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

• General Anesthesia:
  • Intubation is required for pneumoperitoneum
• Optional TAP Block:
  • A regional anesthesia technique for the anterolateral abdominal wall. Local anesthetic is injected between the musculus obliquus internus and musculus transversus abdominis.
• Peripheral IV Access:
  • Two peripheral lines are preferred over a central venous catheter (CVC)
• Arterial Access:
  • Recommended for patients with cardiac risk factors

The patient is positioned in supine on a large vacuum cushion:

• The left arm may be extended outward
• Cushion all extremities and pressure-prone areas to prevent injuries
• The vacuum cushion eliminates the need for additional supports

After trocar placement, the operating table is adjusted to:

• 15° Anti-Trendelenburg position
• 5° Right tilt position (tilt right)
• A protective bar is recommended to shield the patient’s face from the robot arms

Cautions:

• Vacuum cushion integrity: Check for leaks before sterile draping
• Docking safety: Positioning is critical due to the patient being docked to the robot manipulator. Ensure precautions to prevent abdominal wall injuries from patient slippage.

Note: For Xi systems with coupled tables, intraoperative position changes can be made without undocking the robot. In systems without “Table-Motion” functionality, the robot must be undocked and removed from the table before any positional adjustments.

• Surgeon: Operates from the robotic console, ideally with visibility of both the patient and table assistant
• Table Assistant: Positioned on the patient’s right side
• Anesthesia: Positioned at the patient’s head
• Patient Cart (robot): Approaches the patient from the left side
• Surgical Nurse: Positioned to the right of the table assistant

Robotic Instruments:

• Cardiere forceps or Tip-Up grasping forceps
• Bipolar forceps
• 30° camera
• Monopolar scissors
• Vessel sealer extend
• Optional: Suture-cut needle holder

Trocars:

• Four 8 mm robotic trocars
• One or two 11 mm laparoscopic assistant trocars

Basic Instruments:

• 11-blade scalpel
• Dissecting scissors
• Langenbeck retractors
• Needle holder
• Suture scissors
• Forceps
• Gauze sponges
• Swabs
• Suture material:
  • Abdominal wall fascia: Vicryl 0 with UCLX needle for trocars ≥10 mm.
  • Skin closure: 3-0 monofilament, absorbable.
• Veress needle
• Optional: Backhaus clamps
• Adhesive dressing

Additional Instruments:

• Gas system for pneumoperitoneum
• Laparoscopic atraumatic grasping forceps
• Optional: Laparoscopic suction-irrigation system

Instrument Setup with “Two Right Hands”:

• Port 1 (8 mm): Bipolar forceps
• Port 2 (8 mm): 30° camera
• Port 3 (8 mm): Monopolar scissors, vessel sealer extend, or needle holder
• Port 4 (8 mm): Cardiere or Tip-Up grasping forceps

Monitoring:    

• Postoperative observation in the recovery room

Venous Access:

• Remove central venous catheter (CVC) by post-op day 1
• Retain one peripheral cannula (Vigo)

Drains and Tubes:

• Remove nasogastric tube and urinary catheter at the end of surgery

Mobilization:

• Initiate early mobilization on the evening of the surgery
• Gradually resume physical activity in steps

Physiotherapy:

• Routine physiotherapy not required
• Breathing exercises if indicated

Diet Progression:

• Gradual dietary advancement over 4 days:
  • Begin with liquids
  • Transition to pureed food, then to solid foods

Fluids and Infusions:

• Administer 500 – 1000 ml IV fluids on post-op day 1
• Discontinue infusions if oral intake is sufficient thereafter

Laboratory Monitoring:

• Perform labs on post-op day 1: CBC, electrolytes, CRP.
• Repeat every 2 days in normal recovery, or immediately in cases of clinical deterioration.

Antibiotics:

• Administer single-shot prophylactic antibiotic 30 minutes before incision

Thromboprophylaxis:

• Use low-molecular-weight heparin (e.g., Clexane 40 mg), adapted for weight or risk factors, until full mobilization is achieved
• Include physical measures like anti-embolism stockings
• Caution: Monitor renal function and screen for HIT II (history and platelet count)
• Refer to the latest VTE prophylaxis guidelines -  Prohylaxe der venösen Thrombembolie (VTE)

Wound Care:

• Change dressing every 2 days
• Remove non-absorbable staples/sutures after 10 days

Pain Management:

• Baseline Analgesia:
•  Non-steroidal anti-inflammatory drugs (NSAIDs) are typically sufficient
•  Suggested regimen:
  • Novalgin 1 g (4x/day). Paracetamol 1 g (3x/day). Combination allowed (e.g., regular Novalgin with as-needed Paracetamol)
• Administration Options:
  • Novalgin: 1 g in 100 ml NaCl IV over 10 minutes, or oral tablet, or 30–40 oral drops Paracetamol: 1 g IV over 15 minutes every 8 hours, rectal suppository every 8 hours, or oral tablet. Adjust based on age, allergies, and renal function
• As-Needed Medications:
  • For VAS 4: Piritramid 7.5 mg IV/SC. Oxigesic 5 mg acute
  • For persistent pain 4:
  • Extended-release opioid (e.g., Targin 10/5 mg, 2x/day)
• Pain Assessment Tools:
  • Use NRS (Numerical Rating Scale, 0–10), VAS (Visual Analog Scale), or VRS (Verbal Rating Scale)
  • For pain during mobilization, administer as-needed analgesia 20 minutes prior

Discharge and Recovery:

• Discharge: From post-op day 3
• Work Absence: Typically 2 weeks