General Surgery Laparoscopic Nissen Fundoplication patientinformation Rotherham Hospital Your health, your choice, our passion
Laparoscopic Anti-reflux surgery This is a surgical method, which can treat severe gastro-oesophageal reflux. It is an alternative to long-term suppression of acid secretion by the stomach using drugs and to open surgery. What is a Laparoscopic Nissen Fundoplication? Laparoscopic (keyhole) Nissen Fundoplication is an operation to relieve chronic heartburn when it cannot be controlled with medication and/or lifestyle changes. Heartburn is an uncomfortable burning feeling that usually starts in the middle of your chest, behind your breastbone, and moves upwards towards your neck and throat. Heartburn is usually caused when the contents of the stomach is pushed back into the gullet (oesophagus), causing irritation of its sensitive lining. The causes may include: l Gastro intestinal reflux disease (when acid from the stomach flows back up into the oesophagus). l Hiatus hernia (when part of the stomach slides into your chest cavity). l Certain foods, smoking and alcohol may make the symptoms of heartburn worse. Surgery can relieve your symptoms of heartburn. However, in a small number of cases the symptoms can come back. Please discuss any concerns you may have with your surgeon. 3
What are the benefits of keyhole surgery? If the operation is done laparoscopically keyhole then you are likely to recover quicker than if it was done using the open method. You will have less scaring and suffer less pain. What happens before the operation? The pre-assessment nurses will see you before you come into hospital for your operation. Various checks will be carried out to ensure you are fit for the operation to go ahead. The operation will be explained to you and the nurses will give you instructions about fasting and about whether you need to stop taking any of your usual medicines. If you have any questions or concerns, this is the time to talk to the doctor or nurse. Arriving at hospital On the day of your operation you will be asked to report to the Theatre Admissions Unit. Further information will be given to you at your pre-operative assessment visit, along with a leaflet about what happens in Theatre Admissions Unit before your operation. What happens before the operation? You will be seen by the surgeon who will be doing the operation. The operation will be explained to you and you will be asked to sign your consent form for the operation, if you have not done so already. If you are not clear about any part of the operation, please ask for more details. 4
You will also be seen by the anaesthetist to check your health and to discuss your anaesthesia. You will have a general anaesthetic, this means you will be asleep throughout the operation. More details about the anaesthetic will be given to you at your pre-operative assessment visit and by the anaesthetist. What does fundoplication involve? Laparoscopic or keyhole surgery involves making 4 to 5 small incisions in your abdomen through which special surgical instruments are passed into the body. A harmless gas is used to inflate your abdomen to make space for the operation to be performed. This will disperse naturally after the operation. What are the benefits of heyhole surgery? If the operation is done laparoscopically keyhole then you are likely to recover quicker than if it was done using the open method which would involve a 6 to 10 centimetre cut on your abdomen. You are able to recover more quickly from the operation, have less scaring and suffer less pain. How is the operation done? The surgeon will wrap the top part of your stomach around the lower part of your gullet to form a collar. This tightens the closing mechanism at the lower end of the gullet, creating a one-way valve, which prevents stomach acid from moving back into your gullet. 5
Hiatus hernia Where there is a hiatus hernia, the surgeon will bring the stomach back into its original position under the diaphragm, then wrap the upper few centimetres of the stomach around the oesophagus to make a new valve. This prevents acid reflux and heartburn recurring. Permanent stitches are used to keep the stomach in place. Open method In a small number of patients the laparoscopic method cannot be performed. The decision to perform an open procedure is a decision made by your surgeon either before, or during the actual operation. If the surgeon decides to convert a laparoscopic procedure to an open one, this is not a complication but sound surgical judgment and is strictly based on patient safety. Stitches You will have stitches that will be either dissolvable or that will need removing in 7 to 10 days. The nurse looking after you will give you further instructions before your discharge. How long will I stay in hospital? You will normally stay in hospital for two or three days. This may be longer if the open procedure is used. 6
On the ward after the operation You will wake up from your general anaesthetic in the recovery area. The recovery nurse will check your blood pressure and wound sites. As soon as you are fully awake, comfortable and your blood pressure is stable, you will be taken to the ward. On the ward the nurses will monitor your progress and will give you pain relief. You will be encouraged to get up as soon as possible and start with a liquid diet. You may have anything except fizzy drinks. You will stay in hospital for 2 to 3 days and in this time your pain will be monitored and you will be encouraged to eat a blended diet. After the operation/going home You will be seen by the nurse specialist and the dietitians before you are discharged home. The dietitians will give you some suggestions for foods you can eat. Signs to look out for You should call your doctor if you develop any of the following symptoms: l A fever l An unusual degree of pain l Nausea and vomiting and can not eat properly according to your diet plan 7
