Fundoplication,

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Alternative names
Hiatal hernia repair, Anti-reflux surgery

Definition
This procedure corrects a defect in the diaphragm (breathing muscle), which separates the chest cavity from the abdominal cavity. A hiatal hernia occurs when the normal opening in the diphragm is too large. If the defect is not repaired, the stomach or other abdominal contents may bulge (herniate) into the chest, causing heartburn (gastroesophageal reflux) and serious damage to the esophagus.

Description

When the opening (hiatus) in the diaphragm is too large, part of the stomach can slip up into the chest cavity. Gastric acid backflows from the stomach into the esophagus, which can cause gastroesophageal reflux (GER). Over many years GER can damage the lining of the esophagus and in some cases may lead to cancer of the esophagus.

For an open hiatal hernia repair, an incision is made in the abdomen while the patient is under general anesthesia. The stomach and lower esophagus are placed back into the abdominal cavity. The hiatus is tightened and the stomach is stitched in position within the abdominal cavity. The upper part of the stomach (fundus) may be wrapped around the esophagus (fundoplication) to reduce reflux. Sometimes the surgeon will place a temporary tube from the stomach through the abdominal wall to keep the stomach in place.

In some patients, this operation can also be performed laparoscopically (also known as “keyhole” or “telescopic” surgery). In a laparoscopic fundoplication, small (1 cm) incisions are made in the abdomen, through which instruments and a fiberoptic camera are passed .

The laparoscopic procedure is performed using these small instruments while the surgeon watches the image on a video monitor. Laparoscopic fundoplication results in less pain and scarring and shorter hospitalization times than the open procedure but is not suitable for all patients.

Indications
Hiatal hernia repair may be recommended when the patient has some of these symptoms:

• Severe heartburn
  
• Severe inflammation of the esophagus due to the backflow of gastric fluids (reflux)
  
• Narrowing of the espophagus due to acid damage (esophageal stricture)
  
• Chronic inflammation of the lungs (pneumonia) due to frequent breathing in (aspiration) of gastric fluids
  
• A type of hiatal hernia where the stomach is at risk of getting stuck in the chest or twisting on itself (para-esophageal hernia)

Risks
Risks for any anesthesia include the following:

• Reactions to medications
  
• Breathing problems, pneumonia
  
• Heart problems

Risks for any surgery include the following:

• Bleeding
  
• Infection

Risks specific to this surgery include the following:

• Difficulty burping or vomiting (gas bloat), resulting in a bloated feeling after meals. This occurs in about 40% of cases but gradually improves in most patients. Rarely, the bloating can be long term.
  
• Discomfort on swallowing (dysphagia) occurs in 5-40% of patients, but improves over the first 3 months in almost all patients.
  
• Damage to the stomach or esophagus (rare)
  
• Recurrence of the hiatal hernia

Expectations after surgery
Fundoplication is a safe, effective operation. Reflux is greatly reduced or eliminated in 95% of patients.

Convalescence
Patients typically spend 1 to 3 days in hospital after laparoscopic surgery, or 2 to 6 days after open surgery. A tube will be placed into the stomach through the nose and throat (nasogastric tube) during surgery. Some surgeons like to leave the tube in for a few days, while others do not. Small, frequent feedings and avoidance of gas-producing foods are recommended. Most patients go back to work in 2-3 weeks for laparoscopic surgery, or 4-6 weeks after open surgery.

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