43333 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis

Name of the Procedure:

Repair of paraesophageal hiatal hernia (including fundoplication), via laparotomy, with implantation of mesh or other prosthesis.

Summary

A paraesophageal hiatal hernia repair involving fundoplication is a surgical procedure where the stomach is re-positioned back into the abdomen and the hiatal defect in the diaphragm is closed with sutures and reinforced with a mesh. This is performed through a laparotomy, a large abdominal incision.

Purpose

The procedure addresses paraesophageal hiatal hernia, where part of the stomach pushes through the diaphragm next to the esophagus. The goal is to prevent serious complications such as strangulation, reduce symptoms like acid reflux, and restore normal anatomy and function.

Indications

• Symptoms such as severe acid reflux, chest pain, difficulty swallowing, or regurgitation.
• Complications like ulceration or bleeding.
• Failure of other treatments such as medication or lifestyle changes.
• Large or symptomatic hernias.
• Risk of strangulation of the stomach.

Preparation

• Fasting for at least 8 hours prior to surgery.
• Adjustments to medications as directed by the healthcare provider.
• Pre-operative assessments like blood tests, imaging studies (e.g., barium swallow X-rays, CT scan), and esophageal manometry.

Procedure Description

1. Anesthesia: General anesthesia is administered so the patient is asleep and pain-free.
2. Incision: A large incision (laparotomy) is made in the abdomen.
3. Repositioning the Stomach: The stomach is pulled back into the abdominal cavity.
4. Closing the Diaphragm Defect: The defect in the diaphragm is closed with sutures.
5. Fundoplication: The top part of the stomach (fundus) is wrapped around the lower esophagus to prevent reflux.
6. Mesh Implantation: A synthetic mesh or other prosthesis is placed to reinforce the area and prevent recurrence of the hernia.
7. Closure: The incision is closed with sutures or staples.

Duration

The procedure typically takes about 2 to 4 hours, depending on the complexity.

Setting

This procedure is performed in a hospital operating room.

Personnel

• Lead surgeon specializing in gastrointestinal surgery.
• Surgical assistants.
• Anesthesiologist.
• Circulating nurse.
• Scrub nurse or surgical technologist.

Risks and Complications

• Infection at the incision site.
• Bleeding or blood clots.
• Adverse reactions to anesthesia.
• Difficulty swallowing, esophageal strictures, or gas bloat syndrome.
• Recurrence of the hernia.
• Injury to surrounding organs (esophagus, stomach, lungs, or spleen).

Benefits

• Relief from symptoms like acid reflux and chest pain.
• Prevention of serious complications such as strangulation of the stomach.
• Improved quality of life and ability to eat normally.
• Long-term solution to prevent recurrence.

Recovery

• Initial hospital stay of 2-5 days for monitoring and recovery.
• Pain management with prescribed medication.
• Gradual return to normal activities over a few weeks.
• Avoid heavy lifting or strenuous activities for at least 4-6 weeks.
• Follow-up appointments to monitor recovery and ensure the surgical site is healing properly.

Alternatives

• Medications like proton pump inhibitors or H2 blockers to manage symptoms.
• Lifestyle changes such as diet modification, weight management, and elevation of the head during sleep.
• Minimally invasive procedures like laparoscopic surgery (less invasive than laparotomy).
• Pros of alternatives: Less invasive, quicker recovery. Cons: May not be effective for large or complicated hernias, higher risk of recurrence without surgical repair.

Patient Experience

During the procedure, the patient will be under general anesthesia and will not feel anything. Post-operatively, some discomfort and pain at the incision site are expected. Pain management will be provided, and patients may experience temporary difficulty swallowing or gas bloat syndrome. Early mobilization and adherence to recovery instructions can aid in a smoother recovery process.