Chapter 7. Surgery of the Hiatus

Laparoscopic and Open Nissen Fundoplication

• 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.

Laparoscopic and Open Paraesophageal Hernia Repair

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

Absolute

• Inability to tolerate general anesthesia.
• Uncorrectable coagulopathy.

Relative

• 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.

• 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.

Laparoscopic and Open Nissen Fundoplication

• 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.

Laparoscopic and Open Paraesophageal Hernia Repair

• 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.

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