Complications - Toupet Fundoplicatio for GERD, Robot-Assisted

Splenic Injury

• Prevention: Achieved through meticulous dissection
• Management: Hemostasis using robotic methods (e.g., coagulation, hemostatic agents); splenectomy should only be considered as a last resort

Esophageal or Gastric Wall Injury

• Prevention: Careful and precise dissection techniques
• Diagnosis: Can be confirmed intraoperatively using a methylene blue dye test
• Treatment:
  • Suture repair of the defect, ideally covered by the wrap
  • Intraoperative endoscopic evaluation if required
  • For esophageal injuries, a Nissen fundoplication is preferable, avoiding additional sutures on the esophagus

Bleeding

• Short Gastric Arteries:
  • May occur during their transection for fundus mobilization
  • Hemostasis can be challenging in cases of significant visceral adiposity or poor exposure
• Diaphragmatic Veins:
  • Located close to the esophageal hiatus
  • Hemostasis in this area can also be demanding
• Aorta:
  • Positioned posterior to the esophageal hiatus
  • Injury, although rare, is possible and should be managed with extreme caution

Pneumothorax

• Cause: Occurs due to injury to the parietal pleura during mediastinal dissection
• Significance:
  • Only critical if cardiopulmonary problems arise intraoperatively
  •  No immediate intervention is necessary if the patient is stable
• Management:
  • If increased ventilation pressures or poor oxygenation are noted, reduce intra-abdominal pressure
  • If necessary, place an intraoperative chest drain
  • Continue and complete the operation robotically with the chest drain in place
  • At the end of the surgery, ensure proper lung ventilation through manual ventilation with open trocars

Dysphagia

• Relevance: The most significant issue following laparoscopic fundoplication
• Nature: Often occurs immediately postoperatively but is typically temporary and resolves with a favorable prognosis, thus not considered a true complication
• Diagnosis: Radiographic imaging or endoscopy
• Treatment:
  • Regressing to a liquid or soft diet
  • Endoscopic dilation (bougienage), repeated if necessary
• Ultima ratio (rare): Reoperation to convert the wrap into a partial (hemi) fundoplication

Postoperative Leakage

• Management: Reoperation with suture repair of the defect

Postoperative Bleeding

• Management: Reoperation for hemostasis

Recurrent Reflux

• May indicate insufficient tension or a loose initial wrap
• Treatment: Conservative management with proton pump inhibitors (PPI) in uncomplicated cases
• Persistent or refractory cases: Surgical reintervention may be warranted

Wrap Rupture

• Indication: Persistent or recurrent reflux after fundoplication may suggest wrap rupture
• Prevention: Avoid the use of absorbable sutures during surgery
• Diagnosis: Follows the same protocol as preoperative assessments
• Treatment: Indications for surgery are the same as for the primary procedure. Revision surgery can often be performed robotically by experienced surgeons

Postoperative Vomiting

• Management:
  • Antiemetics (e.g., metoclopramide)
  • Prokinetics (e.g., erythromycin, 100 mg three times daily)

Vagal Nerve Injury

• Incidence: Occurs in up to 3% of patients and may result in gastric denervation syndrome.
• Treatment:
  • Surgical correction is generally not effective.
  • Medication management with prokinetics can be beneficial.
  • In cases of persistent gastric emptying disorders, pyloroplasty may be considered.