Nissen Fundoplication / Hiatal Hernia Repair
Patient phenotype
GERD refractory to PPI, large hiatal hernia, sometimes Barrett's. Often obese, cardiopulmonary comorbidities. Older patients with paraesophageal hernia at risk for incarceration.
Procedure
Laparoscopic (≥ 90% of cases). Reduce hiatal hernia, close crural defect, wrap fundus 360° (Nissen) or 270° (Toupet) around distal esophagus. Reverse Trendelenburg + insufflation. ~2-3 hours.
Anesthetic plan
GETA with RSI (full stomach assumption — GERD by definition). OG tube placed AFTER intubation, removed before wrap creation. Surgeon may pass bougie through esophagus during wrap (35-60 Fr) — alert anesthesia.
Setup
- ·Standard monitors + temp
- ·1-2 PIVs
- ·OG tube (placed post-intubation, removed before wrap)
- ·Bougie 50-60 Fr available — surgeon may request you pass it
- ·Forced air warmer
- ·Foley if > 2h expected
Biggest concerns by phase
Aspiration prophylaxis
Symptomatic GERD = full stomach. PPI continued, H2 blocker night before + morning of, sodium citrate 30 mL PO. Modified RSI standard.
OG tube + bougie management
OG tube removed before wrap (will be incorporated into wrap if left in). Surgeon often asks anesthesia to pass calibrating bougie (50-60 Fr) — pass slowly, lubricate, avoid esophageal injury. Stop if resistance.
Pneumothorax from crural dissection
Mediastinal dissection can breach pleura → pneumothorax (often R, sometimes bilateral). Suspect with sudden peak pressure rise + ETCO₂ change + asymmetric breath sounds. Surgeon can place drain through diaphragm.
Pneumoperitoneum + obese patient ventilation
Insufflation + reverse Trendelenburg. Watch peak pressures, use pressure-control if compliance poor. PEEP 5-8.
PONV prophylaxis + extubation
Vomiting postop = wrap disruption risk. Aggressive PONV prophylaxis (dex, ondansetron, scopolamine, droperidol). Smooth emergence. Avoid bucking (esophageal pressure spike).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
65-yo M, BMI 36, paraesophageal hernia with intermittent obstruction, severe GERD on PPI. To OR for Nissen. Walk me through induction.
What an examiner probes for
- ▹Modified RSI with ramped position
- ▹PPI + H2 + sodium citrate
- ▹OG tube management
- ▹Bougie passage technique
- ▹PONV plan + smooth extubation
Sources
- Miller's Ch 71
- SAGES Guidelines GERD/Hiatal Hernia
Anatomy reference
Sourced reference images. 4 matches for "esophagus stomach diaphragm".
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