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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 24-January-2003, Vol 116 No 1168

Diaphragmatic herniation of laparoscopic Nissen fundoplication wrap due to forceful post-operative retching: three case reports
Christopher Wakeman, Philip Bagshaw, Grant Coulter and Kiki Maoate
The open Nissen fundoplication was the standard anti-reflux procedure until 1991, when the first laparoscopic Nissen fundoplication (LNF) was performed in Belgium. Since then, LNF has taken over as the operation of choice for gastro-oesophageal reflux disease (GORD). It has been shown to be as efficacious and as safe as the open procedure.1-3 The three cases described here illustrate one of the serious complications of Nissen fundoplication. That is, herniation of the fundal wrap of the stomach into the thorax, after disruption of the cruroplasty (suturing to narrow the diaphragmatic oesophageal hiatus), due to forceful retching and vomiting in the immediate post-operative period. This complication is rare, but is more frequent with LNF than with the traditional open operation.4

Case reports

The following cases of early diaphragmatic herniation after LNF occurred in Christchurch hospitals between December 1999 and June 2001.
Case 1
A 53-year-old man with a six-year history of severe GORD had an elective LNF. The crura were approximated using two Ethibond sutures and a 360° wrap was fashioned. The wrap was lax so the short gastric vessels were not divided. The surgery was routine. The nasogastric tube was removed at the end of the case.
Severe nausea with retching started in the post-operative recovery room and continued on the surgical ward. Two days post-operatively, because of ongoing pain, a Gastrografin swallow was performed. This showed that the fundal wrap had herniated through the diaphragm. At laparotomy, the cruroplasty was found to have torn apart, allowing the wrap to herniate into the chest. The wrap was reduced into the abdomen by light traction on the stomach and the cruroplasty redone.
Case 2
An LNF was performed on a 12-year-old boy for GORD and recurrent vomiting. A 360° Nissen fundoplication wrap was completed with divisions of the gastric vessels for a loose procedure. A cruroplasty was performed using a single Tycron suture. The surgery was uneventful. The patient had severe retching and dyphagia post-operatively, with dislodgment of the nasogastric tube. This was not replaced. After a gastroscopy and a barium meal, which confirmed a hiatus hernia (Figure 1), a laparoscopy was performed on the tenth post-operative day. Here, the cruroplasty was found to have torn apart and the fundal wrap had migrated into the thorax. The wrap was taken down and redone laparoscopically, and a further cruroplasty done with a Tycron suture.
Figure 1. X-ray confirming presence of hiatus hernia due to post-operative retching of Case 2
CONTENT01.jpg
Case 3
A 39-year-old man had severe retching and pain immediately after an LNF. Post-operatively he did not have a nasogastric tube. A barium meal showed complete gastric outlet obstruction. On the third post-operative day, a laparoscopy revealed a tear in the diaphragm extending from the crura laterally for about 10 cm. Through this, the entire stomach, omentum and transverse colon had herniated into the thorax. The procedure was converted to a laparotomy to repair the defect.
In all three cases, the subsequent post-operative recovery was uneventful, and the patients were symptom free at follow up three months later.

Discussion

Although herniation of Nissen fundal wraps has been previously described, it is timely to raise awareness of this potentially serious and avoidable complication. Frequencies of between 0.8% and 7% have been reported.4–10 Although it is more common with LNF, performing a cruroplasty reduces the frequency.8–10
Several causes have been proposed for this complication. The reduced post-operative pain associated with laparoscopic surgery may mean earlier mobilisation and return to normal activities. This could be associated with increases in abdominal pressure before sufficient scar tissue and adhesions have formed. Gastric distension and vomiting have also been associated with the complication. Again, these cause increased intra-abdominal pressures and reduced intra-thoracic pressure.4,7,9,10 The use of nasogastric tubes post-operatively has not been found to alter the rates of herniation, and they are generally removed at the end of the case.1,3,5
In the three cases here, there was severe retching and vomiting that caused the cruraplasties, and the diaphragm in one case, to be torn apart. Subsequent vomiting caused the fundal wraps to herniate into the thorax. It is clear that post-operative retching and vomiting should be avoided or minimised after LNF. Medical and nursing staff should be informed of the potential complication and its management. Intravenous narcotic should be proscribed whenever possible, and alternative analgesic medications including non-steroidals and panadol used. Early and regular prophylactic use of antiemetics such as Ondansetron should be encouraged. Alternative antiemetics and Dexamethasone should be trialled early on if vomiting and retching does not cease with Ondansetron. If patients have ongoing problems with pain, retching and vomiting or dysphagia, this complication should be considered early and investigated quickly.
Author information: Christopher J Wakeman, Surgical Registrar; Philip F Bagshaw, Associate Professor of Surgery; Grant N Coulter, Consultant Surgeon, Department of General & Vascular Surgery; Kiki Maoate, Consultant Surgeon, Department of Paediatric Surgery, Christchurch Hospital, Christchurch
Correspondence: Professor Philip F Bagshaw, Department of Surgery, Christchurch Hospital, Private Bag 4710, Christchurch. Fax: (03) 364 0352; email: bagshaw@clear.net.nz
References:
  1. Gotley DC, Smithers BM, Rhodes M et al. Laparoscopic Nissen fundoplication – 200 consecutive cases. Gut 1996; 38: 487-91.
  2. Bittner HB, Meyers WC, Brazer SR et al. Laparoscopic Nissen fundoplication: operative results and short-term follow-up. Am J Surg 1994; 167: 193-200.
  3. Hinder RA, Filipi CJ, Wetscher G et al. Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 1994; 220: 472-83.
  4. O’Boyle CJ, Heer K, Smith A et al. Iatrogenic thoracic migration of the stomach complicating laparoscopic Nissen fundoplication. Surg Endosc 2000; 14: 540-2.
  5. Munro W, Brancatisano R, Adams IP et al. Complications of laparoscopic fundoplication: the first 100 patients. Surg Laparosc Endosc 1996; 6: 421-3.
  6. Boggi U, Bellini R, Pietrabissa A et al. Laparoscopic Nissen fundoplication complicated by late gastroesophageal herniation and intrathoraic perforation: a case report with review of the literature. Surg Laparosc Endosc 1999; 9: 57-9.
  7. Seelig MH, Hinder RA, Klingler PJ et al. Paraesophageal herniation as a complication following laparoscopic antireflux surgery. J Gastrointest Surg 1999; 3 95-9.
  8. Watson DI, Jamieson GG, Devitt PG et al. Paraoesophageal hiatus hernia: an important complication of laparoscopic Nissen fundoplication. Br J Surg 1995; 82: 521-3.
  9. Yvergneaux JP, Berghs B, Kint M. Paraoesophageal hernia with acute intrathoracic volvulus of the stomach after laparscopic Nissen fundoplication. Acta Chir Belg 1996; 96: 280-3.
  10. Awad ZT, Magee DJ, Wanis N et al. Type IV hiatal hernia post laparoscopic Nissen fundoplication: report of a case. Surg Today 2001; 31: 156-8.

     
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