Complications - Fundoplication, Short-Floppy-Nissen technique, hiatal repair with mesh augmentation

Injury to the Spleen

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

Esophageal/Stomach Wall Injury

• Prevention through subtle preparation
• Estimate removal of the hernia sac in large hernias, if the risk is too great, 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 with the wrap.
• if necessary, intraoperative endoscopic control
• in case of esophageal lesion: preferably Nissen wrap and avoid additional sutures on the esophagus

Bleeding

• Short gastric arteries: 
  • Possible complication  when transecting the short gastric arteries for stomach fundus mobilization.
  • Hemostasis can be challenging with poor exposure and significant 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 to the parietal pleura during mediastinal preparation.
  • In a stable patient initially without consequence, if ventilation pressure increases or oxygenation worsens, initially reduce intra-abdominal pressure or directly place an intraoperative chest drain.
  • At the end of the operation, ensure good lung ventilation through manual ventilation with open trocars.
  • After releasing the pneumoperitoneum, rapid resolution of the pneumothorax is expected.

Dysphagia

Most relevant problem after laparoscopic fundoplication

Must be distinguished:

• Immediately postoperative occurring transient dysphagia, which arises from surgery-induced swelling and spontaneously subsides 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 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 periesophageal tissue after using a mesh at the hiatus, as these usually cannot be resolved by dilations but 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 partial wraps. In particular, full wraps should not be used in the presence of propulsive esophageal disorders.

Reflux recurrence

• May indicate a wrap insufficiency due to an initially too loose construction. 
• Therapy: Pure reflux recurrences without other complicating factors initially conservatively with PPIs 
• if persistent and therapy-resistant, repeat surgery

Wrap rupture/Wrap insufficiency

• A persistent reflux or newly occurring 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 surgical therapy. 
• The indication and execution of surgery do not differ from the primary procedure. 

Wrap dislocation

• Telescope phenomenon: Slipping of the wrap (so-called "slipped-Nissen") due to insufficient fixation of the wrap to the stomach or esophagus. The wrap now no longer encompasses the distal esophagus and cardia, but rather the corpus and fundus parts of the stomach. Consequence: Combination of reflux from the forming fundus pouch and dysphagia due to the fundus constriction by the wrap.

Therapy: surgical revision/reconstruction, also possible laparoscopically

Gas-bloat syndrome

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

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

Therapy: 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

Mesh migration with esophageal erosion/esophageal stenosis

Mesh perforation into the esophagus/stomach is considered the most dramatic complication of hiatus augmentation. It can occur late postoperatively, with cases known after 7 or 9 years. Occasionally, it may be possible to retrieve the foreign body endoscopically, but usually, a partial esophagogastrectomy (distal esophagofundectomy with continuity restoration through a pedicled jejunal interposition with intramediastinal anastomosis according to Merendino) is indicated.

Mesh infection 0.5%

Surgical revision

Pericardial tamponade/pleural effusion

When fixing the meshes, care must be taken with sharp fixation methods to avoid too deep penetration of adjacent anatomical structures. Especially when using anchors. Alternatively, fixation with tissue adhesive or sutures is recommended