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Laparoscopic Antireflux Procedures

Overview
Sages Guidelines
OR Set-up
Trocars
Instruments
Consent
Billing-Coding
Lap Nissen-360
Lap Toupet-270
w Esophageal Length.
Redo LapNissen
Technical Analysis
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Laparoscopic Antireflux Procedures
Management of Accepted Complications
 
bulletPneumothorax: This complication is secondary to the combination of the creation of a pneumoperitoneum and surgical penetration of the mediastinum. Three pneumothoraces occurred in our series, all of them in the operating room. A sudden change in oxygenation was noted by the anesthesiologist and the diagnosis made on chest x-ray. A chest tube was inserted and the procedure completed.
bulletSub-cutaneous Crepitus: Sub-cutaneous crepitus or emphysema occurs frequently while performing these procedures. It usually occurs on the neck and face and is not usually associated with a pneumothorax.
bulletPostoperative Dysphagia: This is a sensitive issue. We remain convinced most patients who have undergone a Laparoscopic Nissen Fundoplication will develop some form of dysphagia immediately after this procedure. Patients describe an unpleasant, mild solid food dysphagia. All symptoms disappear within four to eight weeks and do not impair the patient's recovery. Twenty-three percent of the patients did not report any such form of dysphagia. Patients should educated preoperatively as to what to expect after surgery. They should also be instructed to eat slowly postoperatively and encouraged to drink lukewarm water to relieve severe symptoms. One patient did develop immediate, post-operative severe dysphagia (liquid and solid) and eventually had to undergo a revision of the fundoplication. Most of these complications are now rare.
bulletPersistent post-operative Dysphagia: Persistent post-operative dysphagia is reported with frequency. It is reported that these symptoms will require post-operative endoscopic dilatation in 1 to 10 % of the cases. Most of these complications can be avoided by performing a floppy fundoplication. However, even with the best techniques these complications do occur. Mild post-operative dysphagia is not usually treated. Patients who demonstrate severe dysphagia for more than six weeks after surgery will need to undergo an Endoscopic dilatation. It is rare to have to surgically take down the actual surgical repair [1 / 500 cases].
bulletPostoperative Atelectesia and Pneumonia: It is imperative postoperative patients are active and ambulate as of the first postoperative day. In addition, they should use an Incentive Spirometer every hour while awake for the first four days after surgery as they are prone to develop severe atelectasis.
bulletRecurrent Reflux: Surgical failures associated are few but taught us valuable lessons. We originally believed that most recurrences occurred secondary to a post-operative torsion of the fundoplication. We now have realized the fundoplication is usually intact. The recurrence of GERD symptoms is usually secondary to a failure of the diaphragmatic or crural closure which generates a partial migration of the fundoplication in the lower mediastinum. For these reasons, it is essential to 1) anchor the fundoplication to the medial diaphragmatic (Three 0 silk sutures) , 2) never complete the fundoplication under tension and to 3) perform a adequate crural closure. We now routinely perform a reinforced Nissen Fundoplication which appears to have better long term result. (see: Redo Laparoscopic Nissen Fundoplication)

 

 

Procedural Videos
> Lap Nissen: 360 Deg. Simple - Full

> Lap Nissen: 360  Deg. Complicated

> Lap Nissen: Using the EndoStich Instrument.

> Lap Nissen: Taking down the short gastric vessels with the UltraShears instruments

> Lap Nissen: Management of Iatrogenic Splenic Tear

> Lap Toupet: 270 Deg. Full

> Reinforced Lap Nissen: 360 Deg. Full

> Lap Nissen with closure of large Paraesophageal Hernia

> LapNissen with Esophageal Lengthening

> Lap Nissen: Revision of Failed Lap Nissen

> Lap Nissen: Revision of Open Nissen Fundoplication

> Lap Nissen with Hepatic Shoulder


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