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Laparoscopic and Open Nissen Fundoplication

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  • Evidence of gastroesophageal reflux disease (GERD) plus:
    • Sequelae of GERD refractory to medical therapy (eg, esophageal strictures, Barrett's esophagus, recurrent aspiration, or pneumonia).
    • Persistent reflux symptoms despite maximal medical therapy.
    • Paraesophageal hernia.

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Laparoscopic and Open Paraesophageal Hernia Repair

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  • Objective evidence of paraesophageal herniation.
  • Many patients are asymptomatic and a large number of cases are found incidentally.

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Absolute

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  • Inability to tolerate general anesthesia.
  • Uncorrectable coagulopathy.

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Relative

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  • Numerous previous abdominal operations (for laparoscopy).
  • Previous esophageal or hiatal surgery (for laparoscopy).
  • For morbidly obese patients with GERD, consider bariatric surgery rather than Nissen fundoplication.

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  • After induction of general anesthesia and endotracheal intubation, the patient is placed supine with legs abducted or in modified lithotomy position.
  • Placing the table at about 30 degrees reverse Trendelenburg further optimizes patient positioning and exposure of the esophageal hiatus.
  • The surgeon stands between the patient's abducted legs, and the assistant usually stands to the patient's left side.
  • Video monitors are positioned at the head of the table.
  • A nasogastric or orogastric tube is inserted for gastric decompression.

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Laparoscopic and Open Nissen Fundoplication

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  • Antiemetics should be administered to prevent early postoperative vomiting as this can lead to disruption of the crural closure and migration of the wrap into the chest.
  • Clear liquids are allowed postoperatively and a soft diet on postoperative day 1. Patients are maintained on a soft diet for 2–4 weeks as perifundoplication edema can narrow the esophagus in the early postoperative period.
  • If pain is more than expected, or the patient vomits in the early postoperative period, a water-soluble contrast swallow study should be obtained to evaluate for disruption of the wrap or unrecognized visceral injury.
  • Patients should avoid heavy lifting for 4–6 weeks following the operation.

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Laparoscopic and Open Paraesophageal Hernia Repair

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  • Postoperative chest radiographs are not routine but should be obtained if significant mediastinal dissection was required.
  • Nasogastric decompression is not necessary.
  • Clear liquids are allowed postoperatively and a soft diet on postoperative day 1, if tolerating liquids well. Patients are maintained on a soft diet for the first 2–4 weeks as edema-related dysphagia is common in the early postoperative period.
  • If pain is more than expected, or the patient vomits in the early postoperative period, a water-soluble contrast swallow study should be obtained to evaluate for disruption of the wrap or unrecognized esophageal and gastric injury.
  • Patients should avoid heavy lifting for 4–6 weeks following the operation.

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  • Pleural injury and pneumothorax.
  • Esophageal and gastric perforation.
  • Splenic injury.
  • Wrap disruption or intrathoracic migration (Nissen fundoplication).
  • Early disruption of repair (paraesophageal hernia repair).

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