Authors
Number of cases
Morbidity (%)
Mortality (%)
Champault (1994) FDCL
940
5
0.3
Dallemagne (1995) (compilation)
2149
1.6 (reinterventions)
3.2.3 Complications/Multicentre Series
Another most recent multicentre study of 7531 patients operated on between 2005 and 2009 shows a 3.8 % morbidity and 0.19 % mortality [17].
Intra-operative complications can be classified into three main groups:
Bleeding-haemorrhage
Perforation (oesophagus, stomach)
Other (pneumothorax-capnothorax, pneumomediastinum-capnomediastinum, laceration, injury or ischaemia in surrounding tissues or organs – liver, stomach, spleen, etc.
3.2.3.1 Haemorrhage
Haemorrhagic complications are rarely reported in literature. The overall rate of bleeding is low and usually without vital impact (rare cause of conversion and of transfusions).
Sometimes the type of intervention favours the bleeding. Dissection and section of the short gastric vessels during Nissen’s operation may cause injury of the spleen or short vessels (Video 3.1). Nissen-Rossetti, Toupet or Hill’s techniques do not seem to cause this type of injury. One of the major bleeding complications is the serious injury of the spleen; this, fortunately, is exceptional in laparoscopic surgery, while, on the contrary, it was quite common during open surgery [15].
A wound of the vena cava inferior or aorta can cause a very severe haemorrhagic accident; this may occur during the dissection of mediastinal oesophagus, during suturing of the diaphragmatic crus or when attaching a prosthesis on the hiatal defect. Be careful.
Otherwise, no significant bleeding from wounds in relatively small vessels or the liver injury by the retractor can often occur without serious consequences and are, often, stopped with a simple coagulation or ligation (Video 3.2).
Contrary to this, recklessly cutting a large left hepatic artery without effective haemostasis can be a cause of serious bleeding (Video 3.3). In the case of a large artery, effective control with ligatures, clips or LigaSure or ultrasonic dissection should be absolutely made before the section.
Video 3.1: Haemorrhage short gastric vessels
Video 3.2: Bleeding from relatively small vessels
Video 3.3: Serious haemorrhage during inattentive dissection of the lesser curvature
3.2.3.2 Digestive Perforations
Digestive Intra-operative complications are primarily represented by perforation of hollow organs (oesophagus and stomach). These complications were rarely mentioned in open series and seem to be rather specific of laparoscopy.
The series of the first years, in the beginning of laparoscopic GERD treatment, some cases of gastrointestinal perforation were published. With increasing experience and because of other reasons, these serious complications are rarely described in the most recent series.
In a survey by the French Association of Surgery, from 1999 [18] which includes 2424 cases from 21 centres, 25 gastrointestinal perforations were reported; 13 are perforations of the oesophagus and 12 of the stomach, with the need for 5 major surgeries and 2 deaths. Champault [15] has reported eight perforations in the research done by the FDCL, in 1994. Hinder [19] has reported 20 cases in 2453 patients. These perforations are estimated to be around 1 % and are quite serious as they are responsible for the majority of deaths reported in those series.
There is a classic mechanism to cause these wounds of the oesophagus and stomach:
Peri-oesophagitis with the cardia fixed in the lower mediastinum
The brachy-oesophagus;
Reoperations
Bad dissection plane with forceful passing behind the oesophagus
Perforation during passage of the tube (Faucher or other)
Electrical lesions of the oesophagus
Aggressive use of the instruments
Perforation by dropping stitches
Large hiatal hernia
Obesity
3.2.3.3 Oesophageal Perforation
Oesophageal perforation is the most important complication of anti-reflux surgery. It represents 0–2 % of cases depending on the series, occurring mainly during the phase of retro-esophageal hiatal dissection region. The consequence varies and can be detected early or late. If it is discovered during the operation, it has the chance to repair perhaps laparoscopically and during recovery. Otherwise, unknown oesophageal perforation may result a severe complication, even death.
In the investigation of the AFC [18], 13 oesophageal perforations have been reported, and 9 were diagnosed intraoperatively, requiring 6 times a conversion. The diagnosis of the other four cases is done within 1–25 days. In 12 cases, the suites were simples. One death has been reported in a patient of 48 years, operated for a complete fundoplication, and, in which the removal of the valve was made by thoracic approach. All oesophageal wounds were sutured, three laparoscopically. A wound of the oesophagus occurred during the passage of tube Faucher (Table 3.2).
