Complications - Fundoplication, laparoscopic according to Toupet

Spleen Injury

• Prevention through subtle preparation
• Hemostatic measures (coagulation, hemostatics)
• Splenectomy as a last resort

Esophageal/Stomach Wall Injury

• Prevention through subtle preparation
• Estimate the removal of the hernia sac in large hernias, if the risk is too high, only detach the hernia sac from the diaphragmatic crura and leave the hernia sac in the mediastinum.
• Diagnosis possible through intraoperative blue test,
  therapy by suturing the defect and ideally covering it with the wrap.
• Possibly intraoperative endoscopic control
• In case of esophageal lesion: prefer Nissen fundoplication and avoid additional sutures on the esophagus

Bleeding

• Short Gastric Arteries:
  • Possible complication during the transection of the short gastric arteries for stomach fundus mobilization.
  • Hemostasis can be challenging due to poor exposure in severe visceral obesity.
• Diaphragmatic Veins:
  • In close proximity to the hiatus,
  • Hemostasis can also be challenging.
• Aorta
  • Runs behind the hiatus
  • An injury is theoretically possible.

Pneumothorax

• Due to injury of the parietal pleura during mediastinal preparation
• Initially without consequence in stable patients
• With increasing ventilation pressure or poor oxygenation, initially reduce intra-abdominal pressure or directly place an intraoperative chest drain
• At the end of the operation, good lung ventilation through manual ventilation with open trocars
• After releasing the pneumoperitoneum, a rapid regression of the pneumothorax is expected.

Dysphagia

Most relevant problem after laparoscopic fundoplication

Must be differentiated:

• Immediately postoperative occurring transient dysphagia, caused by surgery-induced swelling, which subsides spontaneously after a few weeks. It is only a temporary problem with a good prognosis, thus not a complication in the true sense.
   
• Persistent dysphagia due to a too tightly constructed hiatoplasty/fundus wrap or disturbances of the propulsive peristaltic wave. Particularly problematic are persistent stenoses due to scar formation and fibrosis in the peri-esophageal tissue after the use of a mesh at the hiatus, as these usually cannot be resolved by dilations and require resection.
  • Diagnostics: X-ray/Endoscopy
  • Therapy: Downgrading of diet, if necessary, endoscopic dilation (also multiple) at the earliest 4 weeks after the initial procedure
  • Last resort (rare): Re-operation with possible conversion of the wrap to a hemiplication, in the worst case partial esophagogastrectomy.

Note: Dysphagia is less frequently observed after the placement of partial wraps. In particular, full wraps should not be used in cases of propulsive esophageal disorder.

Reflux recurrence

• May indicate a wrap insufficiency due to an initially too loose construction. 
• Therapy: Pure reflux recurrences without further complicating factors are initially treated conservatively with PPIs 
• If persistent and therapy-resistant, re-operation may be necessary

Wrap rupture/wrap insufficiency

• A persistent reflux or recurrent reflux after fundoplication may indicate a too loose wrap or complete dissolution of the wrap (Caution: do not use absorbable sutures!). 
• The diagnostics correspond to those before an operative therapy. 
• The indication and execution of the operation do not differ from those of the primary procedure. 

Gas-bloat syndrome

The term "gas bloat" is used in the literature for a variety of post-fundoplication symptoms attributed to gas-induced stomach distension with simultaneous inability to belch.

• Upper abdominal discomfort
• Feeling of fullness
• Back, chest, and shoulder pain
• Inability to vomit
• Flatulence

Avoidance of carbonated beverages and heavy meals, if necessary, dilation. Surgical reintervention for gas-bloat syndrome is likely a rarity.
 

 Postoperative vomiting

• Antiemetics
• Prokinetics (Erythromycin 3x100mg)

Vagus nerve innervation damage

• A denervation syndrome of the stomach due to vagus nerve innervation damage occurs in up to 3% of patients. 
• Surgical correction is not promising,
• if necessary, medication therapy with, for example, prokinetics.
• In individual cases, a pyloroplasty may be necessary if gastric emptying disorder persists. 

Recurrence of hiatal hernia

• up to 42% in axial hernia, even higher in paraesophageal hernias
• in large hernias, mesh reinforcement of the hiatus is indispensable due to the defect size