What are the possible risks? All operations carry the risk of problems and side effects. Complications are unexpected problems that can occur during or after the procedure. Most people are not affected. Specific risks connected to this procedure are: l Injury to the gullet, stomach, blood vessels and nearby organs. These complications are rare and the surgeon may convert to open surgery to repair any damage. l 1% of patients (1 in 100) may need further corrective surgery to reduce persistent difficulty in swallowing and /or abdominal bloating. l A hernia may develop in one of the wound sites (where a part of the bowel sticks out through the weak area of the abdomen), which may need repairing. This may happen if you put any strain through that area while it is healing. Common side effects l The most common side effect is difficulty in swallowing. This is common immediately after the operation and gradually improves. The amount of food you consume may be less and you may have to eat more slowly than you did before the operation. You will need to adhere to the recommended diet of blended then soft diet for 4 to 6 weeks. l Other common side effects are burping, bloating and increased wind (flatus). l Most of these symptoms settle with time. 8
Driving You may drive again when you can confidently perform an emergency stop. This is usually about 10 days after your operation. You may also wish to check with your insurance company about when you are covered to drive again. Returning to work and resuming normal activities You will need 3 to 6 weeks off depending on the nature of your work. You can resume lifting and strenuous exercise after 6 weeks. Follow-up On discharge from hospital you will be given an appointment to see your surgeon in the Outpatient Department 6 weeks after your operation. Nutrition guidelines after Laparoscopic Nissen Fundoplication Do I need a special diet? Following a special diet after surgery is necessary for healing. After the procedure, your diet will progress in stages beginning with liquids and slowly advancing to a soft diet. We have recommended time periods for each stage as a guideline, however please be aware that everyone s tolerance to food may be different. The dietitian will visit you on the ward to talk to you about these different stages and answer any questions you may have. 9
General Guidelines l Eat small frequent meals (6 to 8 per day) to ensure adequate nutrient intake and to prevent feeling too full. l Sit upright while eating and remain upright for 20 minutes after eating. l To help minimize burping, avoid drinking fizzy drinks, chewing gum or drinking through a straw. l Once on solids, chew food well and eat slowly. l Keep foods moist by adding sauces or gravy. Stage 1 - Liquid diet This diet will begin while you are in hospital and may last for up to 3 days after surgery. Examples of liquids you can consume at this time include: l milk l soup l jelly l ice-cream l hot chocolate l malted drinks e.g. ovaltine, horlicks l more nourishing drinks such as build-up shakes or soups which can be provided on the ward Stage 2 - Pureed diet The next stage introduces food in a smooth pureed texture, to allow easier swallowing. It is recommended that you follow this stage for 3 to 4 weeks. A food processor or blender will be needed to puree foods to the correct consistency and a basic one can be 10
purchased quite cheaply. You may need to add liquid in order to puree some foods, however try to avoid adding water as this dilutes the amount of nutrients. Instead, try stock, gravy, cream, sauce or soup. Please refer to the table on page 14 for food and drink suggestions. Your dietitian will also provide you with a diet sheet entitled Eat well to feel better on a pureed diet for further meal ideas, tips on preparing pureed foods and ways to make it look presentable. Stage 3 - Soft diet If you feel no pain or discomfort on the pureed diet at the end of Stage 2, proceed to a soft diet, avoiding any large solid lumps. If you try to eat foods which have to be swallowed in one lump (like chicken or steak) there is a risk they will get stuck, which can be very uncomfortable. Also remember to chew food well. It is recommended that you follow this stage for 2 to 3 weeks. Please refer to the table on the following page for food and drink suggestions. Your dietitian will also provide you with a diet sheet entitled Eat well to feel better on a soft diet for further meal ideas and tips on how to make foods softer. Stage 4 - Normal diet At the end of Stage 3 you can slowly introduce a normal healthy diet as tolerated. 11
Food Group Pureed Diet Soft Diet (3 to 4 weeks) (2 to 3 weeks) Bread, Porridge mixed to a Porridge. Other Cereals smooth consistency. Breakfast cereals & Potatoes Breakfast cereals softened with milk. softened with milk to Pasta or rice with sauce. a smooth consistency. Mashed potatoes. Pasta pureed with sauce. Jacket potatoes without skin. Mashed potatoes. Bread softened with spread. Pasta, rice, potato added to soup and pureed. Fruit & Fruit juice. Fruit juice. Vegetables Pureed tinned, stewed Tinned, stewed or soft fresh fruits e.g. or soft fresh fruits. peaches, berries, bananas. Mashed or soft cooked Pureed vegetables with vegetables. your favourite sauces. 12
Food Group Pureed Diet Soft Diet (3 to 4 weeks) (2 to 3 weeks) Meat, Fish & Pureed meat, fish, Flaked fish. Alternatives poultry, pulses with Minced beef, chicken gravy/sauce and sauce. or turkey and gravy. Pureed scrambled egg Omelette, scrambled (try mixing in cheese poached or boiled egg. or pureed tomatoes). Baked beans. Well cooked lentils. Milk & Dairy Milk. Milk. Smooth yogurt Yogurt. (without chunks of Cheese. fruit, muesli or nuts). Milk puddings. Cheese spread/soft cheese. Milk based desserts, custard, pureed rice pudding/semolina, ice cream. 13
Further information If you have any further questions or concerns about the information in this booklet, please contact: Pre operative Assessment Unit 01709 427943 Mr Lambertz secretary 01709 427165 Upper GI Nurse Specialist 01709 424077 Nutrition and Dietetics 01709 424297 Useful contact numbers NHS Direct Telephone 0845 4647 Patient Services Telephone 01709 424461 Health Info Telephone 01709 427190 Stop Smoking Service Telephone 01709 422444 A&E Telephone 01709 424455 For GP out of hours, contact your surgery Useful websites www.nhs.uk www.direct.gov.uk www.therotherhamft.nhs.uk If you require this document in another language, large print, braille or audio version, please contact Patient Information on 01709 424281. 14 Produced by Chris Garrison, Mr Lambertz and Nutrition and Dietetics, July 2010. Revised November 2011. Revision due November 2013, Version:2.0 The Rotherham NHS Foundation Trust 2011. All rights reserved.
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