Che Miller, M.D.

Patient Education Literature
We recommend that you read this handout carefully in order to prepare yourself or family members for the proposed procedure.  In doing so, you will benefit both the outcome and safety of the procedure.  If you still have any questions or concerns, we strongly encourage you to contact our office prior to your procedure so that we may clarify any pertinent issues.

Laparoscopic Paraesophageal Hernia Repair and Nissen Fundoplication

This procedure involves the repair of a hiatal hernia with mesh using cameras and long instruments.  It is performed to reduce or eliminate the symptoms associated with a hiatal hernia and/or gastroesophageal reflux.  

Purpose of the procedure:
This procedure is performed when there is a weakness or hole where the esophagus enters the abdomen or in patients with severe GERD/heartburn.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery.  You may brush your teeth in the morning, but do not swallow the water.  The evening before and the morning of surgery you need to take a shower with a bacterial detergent.  Hibiclens is a popular soap that can be obtained at most pharmacies.  If you are on medications that must be taken you need to discuss these with the surgeon prior and/or anesthesiologist.  Certain medications can make this surgery more risky.  Blood thinners (i.e. Aspirin, Coumadin, Plavix, etc.), arthritis medications, and insulin are examples and should be discussed with your surgeon and anesthesiologist.

Description of Procedure:
After the anesthesiologist has you go to sleep, a tube will be placed in your trachea to help you breath.  Then five or six small incisions will be made on your abdomen.  Several ports are placed through these incisions and a camera and long instruments are used to find the hernia, repair it, then wrap the stomach around the esophagus to prevent further GERD.  If the hernia is large or additional strength is needed, more incisions and sutures can be used and at times mesh may be used.  Occasionally, the stomach is sewn to the anterior abdominal wall.

After the procedure:
Following the procedure, you will awaken in the OR and be taken to the recovery room.  Nurses and staff will help you wake further and control your pain.  It is not unusual to feel confused or out of place.  Fluid intake is important.  Most patients will go home the following day, but some may stay several days to help control pain.  You will be sent home with a prescription for pain medicine.  This is a narcotic and will effect your ability to drive or operate machinery.  It is ILLEGAL to drive while taking this medication.  Most of the pain resolves after the first 24-36 hours but may persist for 4 to 5 days.  Continue to drink plenty of fluids. A stool softener is usually given with narcotics to prevent constipation and should be taken as long as you are taking narcotic pain medications.  Early after surgery, a bland diet is best tolerated.  You will be given instructions on what you can eat and when.  This will be a separate form and is very important to follow.  You should avoid heavy lifting for about six weeks. You may do light exercise as you desire and have intercourse. You may drive if you have stopped the narcotic pain medications.  After surgery, your incisions may be covered by dressings or band-aids.  Leave these in place for 24 hours, then you may remove them.  Underneath are striped pieces of tape.  Leave these until either they fall off or their edges curl.  Your sutures are on the inside and will dissolve after 4 wks.  You may shower after 24 hours but you should avoid bathing in a tub for 48 hours.  Do not swim for two weeks.  
Conditions to Look For: 
Although a laparoscopic paraesophageal hernia repair and Nissen is a safe procedure, problems can arise. Should any of the following occur, please contact your physician as soon as possible:
1. Fever greater than 101 degrees.
2. Persistent vomiting after the third postoperative day.
3. Failure to have a bowel movement after four days.
4. Difficulty swallowing.
5. Increasing tenderness at the incisions. Please note that the incisions will be red and uncomfortable for approximately 10 days. If pus develops or if areas of enlarging redness occur, please call your physician
The following is a list of emergencies.  Should any of these develop, proceed to your emergency department.  If you feel that you cannot make to your emergency department or do not have a ride, call 911 immediately.
1)	Weakness or lightheadedness that prevent you from being able to walk.
2)	Chest pain or shortness of breath.
3)	Uncontrollable vomiting.
4)	Blood in your vomit or stools.
5)	Abdominal pain that cannot be controlled with your pain medications
6)	Swelling or rash after you take any medication for the first time.
Risks and Alternative Procedures:
Hernia repair complications are not common and usually minor.  Infection or bleeding may occur within the incisions.  It is quite unusual to require transfusions or surgery. Occasionally hernias can recur, but this is unusual.  An even less common complication is injury to the bowels. If this occurs, more extensive surgery would be required.  Other potential complications are reaction to the sedatives used or complications from heart or lung disease. Hot towels or moist packs often help relieve the discomfort of an irritated vein. The incidence of all of these, together, is less than 12%. Another option for control of symptoms are medications.  These are usually less successful and must be continued for life.
Follow-up Visit
You should see your surgeon for an office visit approximately one to three weeks after the surgery. Please do not hesitate to contact your doctor at anytime if things do not appear to be going smoothly.

Consent for Procedure:
I _______________________ have read the above description of my procedure.  I understand the indications, risks and benefits of surgery listed on this form and explained by my surgeon.  I agree to undergo a paraesophageal hernia repair and Nissen fundoplication any other indicated procedures.  I have had an opportunity to ask questions and have received all the information I need to make this decision.

Surgical Risks
Minor risks of surgery include but are not limited to:  Bleeding, infection, and hernia recurrence.  These can occur in as many as 12% of patients.  Severe risks of surgery include but are not limited to: Anesthetic complications, drug reactions, injury to the bowel, severe wound infection, respiratory failure, cardiac failure, heart attack, kidney failure, and even death.  These can occur in less than 3 percent of patients.

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Patient Signature:				Surgeon Signature				Date