Chapter 17 Laparoscopic Nissen Fundoplication
INTRODUCTION
Since the early 1990s, laparoscopic Nissen fundoplication (LNF) has come to replace open fundoplication as the surgical “gold standard” and procedure of choice for gastroesophageal reflux disease (GERD). Some data suggest that LNF is associated with more life-threatening complications than open fundoplication, but when the learning curve is taken into account, in experienced hands, the laparoscopic approach has proved to have significant advantages over the open procedure.1 The less life-threatening complications of splenectomy and pneumonia seen in open Nissen fundoplication are rare in LNF, but these are replaced with more potentially serious injuries. Despite articles specifically focused on error prevention in LNF, life-threatening and lethal complications still occur.2
First reported in the literature in 1991, LNF is a complex advanced laparoscopic procedure that has excellent outcomes when performed by experienced surgeons. However, even in the best of hands, serious complications can result.3 Rantanen and coworkers1 reported a prevalence of 1.3% for life-threatening complications and 1.2% for non–life-threatening complications. Predictors of success for this operation have been published elsewhere, but overall patient satisfaction has been extremely high.4
Certain patient populations, specifically morbidly obese patients with body mass indexes (BMIs) greater than 30, may be at increased risk for complications with LNF.5 Presumably, in the morbidly obese patient, visibility can be limited in the upper abdomen, creating a more difficult gastroesophageal (GE) junction dissection and more difficulty with takedown of the short gastric and other vessels, leading to a higher complication rate both intraoperatively and postoperatively. However, good data indicate no increased risk of complications in the elderly or the pediatric population.6–8 The only other population at increased risk for complications are those patients with prior extensive upper abdominal surgery.
OPERATIVE PROCEDURE
Trocar Insertion
Trocar Insertion Injuries
Life-threatening and less serious complications can occur with trocar insertion. A standard five-trocar technique is used: a 5-mm port in the right midabdomen, a 10-mm port subxiphoid, a 5-mm port to the left of the xiphoid, a 10-mm port in the left midabdomen, and a Hasson port supraumbilically. Complications of trocar insertion are discussed in Section I, Chapter 7, Laparoscopic Surgery.
Division of the Hepatogastric Ligament
Injury to an Aberrant Left Hepatic Artery
As the hepatogastric ligament is dissected to visualize the right crus and right phrenoesophageal ligament, approximately 10% of patients will have an aberrant left hepatic artery branching off the left gastric artery, making this vessel prone to injury if it is not visualized.9
• Consequence
• Prevention
Dissection of the Crura and Phrenoesophageal Ligament with Lengthening of the Abdominal Esophagus (GE Junction Dissection)
Vagus Nerve Injury
• Prevention
Esophageal Injury
• Consequence
• Repair
• Prevention
Pneumothorax, Pneumomediastinum, and Pneumopericardium
• Consequence
• Repair
• Prevention
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