Intra-operative diagnosis – 9 | ||||
|---|---|---|---|---|
Intervention | Conversion | Laparoscopic suturing | No problems | |
8 FC, 1 FP | 6 | 3 | 3 | |
Postoperative diagnosis – 4 | ||||
Intervention | Time to diagnosis | Reintervention | No problems | Death |
3 FC, 1 Ang | 1–25 days | 4 | 3 | 1 |
Prevention: Especially when there is the higher risk of oesophageal perforation, this can be minimised by the way retro-oesophageal dissection is performed, remaining in contact with the pillars of the diaphragm.
To avoid puncturing the oesophagus, we must not forget the basic principles of anti-reflux surgery: “Dissection of the oesophageal hiatus and not of the oesophagus”. Most importantly, do pay lots of attention to not let go unnoticed any possible injury, in order to not run the risk of a complication that can be catastrophic.
3.2.3.4 Gastric Perforation
Gastric perforations are rarer than oesophagus’s. Literature reports a certain number of cases. The series of Watson [20] reports 1 case out of 200, the series of Champault [15] reports 2 cases out of 940 and Hinder’s reports 5 cases out of 2453 [19].
In AFC’s [18] series, of the 12 gastric wounds reported 3 were pre-operatively discovered and treated; two with sutures and one by a secondary gastrectomy. Nine were postoperatively found, with two necrosis. Six suturing repair and three gastrectomies were performed. One death has been reported in connection with this complication (Table 3.3).
Intra-operative diagnosis – 3 | |||||
|---|---|---|---|---|---|
Intervention | Conversion | Laparoscopic suturing | No problems | Reintervention | Death |
2 FC, 1 FP | 2 | 1 | 2 | 1 gastrectomy | 0 |
Postoperative diagnosis – 9 | |||||
Intervention | Time to diagnosis | Laparoscopic suturing | Laparotomy + thoracotomy | Iterative intervention | Death |
8 FC, 1 FP | 1–15 days | 1 (day 2) | 8 (5 sutures, 3 gastrectomies) | 1 oesophageal stenosis | 1 |
3.2.3.5 Complications: Gastric Wounds
Usually the location is anterior, near the greater curvature. Rarely, it is torn by excessive tension of the valve. In this case, the location can be posterior on the valve, retro-oesophageal, close to the pillars. It can also happen as a perforation of the gastric fundus during the difficult dissection in complicated interventions REDO (Video 3.4).
Video 3.4: Gastric perforation of the fundus, during dissection in a REDO surgery
Other rare event of perforation has been described, on the large gastric tuberosity, because of rough use of traumatic forceps. This type of perforation is easier to recognise and can, often, be repaired by laparoscopy [21]. It is also reported in literature, the ischaemic perforation of the great tuberosity due to extensive gastrolysis. Excessive section of short vessels can lead to shortness of blood supply to the great tuberosity relying on the posterior gastric artery whose anatomical variability does not provide for sufficient substitution vessels [22].
3.2.3.6 “Gaseous” Complications
Gaseous complications are represented by the pneumothorax and the pneumomediastinum.
The pneumomediastinum is a specific complication of any laparoscopic surgery with opening of the lower mediastinum (GERD, Heller, vagotomy, etc.). Most often it is also because, during this extensive dissection, there was an association with high abdominal pressure. But all patients with dissection pushed into the lower mediastinum and in whom there is high abdominal pressure do not have, systematically, a pneumomediastinum. This mechanism is not the only cause to explain the pneumomediastinum. Perhaps there is an anatomical reason?
The pneumothorax is defined by the passage of CO2 into the pleural cavity through a pleural breach. It is not always the result of the operative act. Decreased oxygen saturation, increased airway pressure and, in particular, abnormal movement of the hemidiaphragm can be called signs of pneumothorax. The diagnosis is made by the analysis of the pleural gas where CO2 can be found.
Joris [23] noted that a capnothorax can be bilateral. Usually, it is well tolerated but it should be treated early. Finally, he showed that PEEP is the most efficient treatment, while it is contraindicated in pneumothorax.
