Operation for GERD Laparoscopic Approach

Ketan M. Desai, Nathaniel J. Soper

Introduction

Laparoscopic antireflux surgery (LARS) has assumed a major role in the treatment of gastroesophageal reflux disease (GERD). The advancement in laparoscopic techniques and instrumentation over the past decade has led to an increase in the number of antireflux operations. Although the operation is fundamentally similar to open antireflux procedures, clear benefits to the laparoscopic approach have been described.

In 1955, Rudolf Nissen reported the efficacy of a 360° gastric wrap through an upper abdominal incision to control reflux symptoms. It was not until 1991 that the first laparo-scopic Nissen fundoplication was reported. From that point, acceptance on the part of patients and physicians to proceed with surgical treatment began to grow. Although the minimally invasive approach follows the same surgical principles as the open operation, LARS reduces postoperative pain, shortens the hospital stay and recovery period, and achieves a functional outcome that is similar to that of the open operation.

Indications and Contraindications

Indications

GERD symptoms (heartburn, regurgitation, dysphagia, chest pain) not controlled by medical therapy Volume reflux

Paraesophageal hernia (PEH) with GERD

Inability to take acid reduction medication (allergic reaction, poor compliance, cost) Preference for surgery (young age, lifestyle choice)

Contraindications Absolute Contraindications

■ Inability to tolerate general anesthesia or laparoscopy

Relative Contraindications

■ Previous upper abdominal surgery

■ Morbid obesity

■ Short esophagus

Preoperative Investigation/Preparation for Procedure

History:

Upper endoscopy with biopsies: Esophageal manometry for evaluation of eso-phageal motility disorder: 24-h pH testing:

Presence or absence of typical/atypical GERD symptoms, and acid reduction medication use Evaluation for esophagitis, gastritis, Barrett's metaplasia/dysplasia, hiatal hernia, and strictures Measurement of esophageal body peristalsis and lower esophageal sphincter (LES) position/length/pressure

Following the cessation of proton-pump inhibitors for >7days Intravenous antiemetics are administered prophylactically.

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