Laparoscopic Nissen complication - Forum

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surgery

Re: Laparoscopic Nissen complication - Ärzteforum

Post#11 »

My partner and I have done over 200 lap gastric fundoplications. We did about 30 of the Rosetti type wherein the short gastrics are not divided. When one tries to secure the wrap at the 10-11 o'clock position on the esophagus, you can see the twist the short gastrics are putting on the esophagus. Also, without taking down the upper short gastrics, it becomes more difficult to take down the angle of His, and additionally becomes more difficult to adequately free up the medial border of the left crus. The net result is twist on the esophagus, and an inadequate posterior window. I think that a too-tight posterior window will cause excessive anterior angulation (with subsequent dysphagia being more likely), as well as potentially contributing to necrosis of the wrap.

Even with this dissection, a typical lap fundoplication will take us 45-50 minutes. We have seen no reason to go back to the Rosetti-type fundoplication. While we have found the incidence of late dysphagia (after 2 weeks) to be the same between the two methods, we found the incidence of immediate post-op dysphagia to be substantially less when an adequate posterior dissection is done along with takedown of the upper short gastrics.


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Re: Laparoscopic Nissen complication - Ärzteforum

Post#12 »

I do a fair amount of antireflux surgery both trans abdominal and trans thoracic. I do lap Nissens without dividing the short gastrics and have done about 30. I strongly feel that not all patients with reflux can be treated with the same operation. I do patients with a recurrence or a very large hernia via a trans thoracic route.

About 10 years ago, I was called by a surgeon who had done a Nissen on a patient who was now sick about 5 days later. He told me that the "GE Junction was black " when he scoped the patient. At laparotomy I found that the stomach had an organoaxial volvulus and there was virtual complete dehiscence at the GE junction. I did a partial gastrectomy, jejunostomy and put a big sump drain in the esophagus. I hooked things up 8 weeks later via a left thoracolaparotomy.

I think the most common complication of antireflux surgery is a wrong initial diagnosis. I tell our housestaff that : " First comes Diagnosis, then comes Treatment. If you can remember that, you can usually stay out of trouble."

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