you will need to follow the dietary advice given to you.

When can I have a bath or shower again?

During the first week after your surgery, you are advised not to soak in the bath. This is to help avoid a wound infection. You can have a shower as soon as you are able.

When can I have sex again?

You may have sex again when you feel comfortable, unless you have been advised not to by your Doctor.

When can I drive?

You may drive as soon as you feel comfortable wearing a seatbelt and are able to carry out an emergency stop. You should check with your insurance company for their advice on driving after keyhole surgery.

When can I return to work?

You may return to work when you feel comfortable. This will depend on the type of work you do. Your Doctor or Nurse will advise you.

Will I need a follow-up appointment?

You will receive a telephone review 6 to 8 weeks after your discharge. Following this, you may or may not require a further appointment in the outpatient clinic.

When will I be able to exercise?

You must not do any abdominal exercises or heavy lifting for 6 weeks after your operation.

Contact numbers

If you need further advice or have any problems, please contact the appropriate number below:

University Hospital of North Tees

Surgical Decision Unit

Telephone: 01642 624566 or 01642 624628

Opening hours: 8:00am to 8:00pm (Monday to Friday) and 8:00am to 4:00pm (Saturday to Sunday)

Consultant Secretary

Telephone: 01642 383292 or 01642 383290

Opening hours: 9:00am to 5:00pm (Monday to Friday)

Further information is available from:

NHS Choices

Telephone: 111 (when it is less urgent than 999).

Calls to this number are free from landlines and mobile phones or via the website.

NICE Clinical Guideline (CG184). Gastro-oesophaheal reflux disease and dyspepsia in adults: investigation and management. Sept 2014.

References

1. National Institute for Health and Care Excellence (NICE), 2008, updated 2016 Inadvertent Perioperative Hypothermia. Clinical guideline 65.

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