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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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

Operating room setup

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

References

[1][2][3][4]

  1. Jaffe, Richard. Anesthesiologist's Manual of Surgical Procedures. pp. 545–546.
  2. Joubert KD, Betzold RD, Steliga MA: Successful treatment of esophageal necrosis secondary to acute type B aortic dissection. Ann Thorac Surg 2016; 102(6):e547-9.
  3. Patel A, Young LB, Rundback JH: Percutaneous esophagogastrostomy creation for gastric bypass reversal. J Vasc Interv Radiol 2016; 27(10):1552-3.
  4. Weber C, Davis CS, Shankaran V, et al: Hiatal hernias: a review of the pathophysiologic theories and implication for research. Surg Endosc 2011; 25(10):3149-53.