Perioperative management - Toupet Fundoplicatio for GERD, Robot-Assisted

• Therapy-resistant GERD
• Complicated GERD, such as: LA grade C/D. Peptic stricture
• GERD not fully controlled with medication
• Patient preference to avoid lifelong use of proton pump inhibitors
• Accompanying hiatal hernia types II to IV

Specific Contraindications:

• Esophageal motility disorders, such as: Achalasia. Diffuse esophageal spasm
• Esophageal involvement in autoimmune diseases (e.g., CREST syndrome in scleroderma)

General Contraindications:

General contraindications for robotic surgery align with those for minimally invasive procedures, including:

• Conditions contraindicating pneumoperitoneum, such as:
  • Severe systemic diseases
  • Extensive abdominal adhesions (hostile abdomen)

Relative Contraindications:

Cases where preoperative optimization may mitigate risks:

• Severe coagulation disorders: Quick < 50 %, PTT > 60 sec, platelets < 50/nL
• Significant portal hypertension with caput medusae
• Severe cardiovascular comorbidities making anesthesia risky (e.g., NYHA class III/IV with critical carotid stenosis)

Patient History:

• Typical GERD symptoms
• Long-standing history of reflux
• Positive response to proton pump inhibitors (PPIs)
• Need for increasing PPI dosages, PPI intolerance, or unwillingness to take PPIs
• Reduced quality of life or intolerable reflux symptoms
• Assess patient distress using a quality-of-life index
• Recurrent aspiration episodes

Gastroscopy:

• Always classify reflux esophagitis endoscopically before invasive therapy using the Los Angeles Classification:
  • Diagnosis of a potential hiatal hernia.
• The Los Angeles classification is based on the endoscopic evaluation of the esophagus and distinguishes between four subgroups:
  • Grade A: One or more mucosal breaks < 0.5 cm, not extending between the tops of two mucosal folds.
  • Grade B: At least one mucosal lesion > 0.5 cm but not extending between two folds.
  • Grade C: Mucosal lesions involving multiple folds but less than 75 % of the esophageal circumference.
  • Grade D: Circumferential mucosal lesions involving more than 75 % of the esophageal circumference.

Impedance-pH Monitoring:

• Perform impedance-pH monitoring preoperatively to confirm pathological reflux
• Discontinue PPIs for 7 days before the test if clinically feasible
• DeMeester score > 14.7 is pathological
• Establish pathological acid exposure with symptom correlation

High-Resolution Esophageal Manometry:

• Mandatory to exclude motility disorders with incomplete antireflux barrier function.

Additional Preoperative Assessments:

• Surgical laboratory tests
• Abdominal ultrasound
• Lung function tests for relevant patient history
• Chest X-ray (2 views): For therapy-relevant questions
• ECG: If indicated
• Contrast swallow (Gastrographin): If necessary
• CT abdomen: In cases of endoscopically identified thoracic stomach

Note: The Montreal Classification should be applied for standardized terminology, diagnosis, and treatment planning in GERD.

Outpatient/Inpatient Preoperative Preparation:

• Hygiene: Shower with antiseptic soap the evening before surgery
• Shaving: From nipples to thighs
• Diet: Full diet until instructed otherwise
• Pre-medication Clinic: Ensure clearance and optimization of any preexisting conditions
• Epidural Catheter (PDK): Not indicated
• Antibiotics: Administer Cefuroxime 1.5 g IV in the operating room
• Thromboprophylaxis:
  • Standard: Clexane 40 mg
• Anti-embolism stockings (e.g., compression stockings)
• Breathing exercises: For patients with COPD or large accompanying hiatal hernia
• Anticoagulation Management:
  • Aspirin: Perioperative continuation is allowed
  • Clopidogrel (ADP inhibitor): Pause at least 5 days preoperatively
  • Vitamin K antagonists: Discontinue 7 – 10 days before surgery with INR monitoring and bridge with subcutaneous low-molecular-weight heparin
  • NOACs (new oral anticoagulants): Discontinue 2 – 3 days preoperatively
  • Consult cardiologist if necessary

Bridging Considerations:

• Vitamin K antagonists: Bridge with short-acting heparins if INR is outside the target range
• NOACs: Bridging is generally unnecessary due to their short half-life. For high thrombotic/embolic risk, bridge with unfractionated heparin (UFH) under inpatient conditions

Preparation in the Operating Room:

• IV Access or Central Venous Catheter (if required): Typically placed during anesthesia induction
• Arterial Line: Place if necessary as part of anesthesia preparation

Discussion Topics:

• Indication: Explain the medical necessity for surgery
• Planned Procedure: Detail the surgical approach and postoperative care
• Treatment Alternatives: Present possible non-surgical or alternative interventions

General Risks:

• Bleeding or rebleeding requiring blood transfusion
• Placement of drainage tubes or urinary catheters
• Conversion to open surgery in the event of complications
• Potential need for surgical revision due to complications
• Intra-abdominal abscess requiring intervention (e.g., drainage or surgery)
• Wound infection
• Trocar hernia

Specific Risks:

• Esophageal or gastric injuries
• Damage to adjacent structures (e.g., spleen, pancreas, small intestine, colon, liver, gallbladder)
• Potential need for extended surgery
• Pneumothorax
• Postoperative dysphagia
• Inability to burp
• Increased retention of gas in the gastrointestinal tract
• Vagus nerve injury
• Denervation syndrome or diarrhea
• Risk of recurrence