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
|Sub-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.|
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.
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].|
|Postoperative 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.
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)
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