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Surgery for GERD

Heartburn is a common symptom for GERD. Patients suffering from gastroesophageal reflux disease will experience a burning sensation in the upper abdomen causing discomfort. The other associated symptoms of GERD are dysphagia and fluid regurgitation. Atypical symptoms are sore throat, wheezing, hoarseness, coughing and asthma. LES or lower esophageal sphincter malfunction leads to GERD. The LES muscle acts as a valve encompassing itself at the junction of the stomach and the oesophagus. When food is swallowed it passes through the oesophagus into the stomach during which process, the valve opens. It then closes to prevent the contents from the stomach to reflux back into the oesophagus. Dysfunction of the LES leads to back-flow of gastric contents resulting in GERD. Laparoscopic antireflux procedure or laparoscopic Nissen fundoplication is conducted to manage GERD.

Surgical indications: Indications for the surgery include complications of GERD such as Barrett’s oesophagus, extraesophageal manifestations like aspiration and asthma and recurrent complications of a previous antireflux procedure. A thorough preoperative evaluation of the patient’s medical history and physical examination are done. Several tests are conducted to ensure evidence of GERD. Oesophagogastroduodenoscopy, upper gastrointestinal series, 24-hr oesophageal pH assessment, Bernstein acid test, gastric emptying and oesophageal manometry are also conducted.

Technique

  • Port A serves as a camera port and insertion can be done in any two ways:

    • Technique 1: A Hasson technique is adopted to insert a 10 mm trocar in the supraumbilical location

    • Technique 2: A 5 mm Optiview trocar is used to pass the supraumbilical trocar

  • Under direct visualization, four 5 mm trocars are introduced subcostally

  • Placement of Port B is at the right midclavicular line

  • Port C is positioned right of the midline and Port E is placed in the left midclavicular line

  • To allow retraction and exposure of the left liver, an atraumatic liver retractor is inserted via Port B

  • Dissection is carried out through Port C and Port D

  • Graspers, clamps and electrocautery instruments are inserted through Port E

  • The hiatus is visualized after insertion of liver retractor

  • A Babcock grasper inserted through Port E grasps the stomach and aids in caudal retraction

  • The gastrohepatic ligament is opened and preserved

  • As the dissection is carried down towards the diaphragm, the right crus is exposed

  • The right crus is then delineated from the oesophagus with a blunt dissection

  • Division of the phrenoesophageal ligament is carried out

  • The distal oesophagus is detached from its posterior attachments

  • As the oesophagus is freed, a Penrose is inserted to enclose the oesophagus

  • Meticulous dissection of the hiatus delineates the diaphragmatic crus

  • The posterior oesophagus about 6 cm is mobilized with careful preservation of the inferior phrenic artery

  • After a hiatus repair, a Penrose drain that encircles the oesophagus is removed

  • Sutures are tied extracorporeally or intracorporeally

Dr. Deepak conducts regular check-ups 1 to 4 weeks after the operation. Patients are requested to follow the doctor’s schedule as prescribed to ensure optimum surgical and medical care.

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