Paraesophageal hernia repair involves repositioning of stomach and other organs back into the abdomen, narrowing of the hiatus by sutures and sometimes mesh, and then creation of a fundoplication to limit gastroesophageal reflux.
Prior to having surgery there are tests that may be necessary in order for your surgeon to learn more about how your esophagus and stomach are positioned and functioning.
Tests that may be necessary include:
- Upper GI X-ray
- Upper GI Endoscopy
- 24-hour pH test
- Esophageal manometry
- Chest x-ray
Barium Swallow or Upper GI x-ray is performed to characterize a hiatal hernia’s size and position. It also gives that surgeon information about how your esophagus and stomach function during swallowing.
Upper GI Endoscopy, also known as EGD, is a visual exam of the upper GI tract using a small lighted fiberoptic scope. It is performed so that the lining of the esophagus and the stomach can be seen and evaluated prior to the operation. It is most often performed on an outpatient basis and you will be given a throat anesthetic and intravenous sedation in order for the exam to be performed comfortably. You will not be allowed to eat or drink anything past midnight prior to your procedure. Patients are required to have a responsible person to drive them home. This test may be performed either at UNC Hospitals or at another hospital or clinic. The surgeon will need a full report of this procedure prior to making a determination for surgery.
A 24-hour pH test actually measures the amount of time stomach acid is splashing into the esophagus and how high the acid goes up into the esophagus. It usually requires placing a small thin catheter into the esophagus that is connected to a computer and wearing the tube for 24 hours. A computer analysis is performed and the surgeon is given a report. Most of the time, your surgeon or GI specialist will ask you to stop taking reflux medications for at least 5 days before this test.
Esophageal manometry is a study performed by placing a small thin catheter and measuring the pressure within the esophagus. It tells the surgeon the about the function of your anti-reflux valve and the swallowing pressures generated by your esophagus as it pushes liquid into the stomach.
Bloodwork, EKG, and Chest x-ray are part of a pre-operative "work-up." Some or all of these may need to be performed prior to your operation depending on your age and overall physical health. The pre-operative "work-up" also means that you will need to spend time being interviewed by the anesthesiologist and having a complete physical examination by a resident physician. This is done during a clinic visit. You will be called by a Pre-Care nurse the night before your surgery. The nurse will tell you what time you should arrive at Pre-Care, to begin preparation for your operation
Laparoscopic Hiatal Hernia Repair and Fundoplication:
The afternoon before your surgery (or the Friday before if you are scheduled for surgery on Monday), a Pre-Care nurse will call to tell you what time you should arrive for surgery. If you will not be at home or if it is difficult for the nurse to call you, then you may call (919) 966-2273 between 3pm and 6pm to find out what time to be at the hospital the day of your surgery. You may be told to stop taking medications the night before your surgery. You will receive instructions from the anesthesiologist at the "work-up." Refrain from smoking before the operation. Do Not Eat or Drink After Midnight the night before your operation.
The Day of your Operation
You should arrive at Pre-Care at the time given you. Your family may be with you while you are being prepared for the operation as well as with you in the operating room holding area. They will be instructed to wait in the surgical family waiting room on the 2nd or 4th floor of the Anderson Building while the operation is being performed.
In Pre-Care you will be prepared for surgery. This means changing into a hospital gown, obtaining your vital signs and being interviewed by a nurse. You then will be taken into the operating room holding area where you will meet the anesthesiologist and again more questions may be asked. Once you are placed in the operating room, you will have an intravenous line (IV) placed and you will be given anesthesia for the operation to begin.
In the Ambulatory Procedure Care area you will be prepared for surgery. This means changing into a hospital gown, obtaining your vital signs and being interviewed by a nurse. You then will be taken into the operating room holding area where you will meet the anesthesiologist and again more questions may be asked. Once you are placed in the operating room, you will have an intravenous line (IV) placed and you will be given anesthesia for the operation to begin.
The surgeon uses a laparoscope (a tiny "telescope" attached to a camera) to see a magnified view of your internal organs on a monitor. The operation requires 4 tiny (1/2 inch) incisions along the abdomen near the ribcage and a fifth incision (1 inch) near the bellybutton where the laparoscope and surgical instruments are inserted.
The surgeon operates through these incisions to repair the hiatal hernia and then to wrap the upper stomach around the lower esophagus to create a "collar" effect. Sometimes a tube is left across the abdominal wall to tether the corrected stomach until healing can occur. The outside incisions are usually closed with dissolvable stitches and surgical glue. The glue will come off on its own, or you may remove it in 7-10 days.
A small percentage of operations that cannot be performed laparoscopically and they need to be converted to an "open" operation. Your surgeon will discuss this with you.
The operation lasts from 2 to 4 hours (average 3 hours). Immediately after the operation, you will be taken into the Post Anesthesia Care Unit, (PACU), or recovery room, for approximately 1 to 2 hours. You will be watched closely until you are awake and then you will be transferred to a hospital room. The length of time you will be away from your family may be 6 or 7 hours. Your family will be notified of your condition by the surgeon once the operation is complete.
During the post-operative period you will have:
- Intravenous line (IV) for fluids and pain medication. You will be in control of your pain medicine by receiving Patient Controlled Analgesia or a "PCA" following the operation. This means that a computerized pump will be attached to your IV line, and you will be in control of your pain medicine by pushing a button to give yourself pain medicine as needed. There will be limits to the amount you can get, but it will be enough to keep you comfortable. As with any type of surgery, it is reasonable to expect some amount of pain. This varies with individual patients and depends on your body's response to pain medication.
In addition, you may have:
- Nasogastric tube (NG) a small tube that goes through the nose and into your stomach,to prevent nausea. It may be removed within a few hours or may be left in overnight if necessary.
- Foley catheter-a urine tube to collect urine into a bag, so that an accurate account of your urine can be monitored.
The hospital stay after this operation is usually 2 days. During this time you are monitored closely by the nursing staff. They are specially trained to take care of surgery patients and will assist you in your initial recovery.