Laparoscopic hiatus hernia repair or laparoscopic Nissen’s fundoplication surgery is a surgical procedure performed to repair hiatus hernia with the aid of a laparoscope.
Hiatal hernias happen after the abdominal cavity contents bulge through the esophageal hiatus of the diaphragm. There are several factors which lead to the development of hiatal hernia. These include:
- The enlargement of the esophageal hiatus because of age-related defects
- Depletion of elastic fibers in the phreneosophageal membrane as a person ages
- Increased abdominal, thoracic pressure gradient
- Obesity
There are two types of hiatal hernia. These are:
- Sliding hiatal hernia – it is the most prevalent type of hiatal hernia. It happens when the esophagus and the stomach slide into and out of the chest via the hiatus. These types of hernias tend to be small and usually don’t pose any symptoms. Also, they don’t require treatment many a times.
- Para-esophageal hernia – this type of hernia is uncommon. This type of hernia happens when the stomach pushes via the diaphragm and does not push back. In most cases, it is not serious, but it poses a risk of blood flow to the stomach being blocked. In case this happens, it can cause serious effects, and it is categorized as a medical emergency.
Indications for this surgery
Laparoscopic hiatus hernia repair can be indicated in case of:
- Failure of medical management
- Chronic heartburn despite optimum medical management
- Chronic inflammation of the esophagus as a result of reflux (backflow of gastric fluid)
- Barrette’s esophagus
- Narrowing of the hiatus via the diaphragm
- Pneumonia caused by frequent breathing in of gastric fluids
- Sporadic bleeding caused by esophagitis, discrete esophageal ulcer or Cameron ulcers
Signs and symptoms for which the surgery is performed
Most hiatal hernias don’t have any signs and symptoms, especially if they are small. However, larger hiatal hernias bring signs and symptoms like:
- Belching
- Heartburn
- Abdominal or chest pain
- Difficulty in swallowing
- Feeling very full, especially after meals
- Passing black stools or vomiting blood, which at times is an indication of gastrointestinal bleeding
If these signs and symptoms are persistent and worsening, a patient is advised to seek medical attention.
Diagnosis
When you start experiencing hiatal hernia-related symptoms, notify your doctor immediately. The doctor will first take your medical history and physical examination, which will assist the doctor to have a further understanding of your medical condition. The following are some of the diagnostic procedures used to identify hiatal hernias:
Gastroscopy
In this procedure, the doctor uses a gastroscope to examine the inside of the patient’s body. The gastroscope is usually inserted into the patient’s mouth and pushed down their throat, and is used to detect any issues. Local anesthesia or sedative is used during this diagnostic procedure to assist the patient to relax.
Barium meal X-ray
Also known as barium swallow test, it is a very effective and accurate way of detecting hiatal hernia. During the test, the patient is asked to swallow some barium solution, and once the barium moves through the digestive system, X-ray scans can then be taken to detect any problems.
24 hour pH manometry showing excessive reflux
Treatment modalities
Medical management is the first line of treatment for hiatus hernia and GERD. However, if drugs fail to work, or if the patient is not able to continue with medical management due to lifestyle issues, in case of complications like Barrette’s esophagus etc a patient can be advised to undergo laparoscopic Nissen’s fundoplication surgery.
Medication
Some of the medications which can be prescribed by a doctor include:
- Antacids, which can be very effective in neutralizing stomach acid
- H2-receptor blockers which are used to lower the production of acid
- Proton pump inhibitors which prevent acid production and this gives the esophagus time to heal.
Lifestyle changes
Most hiatal hernia symptoms are as a result of acid reflux. And so, diet changes can reduce these symptoms. It can be helpful to eat smaller meals severally every day rather than the normal three large meals. Also, it is good to avoid taking heavy meals or snacks a few hours before bed. Here are some foods which increase the risk of heartburn, and should be avoided whenever possible:
- Chocolate
- Onions
- Caffeine
- Spicy foods
- Foods made with tomatoes
- Alcohol
- Citrus fruit
Also, these symptoms can be reduced through the following ways:
- Avoid smoking
- Elevating your bed’s head by around 6 inches
- Avoiding lying down or bending over after meals
Advantages of doing laparoscopic hiatal hernia repair
Laparoscopic Nissen’s fundoplication surgery has several benefits. These benefits include:
- The patient usually experiences less pain and discomfort after the surgery
- Lower risk of intra-operative complication
- Early return to normal activities
Side effects or complications of the procedure
Potential risks and complications associated with laparoscopic hiatal hernia repair surgery include:
- Failure of the fundoplication
- Severe swallowing problems
- Infection on the incision sites
- Injury to the esophagus and the stomach during the surgery
- Internal hemorrhage
- Chronic problems with belching and bloating
The patient should, however, notify the surgeon in case of worsening pain, drainage, swelling or bleeding around the incision site. Also, any abdominal pain not caused by flatulence or cramps should be reported. The patient should also seek medical attention for the bloating and swallowing problems continue for several months.
Post-operative care
- Diet – some diets will be restricted after undergoing laparoscopic Nissen’s fundoplication surgery. Mostly, the patient is required to stay on liquids and soft foods for around three weeks after the surgery. Also, a patient can experience poor diet after the surgery, this is normal and should be expected to end within several weeks.
- Wound care – after undergoing laparoscopic hiatal hernia repair surgery, a patient is advised to shower 36 hours after the operation. Also, a patient is supposed to take off the gauze before showering.
- Medications – the doctor will give you prescription for pain medication. Also, a patient is given prescription of anti-nausea medication.
- Activity – laparoscopic hiatal hernia repair surgery doesn’t have significant restrictions postoperatively. Patients are advised to engage in their normal activities soon after the surgery, as long as it doesn’t hurt. Doctors say that resuming normal activities as soon as possible enhances recovery. But, patients should avoid heavy lifting and strenuous activities for up to 12 weeks after their surgery.
- Driving – patients who undergo fundoplication surgery for GERD are usually allowed to drive after a week from surgery.
Laparoscopic hiatal hernia repair surgery cost
The cost of laparoscopic Nissen fundoplication surgery depends on many factors. Laparoscopic Nissen fundoplication surgery cost varies depending on the type of hospital, type of room and duration of hospital stay. Laparoscopic fundoplication surgery for GERD cost also depends on the duration of surgery. The cost of fundoplication surgery for GERD is usually covered by insurance in India.