Antireflux, Laparoscopic Fundoplication

A fundoplication is a surgical procedure that your surgeon does to help prevent heartburn, reflux or gastroesophageal reflux disease (GERD). You may already be on tablets for this and tried changing your diet, however it has not helped. A fundoplication (full or partial) is where your surgeon takes the top of your stomach and wraps it around the base of your oesophagus (full). The surgeon may only complete a partial fundoplication – this means that the stomach is not wrapped the whole way around. 

Surgical Procedures

Nissen (360°)

The fundus is wrapped three quarters of the way around the intra-abdominal oesophagus and sutured at the front.

Toupet (270°)

The fundus is wrapped three quarters of the way around the intra-abdominal oesophagus and sutured at the sides.

Anterior / Dor Procedure (180°)

A loose wrap usually performed on patients with decreased peristalsis of the esophagus.

Other procedures requiring a laparoscopic fundoplication:

• Laparoscopic Heller’s Cardiomyotomy – muscle fibers of the lower esophagus are split and a fundoplication is then performed.
• Laparoscopic Para-oesophageal Hernia repair – is the reduction of a rolling type hiatus hernia with a diaphragmatic repair with or without a mesh and a laparoscopic fundoplication.

What to expect after your operation

• After a general anaesthetic, you may be drowsy.
• You may have general neck / throat ‘soreness’.
• Will most likely have a dry mouth.
• A nurse will monitor your vital signs – blood pressure, pulse, temperature, respirations and oxygen saturations regularly for the first 4 hours post-operatively.
• The nurse will also ask you to rate your pain on a scale of 0 – no pain to 10 – worst pain imaginable and administer pain relief medication as necessary
• After your procedure, you will NOT be able to eat or drink for four (4) hours - then you will commence on a clear fluid diet.
• If you tolerated clear fluids your diet will be upgraded to Free Fluids at the next mealtime.
• If you tolerated free fluids your diet will be upgraded to a special diet Laparoscopic Nissens Fundoplication diet (LNF). You will need to remain on this diet for 4 weeks (see additional handout).
• If you tolerate this diet you will be able to go home.

Post-operative period

• You will have an intravenous Cannula ‘drip’.
• There will be 5 small incisions on your abdomen all dressed with waterproof dressings.
• You may have nausea, shoulder tip pain or abdominal bloating.
• Occasionally, there can be some numbness and / or swelling at the incision sites.

Length of stay in hospital

Please try and have transport arranged for your discharge the day after surgery unless otherwise instructed - Discharge time will be after lunch if admitted for 1 night and will be after breakfast if admitted for 2 nights.

Discharge planning – going home 

Following your discharge, it is very important that you give yourself time to recuperate and heal - Follow the dietary guidelines slowly upgrading the texture of your diet, you should be able to tolerate a full diet by 5-6 weeks - It will be difficult to belch, so where possible you should avoid ‘fizzy’ drinks.

You may have increased flatus ‘wind’, abdominal cramps, diarrhoea or constipation following this procedure.

Wound Care – Leave dressings on for 7 days post discharge, then remove and wash wound in shower. All stitches are underneath the skin, so nothing has to be removed. Observe for signs of infection such as increased redness, swelling, pain, ooze or heat and report to local GP or emergency department.

Be sure to take all prescribed medications.

You will need to make an appointment for 4 weeks to see Dr Daoud.

Risks

• Esophageal injury.
• Bleeding.
• Bowel injury and other visceral injury.
• Spleen injury, which may require losing the spleen.
• Migration of the fundal wrap into the chest which requires an emergency surgery.

Post surgical diet

To reduce surgery risks, your surgeon needs you to be on a low-carbohydrate and low-fat, high protein diet. This diet is to be followed for two weeks after your surgery. After the surgery, there is a staggered reintroduction of foods, which is essential to ensure that foods slide easily into the stomach to help with healing. If you jump ahead and choose foods not suitable for your stage post-op, you may risk the surgical repair.

Here are some tips that will help you eat after your procedure

• Start eating meals in an upright position. If you slouch, this will create pressure and affect food entering the stomach. Stay upright for thirty minutes after your meal. Do not lie down after eating.
• Eat slowly! Practice eating mindfully. Take small bites. Chew food 20 times, wait 20 seconds between mouthfuls. This will help the food pass easily into the stomach.
• Drink slowly. Take your time with drinking and try not to gulp.
• Avoid carbonated beverages, chewing gum, smoking (if applicable), alcohol and drinking through a straw. These actions and carbonated beverages introduce gas into the stomach, which can be uncomfortable post-surgery. Avoid carbonated beverages for four weeks post-op.
• Relax! Make sure you eat in a relaxed state. Enjoy your meals. This will also help prevent any pressure on the stomach.
• Follow the diet as per your dietician. See your dietician three weeks post-op for progression.                                           

Post operatively you will be placed on a fluid diet. 

Week 2 you will be placed on a pureed diet.

Week 3 & 4 you will be placed on a soft diet.

Week 5 onwards you will be placed back onto a solid diet.        

As your stomach needs to recover, you should not eat or drink anything until your surgeon gives you the go ahead in hospital. For the first few days, you will not be able to drink very much. It is important that you start slowly introducing liquids then foods.

In Hospital: To start off with you will be placed on a clear or free fluids diet. Initially, you will not be able to drink very much. Try as much of the clear/free fluids that the hospital gives you. You won’t be able to finish all the drinks provided. Choose the milky-based products first. Make sure you eat and drink slowly. Stop when you feel full.

FIRST 2 WEEKS AFTER SURGERY (WEEK 1-2) - WHEN YOU GET HOME

Once you get home, you will need to replace two meals with the Optifast shakes. For dinner you can have vegetables and meat. Many patients will stick to high protein soups for the first week – your dietitian can email some recipes. You will need to boil the vegetables well and puree these. You will need to cook your meat very well and place these in a blender with 1 tsp of oil/gravy/sauce. Pureed foods need to be soft that it could be similar to baby food consistency. This is important to help the recovery of your stomach. This needs to be followed for two weeks. 

If you have no issues with nausea, vomiting, pain or your bowels, move onto the soft food stage. If you do have issues with nausea, vomiting, pain or your bowels, contact your surgeon or dietitian for advice.

SOFT FOODS (Week 3–4)

Two weeks post-op, you may move onto soft foods. This typically occurs in Week 3 to Week 4 following your surgery. You should only progress to this stage if you have tried pureed foods and did not experience any nausea, pain, vomiting or issues with your bowels. If you did have these symptoms, stay on the pureed foods for another three days.

This is the next stage to reintroduce foods. Remember to eat slowly, chew your food well and keep fluids away from mealtimes.

FOODS TO AVOID AFTER SURGERY IN 5 WEEKS

• Soft or doughy breads
• Pasta
• Carbonated beverades / fizzy drinks
• Rice
• Steak
• Tough, dry, red meat
• Salted or roasted nuts
• Popcorn
• Other fibrous foods – eg. corn, skins on fruit and vegies
• Alcohol
• Avoid sugar, sugar containing foods and concentrated sweets
• Fruit juice
• Deep fried foods
• Foods high in saturated fat