Hiatus hernia(Laparoscopic Nissen Fundoplication) Care Plan
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Nissen fundoplication is a surgical procedure used to treat larger, symptomatic hiatal hernia and reflux. During fundoplication surgery, the upper curve of the stomach (known as the fundus) is carefully wrapped around the junction of the esophagus and stomach and sewn into place. This creates a barrier that prevents the flow of acid into the esophagus. The hiatal opening is also reduced in size with sutures.
A hiatal hernia is a condition in which the upper part of the stomach bulges through an opening in the diaphragm. The diaphragm is the muscle wall that separates the stomach from the chest. The diaphragm helps keep acid from coming up into the esophagus. When you have a hiatal hernia, it's easier for the acid to come up. The leaking of acid from the stomach into the esophagus is called gastro esophageal reflux disease (GERD). GERD may cause symptoms such as
A dry cough
Hiatal hernias are common, especially in people over age 50. If you have symptoms, eating small meals, avoiding certain foods, not smoking or drinking alcohol, and losing weight may help. Your doctor may recommend antacids or other medicines. If these don't help, you may need surgery if--
Your symptoms do not get much better when you use medicines.
You do not want to keep taking these medicines.
You have more severe problems in your esophagus, such as scarring or narrowing, ulcers, and bleeding.
You have reflux disease that is causing aspiration pneumonia, a chronic cough, or hoarseness.
Anti-reflux surgery is also used to treat a problem where part of your stomach is getting stuck in your chest or is twisted. This is called a para-esophageal hernia.
Treatments: The most common procedure of this type is called fundoplication. In this surgery, your surgeon will:
First repair the hiatal hernia, if present. This involves tightening the opening in your diaphragm with stitches to keep your stomach from bulging upward through the opening in the muscle wall. Some surgeons place a piece of mesh in the repaired area to make it more secure.
Wrap the upper part of your stomach around the end of your esophagus with stitches. The stitches create pressure at the end of your esophagus that helps prevent stomach acid and food from flowing up into the esophagus.
Surgery is done while you are under general anesthesia so you are asleep and pain-free.
The procedure: Laparoscopic repair
Your surgeon will make 3 to 5 small cuts in your belly. A thin tube with a tiny camera on the end is inserted through one of these cuts.
Other surgical tools are inserted through the other cuts. he laparoscope is connected to a video monitor in the operating room.
Your surgeon does the repair while viewing the inside of your belly on the monitor.
The surgeon may need to switch to an open procedure in the case of problems.
This is a new procedure that can be done without making cuts. A special camera on a flexible tool (endoscope) is passed down through your mouth and into your esophagus.
Using this tool, the doctor will put small clips in place at the point the esophagus meets the stomach. These clips help prevent food or stomach acid from backing up.
Before the Procedure
You may need the following tests:
Blood tests (complete blood count, electrolytes, or liver tests)
Esophageal manometry (to measure pressures in the esophagus) or pH monitoring (to see how much stomach acid is coming back into your esophagus)
Upper endoscopy. Almost all people who have this anti-reflux surgery have already had this test. If you have not had this test, you will need to do it.
X-rays of the esophagus
Always tell your doctor or nurse if:
You could be pregnant
You are taking any drugs, and even supplements, or herbs you bought without a prescription
Before your surgery:
You need to stop taking aspirin, ibuprofen, vitamin E, clopidogrel, warfarin, and any other drugs or supplements that affect blood clotting several days to a week before surgery.
Ask your doctor, which drugs you, should still take on the day of your surgery.
On the day of your surgery:
Do not eat or drink anything after midnight the night before your surgery.
Take the drugs your doctor told you to take with a small sip of water.
Shower the night before or the morning of your surgery.
Your doctor or nurse will tell you when to arrive at the hospital.
After the Procedure
Most people who have laparoscopic surgery can leave the hospital within 1 to 3 days after the procedure. You may need a hospital stay of 2 to 6 days if you have open surgery. Most patients go back to work 2 to 3 weeks.
Anti-reflux surgery is a safe operation. Heartburn and other symptoms should improve after surgery. Some people still need to take drugs for heartburn after surgery.