These complications are, in fact, very frequent and less serious.
Pneumothorax requires:
A pleuropulmonary breach during surgery
A rupture of an emphysema bullous by increased pressure in the airways
Pleural wounds most often affect the left pleura. The main mechanism is the extensive dissection in the lower part of the mediastinum and going through the wrong retro-oesophageal plan during the dissection of the left side (Video 3.5).
Video 3.5: Pleural wound during mediastinal dissection
3.2.3.7 Other Complications
Some anecdotal complications are increasingly reported:
3.3 Guide to Prevention and Management of Intra-operative Complications
Prevention of complications is the best treatment. Only perfect planning and excellent execution of the technique can minimise complications and their sequelae.
Surgical complications of laparoscopic techniques for GERD are, in general, due to non-compliance with well-standardised surgical steps.
The risk of complications and failure may decrease considerably if there is:
A correct indication
Good choice of techniques
The respect for surgical principles and well-standardised rules
For this reason, we describe, step by step, a classical laparoscopic Nissen operation, emphasising basic principles of anti-reflux surgery and identifying critical technical points.
3.3.1 Operating Phases of the Typical Anti-reflux Surgery
Step-1: Dissection of the gastro-oesophageal junction
Step-2: Dissection and mobilisation of the oesophagus
Step-3: Preparation and mobilisation of the gastric fundus
Step-4. Approximation of diaphragmatic pillars (cruroplasty)
Step-5: Creation of the fundus valve (fundoplication)
3.3.1.1 Step-1: Dissection of the Gastro-Oesophageal Junction
Best Exposure of Hiatal Area
First step of the intervention is to have a good exposure in the hiatal region; for this, a liver retractor is used to lift the left lobe of the liver in order to get a broad view and a perfect exposure.
Remark: For work in the hiatal region, to have a good liver retractor is indispensable. The choice of the retractor and its good handling is important. During surgery, a mechanical arm fixed to the right of the operating table, in order to get long-time stability, can hold it.
Risk: Liver haemorrhage
Mechanism: Inappropriate retractor, careless use
Prevention: Select a special atraumatic retractor for the liver, place it carefully and monitor the position during surgery (Fig. 3.1).
Fig. 3.1
Two different types of liver retractors
Best Position of the Working Area
After having installed the liver retractor and obtained a correct working area, the assistant seizes the stomach under the oeso-gastric junction with a grasper and pulls it down and to the left. The gastro-oesophageal junction should remain tense by the pull on that forceps for the security and efficiency of the dissection.
Remark: The caudal and leftwards traction of cardia with an atraumatic and appropriate grasper is essential to effective work.
Risk: Laceration or even perforation of the stomach.
Mechanism: Use a traumatic grasper and pull excessively and without care and attention.
Prevention: Use only an atraumatic grasper to hold on the cardia and draw up the necessary requirements.
Opening of the Lesser Omentum and Access to the Right Crus
After good exposure, the lesser omentum is to be sectioned, to allow access to the right crus of the diaphragm. The pars flaccida and pars condensa of the lesser omentum are incised by, at the same time, targeting the upper part of the right crus, which is an essential referral point, before addressing the dissection of the back part of the oesophagus. It is, often, under question whether to preserve or to cut the left hepatic artery which, often, accompanies a left hepatic vagus nerve (Fig. 3.2).
Fig. 3.2
The large size of the left hepatic artery vagus nerve are preserved
Remark; These branches of artery and nerve pass horizontally in the middle of the working field and divide it in two compartments. If it is not cut, working through the upper or lower window of this space will not be very easy.
Recommendation: It is recommended, if possible, to preserve a big size artery, without cutting it, even if it makes the approach to the area difficult. If it does not seem very important, this slim branch in the omentum may be cut between two points of haemostasis in order to have suitable working fields. Conversely, if there is an artery of big size, it is advisable not to cut it, even if it makes the approach to the hiatus harder. In the case of a very thin patient, this is not a problem, but, sometimes, in more obese patients, it is hard to find the crus; so, maybe it is quite helpful to look from below. Meanwhile, this window must be large enough just to admit the fundoplication wrap.
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