Management of Complications

During the operation one may encounter bleeding, esophageal perforation, or splenic injuries. Splenic injuries are more frequently reported in open surgery and have become rare incidents in laparoscopic procedures. Two other problems might be encountered postoperatively: mediastinitis and subphrenic abscesses due to delayed esophageal necrosis, mechanical problems associated with a tight wrap, a slipped wrap, or early breakdown of the repair.

 Bleeding During the Procedure. Some bleeding may occur during the process of dissecting behind the esophagus while creating the window. It is very hazardous to use electrocautery to stop the bleeding, especially in the blind area behind the esophagus. Compression with a piece of laparoscopic 2 × 2 in. gauze inserted through one of the trocars will usually control a minor bleed, such as from a small esophageal vein.

More severe bleeding may occur during division of the short gastric vessels, with the formation of a large hematoma in the gastrosplenic ligament that renders the dissection very difficult. It is therefore advisable to control the vessel immediately using an atraumatic clamp, clean and irrigate around the area, and then selectively apply clips to the bleeding site. The flat blade of the harmonic shears also works well in this situation.

Bleeding from an injury to the spleen is more difficult to control. Again, compression using 2 × 2 in. gauze is best employed, together with application of high-vol- tage monopolar current. If the splenic injury is not very large it may be possible to control the situation by applying collagen pads or other hemostatic products, such as Tisseel. If the bleeding is not controllable, the decision for conversion should be made promptly.

 Perforation of the Esophagus. Esophageal perforation can occur during insertion of the large bougie. Such an incident is preventable if the bougie is inserted very slowly by an experienced anesthesiologist under supervision of the surgeon, carefully avoiding anterior retraction of the esophagus that angles the esophagus and leads to perforation (Fig. 5.15). If theperforation is recognized during the operation, and if the level of skill of the surgeon is high,the perforation can be closed laparoscopically and the fundoplication can be applied as a “plasty” procedure to cover it. Otherwise, conversion should be the rule for repair.

Any postoperative fever, tachycardia, or signs of intraabdominal sepsis can indicate esophageal perforation. Even a modest left pleural effusion should raise the alarm. This complication is severe and may lead to death; it should be ruled out immediately by a gastrographin swallow or a CT scan with oral and IV contrast followed by upper gastrointestinal endoscopy if necessary. If an esophageal perforation is confirmed and the patient has become severely septic, the only option is to operate immediately to divert the esophagus. Diversion is the safest way to save the patient’s life and is preferable to a primary closure of the perforation. At this stage, it is best done using an open approach.

Fig. 5.15 A common site of esophageal perforation on its posterior aspect

 Mechanical Problems. Mechanical problems can be related to a tight, slipped, or broken wrap (Fig. 5.16).

These complications are avoidable because they are the result of a flawed technique. Breakdown of the wrap is due to dislocation of the sutures from the stomach and the esophagus. Tightness is due to nondivision of the short gastric vessels or noncalibration with a 60 Fr bougie. Tightness leading to dysphagia is an indication for dilation via upper GI endoscopy. If this is not successful, then the wrap has to be taken down. This can be done laparoscopically if the surgeon has special expertise, but it is safer to perform the operation using an open approach. The same remark applies to breakdown of the repair due to improper suturing. One should also distinguish a slipped wrap caused by the sutures not involving the esophagus and allowing the stomach to “slip” behind the wrap from a wrap that was initially performed around the body of the stomach and not around the gastroesophageal junction; they present similarly on X-ray.

A final comment should be made about the short esophagus. This is usually defined on endoscopy as a distance of more than 4 cm between the gastroesophageal junction and the crura. A short esophagus is usually associated with a complication such as a stricture or Barrett’s esophagus. Technically it is possible to lower the gastroesophageal junction by a careful dissection of the esophagus in the mediastinum. With a very short esophagus, the only possibility could be to approach it through a thoracotomy and perform a lengthening procedure (such as a Collis–Belsey). While it may be possible to bring the “short” esophagus down, it is definitely safer to perform an

Fig. 5.16   Mechanical complications after Nissen fundoplication: (a) tight wrap; (b) slipped 

wrap; (c) breakdown of the repair

antireflux procedure through a thoracic approach than to struggle to put a wrap inappropriately under tension around the body of the stomach or around the esophageal body itself. An elegant solution is the performance of a laparoscopic abdominal Collis gastroplasty.

A 48 French bougie is inserted into the stomach and positioned along the lesser curvature, under laparoscopic control. A 21 or 25 size circular stapler is introduced through one of the left lateral ports, which is enlarged to accommodate a 33 mm port. The central rod of the stapler perforates first the posterior and then the anterior gastric wall at a distance of about 4 cm from the angle of His, and the anvil is introduced into the abdominal cavity. The anvil is connected to the rod using specially designed laparoscopic forceps. The circular stapler is fired, thus creating a punched hole in the stomach. An endolinear cutter 60 is then introduced and the jaws placed in the gastric hole with the tip pointing at the angle of His. The cutter is fired thus creating a Collis lengthening gastroplasty (Fig. 5.17). The staple lines are inspected and checked with methylene blue for potential leaks. Two running sutures will secure the staple lines. The procedure is completed with the creation of a floppy Nissen fundoplication with the remaining fundus.

Another technique is a fundectomy with a Collis–Nissen. After mobilizing the fundus, it is divided and resected using several firings of horitzontally placed cutters with blue loads. Then an articulating cutter, which has been calibrated with a 40 Fr Bougie, is placed vertically along the side of the esophagus and fired, creating a lengthened “neoesophagus.” The fundus is then wrapped around this neoesophagus in the usual manner.