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Consent: Laparoscopic Anti-reflux Surgery (Nissen Fundoplication)

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Last updated: March 12, 2021
Revisions: 5

Last updated: March 12, 2021
Revisions: 5

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This article is for educational purposes only. It should not be used as a template for consenting patients. The person obtaining consent should have clear knowledge of the procedure and the potential risks and complications. Always refer to your local or national guidelines, and the applicable and appropriate law in your jurisdiction governing patient consent.

Overview of Procedure

Laparoscopic Nissen fundoplication is a widely accepted approach for the surgical management of Gastro-oesophageal reflux disease (GORD) .

For the procedure, the gastric fundus is wrapped around the lower end of the oesophagus and sutured in place. For a Nissen fundoplication, a full 360 degree wrap is performed (Fig. 1).

Prior to undergoing surgery, patients should have pre-operative work-up with oesophagogastroduodenoscopy (OGD), 24 hour pH testing and/or oesophageal manometry studies. Anti-reflux surgery should not be offered to morbidly obese patients (BMI >35kg/m2) due to the high rate of failure.

Figure 1 – The 360 degree wrap, as seen in a Nissen fundoplication

Complications

Intra-Operative

Complication Description of Complication Potential Ways to Reduce Risk
Haemorrhage In laparoscopic surgery, port insertion can damage any intra-abdominal organ, including the abdominal aorta.
Injury to surrounding structures including oesophagus, stomach, bowel, liver, and spleen All nearly organs can be inadvertently damaged during the procedure. Of note, injury to the liver may occur as a result of the liver retraction required intra-operatively
Conversion to open surgery including full laparotomy* This may be necessary if the procedure is difficult.
Drain insertion In the presence of a large hiatus hernia, a thoracic drain should be placed through the defect to prevent fluid accumulation in the mediastinum
Anaesthetic Risks Includes damage to the teeth, throat and larynx, reaction to medications, nausea and vomiting, cardiovascular and respiratory complications Forms a part of the anaesthetist assessment before the operation

*This is not a true complication, merely a consequence of difficult pathology, but always should be included

Early

Complication Description of Complication Potential Ways to Reduce Risk
Pain The patient will have local anaesthesia into the wounds and simple analgesia post operatively
Abdominal fullness, dysphagia, postprandial discomfort Symptoms related to oedema at the site of the fundoplication Patients are advised to have a liquid or blended diet for around 3 weeks post-operatively
Infection Superficial wound infection is possible, however collections in the pelvis or paracolic gutters can also occur. Peri-operative antibiotics will reduce the risk of wound infections
Scarring Any scar may form a keloid scar, particular in high-risk ethnicities.
Pneumothorax or surgical emphysema A pneumothorax may occur following excessive hiatal dissection and a pneumomediastinum can occur as a result of intra-peritoneal gas pressures
Oesophageal or gastric perforation Damage during the dissection or repair can lead to viscus perforation
Blood Clots DVTs and PEs are a possibility in any operation. The risk is increased in patients with a raised BMI, on the pill, recent flights, previous DVT, pregnancy, smokers, cancer and prolonged bed rest The patient will be given anti-embolism stocking and low molecular weight heparin peri-operatively to minimise this risk as deemed appropriate
Stroke, MI, Kidney Failure, Death Although small, this is always a risk in any major surgery

 

Late

Complication Description of Complication Potential Ways to Reduce Risk
Bloating/ difficulty belching Inability to belch as a result of the fundoplication can lead to significant abdominal bloating and discomfort Avoid carbonated drinks
Dysphagia May result from wrap migration or the wrap being too tight
Hernia Any incision through the abdominal wall has the potential to cause a hernia in future, either through a port site or in open surgery. Avoid strenuous lifting for around 6 weeks post-operatively
Adhesions Abdominal surgery may cause adhesions as a reaction to the procedure.
Failure and re-do surgery If symptoms recur or are severe, patients may require re-do surgery to modify the wrap
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