Open Nissen Fundoplication Periprocedural Care

Updated: Feb 16, 2017
  • Author: Nicole E Sharp, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Periprocedural Care

Preprocedural Planning

Obtain a detailed history and physical examination. Clinical predictors of response to antireflux surgery are lacking; thus, a thorough preoperative evaluation is needed for appropriate patient selection to ensure the best clinical outcome. [14]

Before surgical intervention, patients must undergo anatomic or physiogic testing to confirm that there is objective evidence of gastroesophageal reflux disease (GERD). Anatomic examination includes the use of esophagogastroduodenoscopy (EGD) with or without biopsy and contrast radiography (eg, upper gastrointestinal series). Physiologic examination may include 24-hour esophageal pH assessment, esophageal manometry, intraluminal impedance monitoring, gastric emptying testing, and the Bernstein acid test.

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Equipment

An atraumatic liver retractor is necessary to elevate the liver for exposure of the hiatus. A self-retraining device is needed to hold the liver retractor if an additional assistant is not available. An appropriately sized bougie may be used by some surgeons. A coagulation device of choice (monopolar, bipolar, or ultrasonic) should be available. A flexible endoscope should be available for emergency use should the need arise for endoscopic evaluation of the esophagus or stomach. A curved instrument of choice or Penrose drain can be used to encircle the esophagus.

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Patient Preparation

Anesthesia

General endotracheal anesthesia is used. A nasogastric or orogastric tube is often placed to assist in decompression of the stomach during the procedure.

Positioning

In the transabdominal approach, patients are placed in the supine position, with the arms tucked. Some surgeons ensure that patients are stable by using a beanbag or egg-crate foam. The bed is placed in the reverse Trendelenburg position to displace the bowel inferiorly. The surgeon is positioned between the patient’s legs, and the first assistant is on the patient’s left.

In the transthoracic or thoracoabdominal approach, the patient is positioned with the left side raised so that a midline laparotomy can be supplemented by a left anterolateral thoracotomy.

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Monitoring & Follow-up

Patients are most commonly discharged between postoperative days 2 and 5. The authors recommend that patients abstain from lifting anything heavier than 10 lb for 6 weeks postoperatively.

Close follow-up is necessary to ensure patient compliance with diet and early identification of potential complications. In the authors' practice, patients are seen at 1 week, 2 weeks, 4 weeks, and 8 weeks postoperatively, then yearly after that.

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