Final decision to go ahead for GERD/Hiatus hernia/Acid reflux surgery
All the patients who are considered for surgery for Acid reflux are scheduled for esophageal manometry and 24 hr pH Impedance study. These investigations are needed to give us all the detailed information regarding the functioning of your food pipe and the lower esophageal sphincter (the LES valve). It will also confirm the diagnosis of GERD, will give us the details of its severity. Thus it will ensure us about the results of the surgery. Some modifications in the surgery are also done based on these tests to give you the best outcomes after surgery.
Once these tests are done the surgeon will discuss with you in detail the result of this test. He will also give his opinion on whether to go ahead with surgery or make any changes in the plan of treatment. He will talk about the outcome of surgery, the need for medications post-surgery, and the possible difficulties in taking diet in the initial phase post-surgery. Finally, a joint decision about the surgery will have to be taken by you and your surgeon. The surgery for GERD and Hiatus Hernia is called Laparoscopic Fundoplication surgery.
Preparations prior to admission
Once a decision is made regarding your Laparoscopic fundoplication surgery, its date and time, the surgical team contacts the Operation Theatre in-charge to fix the timing of surgery. The OT in-charge also updates the anesthetist doctor regarding the date and time of surgery. The surgeon will also give a call to the anesthetist to discuss what surgery is planned, what is expected during the surgery. The anesthetist would like to know at this stage whether the patient is having any medication condition, which would need further investigation or optimization with medication prior to surgery. In a situation where such is the case, your surgeon will advise you to do so and that may need to delay the surgery if needed.
The OT in charge will make sure that the instruments are properly sterilized prior to your surgery, all the devices are working properly and all the materials needed for surgery are available in the OT during the surgery.
What happens when you get admitted
Once you get admitted, the doctor on duty will check all your investigations and your surgeon’s instructions. The doctor will also ensure that you have not had food and water for 6 hours prior to the scheduled time of surgery. Then he/she will call your surgeon and update him regarding your admission and all your prior investigations. Your surgeon will also be updated regarding your current temperature, pulse, blood pressure, sugars. With advice from your surgeon, the on-duty doctors will get the remaining investigations like ECG, blood test, and X-ray.
The anesthetist doctor will also be updated regarding your admission, your prior, and recent investigation reports. Preparation of your surgery site is done by shaving the necessary part. Your consent for surgery will be taken at this time. While doing all this, the doctor on duty will try to calm down your and your dear one’s nerves. Everyone in the hospital is aware of your anxiety prior to surgery and will be trying their best to make you comfortable.
What happens in the operation theatre before you are given anesthesia
In the recovery room
You shall be shifted to the OT recovery room about 10-15 minutes prior to the time fo surgery. Again the nursing staff will recheck all your investigations. They will reconfirm that all the preparations are done properly. You surgeon or anesthetist or both will come and meet you, mainly with the intent to calm you down. You will be asked to go to the washroom to pass urine prior to finally shifting you to the operation theatre.
Inside the operation theatre
When you enter the theatre, you will be able to see a couple of OT staff getting all the instruments and the gadgets ready. You will be made to lie down on the OT table. An intra-venous line or an IV line will be taken in your hands to administer medications. Also, ECG leads, blood pressure cuff and a pulse-oxygen sensor will be applied. They will monitor your pulse, BP, oxygen levels, and heart activity throughout your surgery. Again the anesthetist doctor, OT staff, and the surgeon will be talking to you during this whole process so that all this doesn’t seem scary.
Once these preparations are done, the anesthetist will place a mask on your face and ask you to breathe through it. Anesthetic gases are coming from this mask and will make you a bit sleepy. Further medications are given through your IV line to put completely to sleep. When you go to deep sleep the anesthetist will place a tube into your windpipe through your mouth. This tube and a ventilator machine will make you breathe during the entire surgery. The anesthetist controls the depth of your sleep, your breathing, and keeps a vigil eye on the monitor. The monitor shows your pulse, BP, oxygen levels, and heart activity. So now is your time to relax and sleep. He will gradually bring you back to the conscious state once the surgery is over.
