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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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Laparoscopic and Open Nissen Fundoplication

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Expected Benefits

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  • Approximately 80–90% long-term control of reflux symptoms.
  • Cessation of medical antireflux therapy may be possible postoperatively.
  • Treatment of extraesophageal reflux symptoms such as aspiration.

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Potential Risks

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  • Esophageal perforation and splenic injury (< 1% of patients).
  • Wrap migration into the chest (up to 10% of patients).
  • Dysphagia (common early in the postoperative period but diminishes over time; 10–15% of patients experience occasional mild dysphagia in the first few weeks after the operation but only 1–2% require esophageal dilation).
  • Excess gas and bloating (common), which usually resolve with time.
  • Conversion from laparoscopic to open fundoplication (occurs < 5% of the time).

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Laparoscopic and Open Paraesophageal Hernia Repair

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Expected Benefits

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  • Prevention of strangulation, volvulus, incarceration, bleeding, and perforation of the herniated stomach.
  • Many patients with paraesophageal hernias also have a defective lower esophageal sphincter; therefore, an antireflux procedure or fundoplication is also typically performed at the time of operation with the expected benefits listed earlier.

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Potential Risks

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  • Mortality rate of up to 50% for patients presenting with acute surgical emergencies related to the hernia; this occurs in up to 17% of patients with paraesophageal hernias.
  • Conversion from laparoscopic to open repair (approximately 3–5%).
  • Surgical complications include:
    • Surgical site infection.
    • Bleeding.
    • Injury to the esophagus and stomach.
    • Early disruption of the repair, with recurrence rates as high as 20–40%.
    • Complication rates vary widely from 2–17%.

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  • Laparoscopic instrument set including:
    • Straight (0 degree) and angled laparoscopes (30 or 45 degree).
    • Atraumatic liver retractor.
    • Atraumatic grasping instruments.
    • Bipolar or monopolar electrosurgical devices.
    • Ultrasonic dissector.
  • General instrumentation set in case of conversion to open procedure.

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Laparoscopic and Open Nissen Fundoplication

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  • A 24-hour pH test is the gold standard to confirm the presence of gastroesophageal reflux but is not mandatory in patients with esophagitis and typical symptoms (heartburn, regurgitation).
  • Before surgery, all patients should undergo upper endoscopy to rule out Barrett esophagus and malignancy.
  • Esophageal manometry is required in all patients preoperatively to rule out severe motility disorders (eg, achalasia or scleroderma).
  • An upper gastrointestinal contrast study may be ...

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