Nissen Fundoplication

Induction and the full stomach - treat the stomach as unprotected whatever the chart says about fasting, since the incompetent sphincter is the reason for the operation. Masking inflates a stomach with nothing holding it shut, so use a rapid sequence, table head-up, suction on the field, tube secured before prolonged mask ventilation.

Gastric decompression - once the airway is secured, place an orogastric tube and empty the stomach, because a distended fundus obscures the hiatus and is the one the surgeon has to wrap.

Ownership of the orogastric tube - that tube is yours: it comes out before the wrap is sewn, and you say so out loud. A tube left across the gastroesophageal junction and stitched into the wrap is a return to the OR.

Bougie passage - when the surgeon asks for the bougie, pass it slowly with the head neutral, only while the tip is watched laparoscopically, and stop at resistance. Blind forceful passage through a freshly dissected, narrowed hiatus is the classic esophageal perforation here, and it may not declare until the next day as tachycardia and pain.

Insufflation and ventilation - 15 mmHg of CO2 pushes the diaphragm cephalad, so peak airway pressures climb, FRC drops, and absorbed CO2 lifts your end-tidal number. Increase minute ventilation, and recheck tube depth, because the carina moves up toward a tube that does not.

Steep reverse Trendelenburg - the tilt strips venous return while the induction agent is still on board, so have a vasopressor drawn up and tilt in steps. Confirm the patient is secured to the footboard, because a slide on a steep table with the arms out is a brachial plexus injury.

Capnothorax at the hiatus - the mediastinal dissection sits directly against the pleura, and entering it lets CO2 into the chest. The tell is rising peak airway pressure with falling saturation during the hiatal dissection, not during port placement. Tell the surgeon and drop the insufflation pressure.

Managing the capnothorax - CO2 absorbs fast, so most are managed with PEEP and increased FiO2 rather than a chest tube. Do not needle a chest on suspicion alone when the differential includes a mainstem intubation.

Paralysis until desufflation - keep deep neuromuscular blockade for the entire insufflated portion, because dissection is happening millimeters from the pleura, the aorta and the esophagus, and a diaphragm that twitches is a perforation.

PONV and the fresh wrap - retching generates the pressure gradient the new wrap least tolerates and can disrupt the sutures or pull the repair into the chest. Run full prophylaxis, and consider a propofol-based technique for the highest-risk patients.

Analgesia plan - expect port-site pain plus shoulder tip pain from residual CO2, which opioids treat poorly. Build around acetaminophen, ketorolac if the surgeon accepts an NSAID near a fresh suture line, and port-site local or a subcostal transversus abdominis plane block. Every opioid avoided is nausea avoided.

Emergence and extubation - plan a short-acting technique from the start, because a slow wake-up in a patient who refluxes is a second aspiration risk. Bucking stresses the repair the way vomiting does, so aim for a calm awake extubation with the stomach decompressed, and suction under vision, never blindly with a catheter that could reach the wrap.

Body habitus - the GERD population overlaps with obesity and obstructive sleep apnea, which shortens the apneic window at the induction where you are committed to a rapid sequence. Ramp the patient and preoxygenate to a high end-tidal oxygen.

Gastroesophageal reflux disease (GERD) here is mechanical, not just secretory. The lower esophageal sphincter is incompetent, and in most surgical candidates the crura of the diaphragm have stretched enough that the gastroesophageal junction slides up into the chest as a hiatal hernia. That destroys the normal angle of His and the abdominal segment of esophagus that would otherwise be compressed by intra-abdominal pressure, so gastric contents track back up freely. Chronic acid exposure produces esophagitis, stricture, and Barrett's metaplasia, and repeated nocturnal microaspiration produces cough and reactive airway symptoms that often outlast the heartburn. Fundoplication rebuilds the barrier: the gastric fundus is wrapped around the distal esophagus so that any rise in gastric pressure squeezes the wrap shut. A full 360 degree Nissen gives the strongest barrier; a 270 degree posterior Toupet trades some reflux control for less resistance to swallowing and is chosen when manometry shows weak esophageal peristalsis.

Access - five ports across the upper abdomen, CO2 pneumoperitoneum to roughly 15 mmHg, steep reverse Trendelenburg with a footboard. Patient is in low lithotomy so the surgeon can stand between the legs; a retractor holds the left lobe of the liver off the hiatus.

Hiatal dissection - the gastrohepatic ligament is opened, both crura are exposed, and the distal esophagus is mobilized up into the mediastinum until 2 to 3 cm of it sits tension-free below the diaphragm. This is the step that can enter the pleura.

Short gastric division - the short gastric vessels are taken with a harmonic scalpel or bipolar device to free the fundus so the wrap lies without tension. This and a capsular tear of the spleen are the two real bleeding sources in the case.

Crural repair - the hiatus is narrowed behind the esophagus with interrupted sutures, sized so it is snug but not obstructing. Large defects may get mesh reinforcement.

Calibration - the surgeon asks for a bougie, typically 50 to 60 Fr, passed into the stomach so the wrap and the reconstructed hiatus are sized around it rather than around a collapsed esophagus.

Wrap - Nissen: the fundus is passed behind the esophagus and sutured to itself anteriorly as a short, floppy 360 degree collar about 2 cm long. Toupet: the fundus is passed behind the same way but each edge is sutured to the side of the esophagus and to the crus, leaving the anterior surface uncovered as a 270 degree partial wrap.

Closure - bougie withdrawn, wrap inspected, ports removed and fascial defects closed. Nothing more than local infiltration at the port sites.

Toupet within the same case - the anesthetic is identical up to the wrap itself. The decision between a 360 degree Nissen and a 270 degree Toupet is often made intraoperatively on the strength of preoperative manometry, so do not be surprised by a change in plan at the wrap. Practical difference for you: partial wraps produce less early dysphagia, so a Toupet patient is more likely to tolerate liquids and go home sooner.

Redo fundoplication and large paraesophageal hernias are different operations wearing the same name. Adhesions from the prior wrap lengthen the case well past the numbers here, blood loss goes up, and the pleura is entered far more often. Ask preoperatively whether this is a primary or a revision and set up accordingly.

If the wrap is being done together with a Heller myotomy for achalasia, the esophagus is already dilated and holds retained food for days regardless of fasting. That is the highest aspiration-risk version of this case, and a Dor anterior wrap is usually chosen instead so the myotomy stays covered but unobstructed.