Incidence and severity of adverse events in laparoscopic Nissen fundoplication; an anesthesiologist's perspective

ABSTRACT

Laparoscopic fundoplication is surgical treatment of choice for gastroesophageal reflux disease. The primary objective of our study was to determine the incidence and severity of intraoperative and postoperative [up to 48 hours after surgery] complications in laparoscopic Nissen fundoplication. We retrospectively analyzed case files and anesthesia charts of patients operated for this surgery from 2005 to 2011 and recorded the incidence and severity of intraoperative and postoperative [up to 48 hours after surgery] complications. 63 patients undergoing laparoscopic surgery for either a sliding [76%] or paraesophageal hiatus hernia [24%] were included in the study. Mean age was 41.6 +/- 13.3 years and mean surgical duration was 4.5 +/- 1.5 hours. Hypertension [28.5%], bradycardia [22.2%], high mean airway pressures [17.4%], desaturation [17.4%], arrhythmia [15.8%], bronchospasm [9.5%], pleural injury [6.3%] and subcutaneous emphysema [4.7%] were the main intraoperative complications. Abdominal pain [79%], radiological evidence of atelectasis [31.7%], breathlessness [22%], nausea and vomiting [20.6%], chest pain [9.5%] and pneumothorax [3%] were reported in early postoperative period. Pleural effusion [19%], pneumonia [3%], abdominal fluid collection [3%] and bed sore [1.5%] were seen in late postoperative period [after 24 hrs]. There was no mortality and the incidence of mild [grade 1], moderate [grade 2; grade 3] and severe complications [grade 4] was 31.5, 62.3 and 5.26% respectively. Injury to splenic artery, injury to stomach and difficult dissection due to adhesions was the reason for conversion to open surgery in three patients. Hypertension, bradycardia, higrrmean airway pressures and desaturation are the commonest intraoperative complications. Pneumothorax is common but clinically asymptomatic. Monitoring of airway pressure, KtCO2, SpO2 and intermittent chest auscultations is needed to detect it. Multimodal analgesia is needed for abdominal pain. Lung recruitment manoeuvers, chest physiotherapy and early mobilization are needed to prevent atelectasis, pleural effusion and pneumonia in the postoperative period