Know the team that performs your surgery
Your surgery is not performed just by your surgeon. There is a whole team at work during the surgery. Any surgery, even when they are routinely done is a complex set of multiple tasks done by many people in the team. Minimal post-surgery pain and fast recovery may make this process simple, but actually, it is not so.
There are 6-7 people in the OT during the surgery actively working to make it a success. This includes an anesthetist and a support staff with him for the anesthesia part.
About four people including the surgeon perform the surgery. The surgeon is accompanied by a camera person, an assistant, and a trolly staff. The camera person is in charge of the camera and guides the vision of the surgeon during the entire surgery. The assistant helps the surgeon during the surgery as and when needed, mainly to help make the working space. The trolly person helps in the exchange of instruments and getting the necessary material on the trolly as needed during the surgery.
Apart from this, there is a runner staff as a stand-by, in case something is needed unexpectedly during the surgery. Good and coordinated teamwork is needed to give you the desired results.
How will your GERD/Hiatus hernia surgery progress
Anesthesia and preparation for surgery
Once you are completely put to sleep and the anesthetist doctor says all in control, the surgical team starts their action.
At first, they start preparing the part where the surgery is to be done, that is your tummy. It is made germ free by applying betadine solution methodically. This is called “painting”, that is painting the part with betadine. Then whole your body except your tummy is covered with sterile drapes. This is called “draping”, that is separating the germ-free part of surgery from the rest of the body with sterile drapes (germ-free cotton sheets).
Then, the team prepares all the gadgets. This includes the laparoscopic system and the energy source. The laparoscopic system includes the camera, a laparoscope, a light source cable, and an insufflating tube to fill Co2 gas in your tummy. All this is pre-sterilized by a special method called ETO sterilization. The energy source is the device that will help in doing the surgery in a bloodless manner.
Gas insufflation of tummy, local anesthetic injection, and port placement
Once all the setup is ready, the surgeon will inject a small amount of local anesthetic solution at the place where the first cut is to be made. This will help the surgeon in keeping you pain-free once you are awake after surgery. Then a small cut is made a bit above your navel and a special needle is inserted in your tummy through this cut. After confirming that it is in the proper place the insufflating tube is attached to this needle and CO2 gas insufflation is started. Once adequate gas in filled in your tummy to create space, the needle is removed and the first port is inserted into your tummy through the same cut. This port is a hollow metal tube, through which the laparoscope and instrument can go inside your tummy. Gas is also continuously filled to maintain the space throughout the surgery.
Now is the time to insert the laparoscope inside your tummy, and the live images are seen on the monitor in front of the surgical team. The surgeon now inspects the inside of your tummy before proceeding with the surgery. Once that is done, four more ports are placed after injecting the anesthetic solution before giving cuts. These four new ports are placed under laparoscopic vision. This means when they are placed the surgeon can exactly see them coming inside the tummy through a laparoscope. Hence the surgeon can place them exactly at the site where needed in your case.
Now the actual surgery starts. The camera person shows the exact area of surgery with a clear focus. The assistant inserts one instrument through one of the ports and holds the fundus (top part) of the stomach and pushes it towards your left shoulder. Now your surgeon has clear access and vision to the area of surgery. He cuts the thin tissue over the hiatus and esophagus with the help of an energy device. By doing this he clearly identifies the muscles of the diaphragmatic hiatus and mobilises the lower part of your food pipe all around.
The surgeon then takes stitches at the muscles of the hiatus and closed the enlarged hiatus, and makes is of the normal size. Of the size that will just allow the esophagus to pass. Futher the fundus of the stomach is pulled behind the lower part of the foodpipe and wraped around the LES valve. This wrap is kept in palce by taking few stiches.
The surgeon will finally inspect the whole area of surgery. This is to recheck that the hiatus is reduced to adequate size, the wrap is not too tight and there is no bleeding. Now all the instruments and ports are removed under laparoscopic vision. The gas is emptied out of the tummy. The muscles of the tummy wall at the site of 10 mm ports (the larger ports) are closed with one stitch. This stitch is self-dissolving and will dissolve after a few months. the 5 mm ports do not need such stitch around the muscles. The skin cuts are then closed with glue and covered with bandages. Now you are ready to be awakened.
