Abstract
GERD is the failure of the anti-reflux barrier, allowing abnormal reflux of gastric contents into the oesophagus, which causes different symptoms and complications.
It is a mechanical disorder, caused by a defective lower oesophageal sphincter (LES) and for this reason, the surgery is a successful therapeutic option, in well-selected patients, is to restore this defective zone and create a new barrier to prevent gastro-oesophageal reflux. The laparoscopic Nissen procedure is the most used technique and the gold standard.
Today all types of fundoplication can be carried out in good conditions for well-selected patients, in accordance with well-defined rules. However, surgery is burdened by some complications, side effects and non-negligible reintervention rates (Edizioni Minerva Medica 2:7–13, 2010).
Surgical complications of laparoscopic techniques for GERD are generally rare and due to non-compliance with well-codified rules. They are the incidents that occur during intervention (preoperative complications) or the ones that appear during the postoperative course (postoperative complications). They are related to the technique, to the experience, to the instrumentation and terrain, etc.
Intraoperative complications can be classified into three main groups:
– Bleeding-haemorrhage
– Perforation (oesophagus, stomach)
– Others
These intraoperative complications of laparoscopic techniques for GERD are generally due to non-compliance with well-standardised surgical steps.
For this reason, we describe step by step a conventional laparoscopic Nissen operation, focusing on the basic principles of anti-reflux surgery and identifying critical technical points. We have enriched this chapter with selected images demonstratives and also some video clips showing the significant surgical act.
In the last part of this chapter, the postoperative complications and failures are described: recurrent reflux symptoms, gas-bloat syndrome and dysphagia are studied by analysing causes, précising tips and tricks and recommendations.
In preparing this chapter, a broad study of literature especially these last 25–30 years of the laparoscopic period were made. The sources, analyses and recommendations of the EAES, SAGES and AFC-SFCL were widely used.
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3.1 Electronic Supplementary Material
Video 3.1
Haemorrhage of short gastric vessels: Sometimes dissection and section of the short gastric vessels during Nissen’s operation may cause injury of the spleen or of the short vessels themselves. In this video clip (2′.15), it is shown how the surgeon stops moderate bleeding that occurs on short gastric vessels, aiming at several small bleeding points using the LigaSure (MP4 98689 kb)
Video 3.2
Bleeding from relatively small vessels. The bleeding from wounds in relatively small vessels can often occur without serious consequences, and it is, often, stopped with simple coagulation. In this very short video clip (0′.23), a relatively small bleeding occurs during dissection of hiatal region and is controlled with precise coagulation (MP4 6699 kb)
Video 3.3
Serious haemorrhage during inattentive dissection of the lesser curvature. During dissection of the lesser omentum, there is, often, a question of whether to preserve or to cut the left hepatic artery. This, often, is accompanied by a left hepatic vagus nerve; it is recommended, if possible, to preserve a large-sized artery, without cutting it. If the artery is not cut, working through the upper or lower window of this space will not be very easy. However, if needed, it may be cut between two points of haemostasis in order to have a suitable working field; it must be, effectively controlled, with ligatures, clips or proper devices as LigaSure or Ultrasonic Dissector. In this video clip (2′.22), the section of a large artery without effective haemostasis causes important bleeding, and this serious haemorrhage is controlled with difficulty using only a bipolar cautery (MP4 104964 kb)
Video 3.4
Gastric perforation of the fundus, during dissection in a REDO surgery. In any REDO surgery, dissection is primordial and must be done with extreme caution. Before revision surgery, a clear definition of the anatomy shall always be done before any other step. At this point, it can happen to have a perforation of the gastric fundus during the difficult dissection in these complicated interventions. In this video clip (3′.53), the surgeon is working with the hook of monopolar cautery, trying to have a clear definition of possible anatomical changes. When the surgeon is dissecting the adhesions, small bleeding occurs during dissection; the surgeon coagulates it with the monopolar cautery and a perforation on the gastric fundus wrap is shown. The surgeon decides to repair this opening of gastric fundus with sutures and performs it laparoscopically using the mechanical suturing apparatus “Endo Stitch”. Some points to be noted in this video clip are: Careful dissection is very important in any REDO surgery. Hook coagulator may be necessary to dissect tight tissues but can be dangerous when used inattentively. Intraoperative finding of a gastric fundus perforation is important, and its immediate repair with laparoscopic sutures is the correct solution. This is to be recommended if possible, as we see in the film (MP4 160313 kb)
Video 3.5
Pleural wound during mediastinal dissection. Pneumothorax is, in fact, very frequent and a not very serious complication of GERD surgery. It can be produced by a pleural wound during extensive mediastinal dissection. 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. In this video clip (0′.55), the surgeon opts to repair the breach with some sutures using the mechanical suturing apparatus “Endo Stitch” (MP4 35319 kb)
Video 3.6
Partial splenic infarction. This complication is very rare, and very few cases have been published in the literature. In this video clip (2′.03), the surgeon tried several times to stop the moderate bleeding in the hilum of the spleen with coagulation without identifying the vessels. After this, a demarcation line becomes visible on the spleen. This partial splenic infarction may be due to the undesirable section of some vessels of the spleen, at the hilum (MP4 70940 kb)
Video 3.7
Hiatal repair with mesh. The use of a mesh to close or to reinforce a wide hiatus is currently being discussed. Some surgeons only use it in selected cases, which end up being the majority. Literature has few papers widening the indication. In this video clip (2ʹ.04), a cruroplasty is seen, with mesh placement, after closing the pillars with sutures. It is a polypropylene mesh, in a “U” format, repositioned below the oesophagus, not too close and spread over the pillars, which are already approximated by the sutures. The mesh is fixed to the pillar with some tackers (MP4 95241 kb)
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Avci, C. (2016). Complication in Laparoscopic GERD: A Guide to Prevention and Management. In: Avci, C., Schiappa, J. (eds) Complications in Laparoscopic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-19623-7_3
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