Esophagastric fundoplication

Esophagastric fundoplication

Anesthesia type	General
Airway	ETT (DLT if thoracic approach)
Lines and access	Large bore PIV ± Arterial Line
Monitors	Standard
Primary anesthetic considerations
Preoperative	Patients often Obese
Intraoperative	RSI frequently indicated
Postoperative	± epidural or PCA
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Editor rating	Comprehensive
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Esophagastric fundoplication is a type of procedure where the stomach is wrapped around the lower segment of the esophagus in order to prevent reflux or treat hiatal hernias. Multiple variants exist, and approach to surgery can be transabdominal, transthoracic, or laparoscopic. See Belsey Mark Fundoplication for anesthetic management of this variant, which is discussed separately.

Overview

Indications

• Esophageal reflux refractory to medical management
• Hiatal hernia

Surgical procedure

• Multiple variants essentially wrapping the stomach fully or partially around the lower segment of the esophagus
• Nissen Fundoplication, where the stomach is wrapped fully around the esophagus, is the standard that other variants are compared to
• Nissen results in full 360 degree wrap of the stomach around the esophagus, while the other approaches are partial wraps
• Approach can be transabdominal, transthoracic, or laparoscopic

Preoperative management

Patient evaluation

System	Considerations
Airway	Many patients have co-morbidities including obesity, careful evaluation of airway for signs of difficult intubation (Mallampati, neck thickness, thyromental distsance)
Neurologic	Standard evaluation
Cardiovascular	Standard evaluation
Pulmonary	Standard evaluation
Gastrointestinal	Check for active reflux or nausea/vomiting that would require RSI

Labs and studies

• CBC
• BMP
• ± PTT/INR
• ± Type and Screen

Patient preparation and premedication

• Aspiration precautions if severe GERD
• Check for ERAS protocol
• ± Benzodiazepine premedication

Regional and neuraxial techniques

• N/A if laparoscopic approach

Intraoperative management

Monitoring and access

• Standard monitors
• Large bore PIV
• ± Arterial Line depending on patient comorbidities

Induction and airway management

• RSI for active reflux or nausea
• Otherwise standard induction with ETT
• DLT if thoracic approach

Positioning

• Supine

Maintenance and surgical considerations

• Standard maintenance
• If epidural is in place, can consider combined approach with intra-op epidural infusion

Emergence

• Routine. Ensure well suctioned of any gastric contents.

Postoperative management

Disposition

• PACU
• Floor admission

Pain management

• If open approach, can consider epidural vs PCA for post-op pain control

Potential complications

• Dysphagia
• Recurrent hernia or reflux
• Splenic laceration
• Vagus nerve injury
• Atelectasis
• Esophageal or gastric perforation
• Hemorrhage
• Pneumothorax
• Capnomediastinum

Procedure variants

	Nissen (Toupet)	Laparscopic Nissen	Hill
Unique considerations	Midline abdominal incision	Laparoscopic incisions	Midline abdominal incision
Position	Supine	Supine, split legs	Supine, split legs
Surgical time	1-2 hrs	1-2 hrs	1-2 hrs
EBL	100-150 mL	50mL	100-150mL
Postoperative disposition	PACU then floor	PACU then floor	PACU then floor
Pain management	Consider thoracic/lumbar epidural vs PCA	Multimodal pain management	Consider thoracic/lumbar epidural vs PCA
Potential complications	See above	See above	See above