What happens once the surgery is over
Once the surgery is done, the anesthetic doctor will change the medications such that you will start to awake. Once he is sure you are awake enough to breathe yourself and gulp the saliva, he will remove the tube from your windpipe. He will make sure you are comfortable, pain-free, and breathing well. Once he is convinced about your wellbeing, we will shift you to a shifting bed. You are then taken to the recovery room on this bed itself.
In the recovery room, your pulse, BP, and oxygen will be monitored for about 10 minutes. This is the time when you would be still very sleepy. Hence, one staff will be there to comfort you and monitor your condition. The surgeon and anesthetist will also visit you to make sure you are doing well. They will also talk to the relatives and update them about your condition and will allow them to meet you. All this is done to relieve you and your relatives from the anxiety of surgery.
What happens once you are back to the room
Recovery: Initial few hours
Once you are reasonably awake you would be shifter back to your room. You would be allowed to rest for a couple of hours. On duty, the doctor will be there in case you need any help. After 2 hours, the staff will check your pulse, BP, and oxygen levels. And once they make sure you are well awake, you would be advised to sit. Gradually, as you feel comfortable water and then other liquids will be started orally. You would be advised to get out of bed, walk a few steps in the room under the observation of staff. At his point in time, all the IV drip and medications are stopped.
Once all this goes well, you would be advised to go to the washroom and pass urine. Initially, there may be a little bit pain, but that reduces once you start moving around. In case the pain is more, further medications will be given by the doctor after a telephonic talk with your surgeon. All the medications are given orally once liquids are started and you do not have vomiting. Even if all is well, your progress will be updated to your surgeon by the on-duty doctor.
Further recovery and discharge
After about 4-5 hours of surgery, once you have tolerated liquids, a soft diet will be started. The surgeon also will make a visit to ensure all is processing well. Any of your apprehensions about going home will be addressed by him during this visit. You can have a shower the next morning, as the bandages are wash-proof.
Once you are relatively pain-free, tolerating liquids and food, have passed urine, you are ready for discharge. The discharge can be done on the same day for young patients with no other medical problems and coming from the same city. For all the rest, discharge is generally done the next day of surgery.
Follow up visit at the clinic after GERD/Hiatus hernia surgery
You will be called for a follow-up visit in a couple of days after discharge. The main aim is to ensure that you are doing well and check your wounds. The surgeon will check your wounds, clean it, and reapply the bandages. He will discuss how to progress with your diet and resuming activities after surgery. Any other questions of yours would be answered at this time.
Generally, a soft diet is advised for a couple of days. There can be a little difficulty in swallowing food for the initial few days. All you have to do is eat slowly and chew properly. This should settle in about a week. Once you are able to eat a soft diet reasonably well, we can gradually start all other food as per your normal diet. In the initial few weeks, you should eat a small quantity at a time, as you may feel full with less amount of food. This is a temporary phenomenon and should gradually improve in a few weeks.
The bandages are now to be removed by yourself, at home while bathing after 5 days. If for any specific reason, your wounds need to be rechecked, then your surgeon would specify.
The next visit would be a month, two months, and three months later, just to make sure you are doing well. If you are coming from another city, this follow-up can be done by a telephonic call. It is mainly to ensure you are progressing well with your diet and if any medications need to be continued. In between if you any issues you can schedule an appointment as per need. We recommend patients to come for an in-clinic follow-up at least once after 6 months for a thorough check-up.
ADROIT centre for Digestive and Obesity surgery is performing all kinds of the esophagus, stomach, and other advanced laparoscopic surgery routinely. Our outcomes are par with international standards and our patient satisfaction level is great. We have all the facilities for a thorough evaluation of GERD, Acid reflux, Hiatus hernia, and Achalasia cardia problems at our clinic. We have a huge experience in the treatment of GERD and a large number of happy patients. Click the below links to listen to our patient’s feedback.
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