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.

Laparoscopic and Open Nissen Fundoplication

Expected Benefits

• 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.

Potential Risks

• 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).

Laparoscopic and Open Paraesophageal Hernia Repair

Expected Benefits

• 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.

Potential Risks

• 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%.

• 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.

Laparoscopic and Open Nissen Fundoplication

• 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 ...