You may need another surgery in the future if you develop new reflux symptoms or swallowing problems. This may happen if the stomach was wrapped around the esophagus too tightly, the wrap loosens, or a new hiatal hernia develops.
Repair of your hiatal hernia requires some diet restrictions after surgery. You will need to stay on a liquid/soft diet for approximately three weeks after surgery. During that time, you can try or experiment with eating soft, mushy foods like tuna, mashed potatoes, eggs, cottage cheese, and thick soups. The reason for liquids is that there will be some swelling where your hernia was repaired. You may also notice that swallowing feels a little tight. This will improves as the swelling goes down. With time, you will be able to digest foods normally.
Also, do not drink carbonated beverages for three weeks following surgery.
Some patients find that their appetite is poor or that foods do not taste good after surgery. This is a normal result of the stress of surgery and manipulation inside the belly. Your appetite should return in several weeks. If you do not eat, this is OK; the most important thing is to drink liquids.
It is OK to shower starting around 36 hours after surgery. If you have little patches of white gauze on the incisions, take off the gauze before showering.
You should see little pieces of tape directly attached to your skin. It is OK to get these little tapes wet in the shower. The tapes will begin to peel up on the ends 7-10 days after surgery at this point they have done their job and it is OK for you to peel them the rest of the way off if you wish. You do not have to have them on when you come for your postoperative visit.
We try to close your incisions to leave the smallest possible scar. Do not put any ointment or other medication on your incisions: it will not improve or speed up healing.
You will be given a prescription for an oral pain medicine. This medicine can be constipating and we recommend taking Milk of Magnesia (two tablespoons; twice a day) while taking the pain pills to avoid constipation. You will also receive a prescription for an anti-nausea medicine (usually Phenergan). You should only take this pill if you feel nauseated. It is important to avoid retching and vomiting postoperatively or you could disrupt the repair of your hernia. Unless your surgeon advises you otherwise, you should continue all of your pre-operative medications on the same dose and schedule.
There are no significant restrictions on activity after surgery, That means it is OK to walk, climb stairs, have sexual intercourse, mow the lawn, or exercise, as long as it does not hurt. In fact, returning to normal activity as soon as possible will most likely enhance your recovery. Try to avoid heavy lifting (greater than 20-30 pounds) for several weeks, if possible.
Common things to expect at home:
Some patients find that they have diarrhea or loose bowels for the first days after their hernia repair. In the vast majority of cases, the bowel function normalizes with time.
You will need extra fluids throughout the day to meet your fluid needs.
You may also feel easily fatigued for a week or two following the surgery. These factors will put some limitations on your activity, but you will not cause any damage, even if some soreness is experienced.
Everyone returns to work at different times. As a rough guide, most people take at least one to two weeks off prior to returning to work. If you need particular documentation for your job, call the office.
Driving- Assuming the surgery is done laparoscopically, you will usually be released to drive when you have not needed the narcotic (prescription) pain medications for two days.
Other Issues-The first bowel movement may occur anywhere from one to five days after surgery. As long as you are not nauseated or having abdominal pain, this variation is acceptable. Remember that it is very common to pass a lot more gas from your rectum; this is because you will not be able to really belch.
Schedule for Consultations/Diagnostic tests:...more
Walk early and recover fast. Brief walks are needed sooner to reduce risk of blood clots
Patients feel like doing activities within a few days of having their operation. You should not lift anything heavier than 8 to 10 pounds for 2 weeks. After this period of time you can begin lifting heavier objects being aware that if your abdomen hurts you should not be lifting. Walk as much as is comfortable for you, moderate exercise helps improve circulation. You can shower the day after the operation. You can resume sexual relations when it feels comfortable for you.
Get back on a regular exercise schedule after 6 weeks, remember to avoid recurrence of hernia maintaining a healthy weight is very important.
-There is usually minimal pain associated with this operation. The abdomen will be sore as well as the small incision sites, and some patients have shoulder pain for the first day or two. The shoulder pain is caused by gas left in your abdomen during the operation.
Driving a Car
-As long as you are not taking pain medicine stronger than Tylenol and when you feel as though your reaction time is normal, you may begin driving. Do not drive if you are taking any kind of pain medicine or medicine that impairs your judgment. Most patients wait until they no longer feel their abdomen is sore.
-Most patients feel strong enough to return to work in a 1 to 2 weeks following the operation. Some patients may return to work sooner if they do desk work. If you do work that requires you to lift or bend then you may need to be placed on restricted work duty until you have your post-operative appointment. If you need a letter or work excuse to be sent to your employer, please let your surgeon or the GI Surgery nurse know.
-Normal bowel habits may be altered by several factors regarding surgery. Constipation is common. Anesthesia, decreased activity and narcotic pain medications are factors that may cause constipation. You should be aware to increase fiber in your diet as soon as possible and to increase your fluid intake. If necessary you may take a mild laxative.
The diet will help control diarrhea, excess gas and swallowing problems, which may occur after this type of surgery.
Keeping Your Stomach from Stretching
-Eat small, frequent meals (six to eight per day). This will help you consume the majority of the nutrients you need without causing your stomach to feel full or distended.
-Drinking large amounts of fluids with meals can stretch your stomach. You may drink fluids between meals as often as you like, but limit fluids to 1/2 cup (4 fluid ounces) with meals and one cup (8 fluid ounces) with snacks.
-Sit upright while eating and stay upright for 30 minutes after each meal. Gravity can help food move through your digestive tract. Do not lie down after eating. Sit upright for 2 hours after your last meal or snack of the day.
-Eat very slowly. Take your time when eating.
-Take small bites and chew your food well to help aid in swallowing and digestion.
-Avoid crusty breads and sticky, gummy foods, such as bananas, fresh doughy breads, rolls and doughnuts. These types of foods become sticky and difficult to swallow.
-Toasted breads tend to be better tolerated.
-Lastly, if you eat sweets, consume them at the end of your meal to avoid a group of symptoms referred to as dumping syndrome. This describes the rapid emptying of foods from the stomach to the small intestine. Sweetened beverages, candy and desserts move more rapidly and dump quickly into the intestines. This can cause symptoms of nausea, weakness, cold sweats, cramps, diarrhea and dizzy spells.
-Avoid drinking through a straw. Do not chew gum or tobacco. These actions cause you to swallow air, which produces excess gas in your stomach. Chew with your mouth closed.
-Avoid any foods that cause stomach gas and distention. These foods include corn, dried beans, peas, lentils, onions, broccoli, cauliflower and any food from the cabbage family.
-Avoid carbonated drinks, alcohol, citrus and tomato products.
When will I be able to eat a soft diet?
-After Nissen fundoplication surgery, your surgeon will advance your diet slowly. Generally, you will be on a clear liquid diet for the first few meals. Then you will advance to the full liquid diet for a meal or two and eventually to a Nissen soft diet.Please be aware that each patient's tolerance to food is different. Your doctor will advance your diet depending on how well you progress after surgery.
-Clear Liquid Diet
-The first diet after surgery is the clear liquid diet. It includes the following liquids:
-Flavored gelatin (Jell-O)
-Decaf tea and coffee
-Caffeinated beverages are permitted based on tolerance
-Carbonated drinks (sodas) are not allowed for the first six to eight weeks after surgery. After this time you can try them again in small amounts.
-Full Liquid Diet
-The full liquid diet contains anything on the clear liquid diet, plus:
-Milk, soy, rice and almond (no chocolate)
-Cream of wheat, cream of rice, grits
-Strained creamed soups (no tomato or broccoli)
-Vanilla and strawberry-flavored ice cream
-Blended, custard styled or whipped yogurt (plain or vanilla only)
-Vanilla and butterscotch pudding (no chocolate or coconut)
-Nutritional drinks including Ensure, Boost, Carnation Instant Breakfast (no chocolate-flavored)
-Note: Dairy products, such as milk, ice cream and pudding, may cause diarrhea in some people just after surgery. You may need to avoid milk products. If so, substitute them with lactose-free beverages, such as soy, rice, Lactaid or almond milks.