Laparoscopic Upper GI Surgery

Lap UGIE Fundamentals - Peeking & Prepping

• Pneumoperitoneum:
  • CO2 insufflation: 12-15 mmHg.
  • Access: Veress (blind), Hasson (open), optical.
  • Physiology: ↑IAP → CV (↑MAP, ↑SVR) & respiratory effects.
• Patient & OR Setup:
  • Position: Supine, reverse Trendelenburg, arms tucked.
  • OR: Ergonomic monitors, insufflator, light source.
  • Anesthesia: GA, ETT, muscle relaxation.
• Ports & Instruments:
  • Ports: Triangulation; umbilical camera port.
  • Trocars (5-12mm), Laparoscope (0°/30°).
  • Instruments: Graspers, dissectors, energy (mono/bipolar, ultrasonic).
• Pre-op Prep:
  • NPO, consent.
  • DVT & antibiotic prophylaxis.

⭐ Veress needle entry is typically at Palmer's point (left subcostal margin, mid-clavicular line) in patients with previous midline surgery to avoid adhesions.

Lap Fundoplication - GERD Gone Gently

Gold standard surgical treatment for severe/refractory Gastroesophageal Reflux Disease (GERD) and large hiatus hernias. Aims to restore Lower Esophageal Sphincter (LES) competence.

• Indications:
  • Chronic GERD unresponsive to Proton Pump Inhibitors (PPIs)
  • GERD complications: Barrett's esophagus, peptic stricture, severe esophagitis (e.g., LA Grade C/D)
  • Symptomatic paraesophageal or large mixed hiatus hernia (Type II-IV)
• Pre-operative Essentials:
  • Upper GI Endoscopy (EGD) + biopsy
  • Esophageal manometry (crucial for wrap choice, assesses peristalsis)
  • 24-hour pH monitoring (confirms abnormal acid exposure)
• Types of Fundoplication (Wrap):
  • Nissen: Total (360°) fundoplication; most common, highest anti-reflux efficacy.
  • Toupet: Posterior partial (270°) fundoplication; less postoperative dysphagia.
  • Dor: Anterior partial (180-200°) fundoplication; often used with Heller's myotomy for achalasia.
• Key Complications:
  • Dysphagia (most frequent, often transient)
  • Gas bloat syndrome
  • Wrap failure (slippage, migration, disruption), recurrent hernia

⭐ Toupet (posterior partial 270°) fundoplication is generally preferred over Nissen in patients with documented impaired esophageal motility to minimize the risk and severity of postoperative dysphagia.

Lap Heller Myotomy - Esophageal Ease

• Definitive surgical treatment for Achalasia Cardia, relieving dysphagia.
• Procedure: Longitudinal extramucosal myotomy of Lower Esophageal Sphincter (LES) & proximal stomach.
  • Myotomy length: 6-7 cm on esophagus, 2-3 cm onto gastric cardia.
• Commonly combined with an anti-reflux procedure (fundoplication) to prevent iatrogenic GERD:
  • Dor fundoplication (anterior partial, 180-200°) is frequently preferred.
  • Toupet fundoplication (posterior partial, 270°) is an alternative.
• Key Complications: Esophageal perforation (most common intra-operatively), postoperative GERD, persistent/recurrent dysphagia.
• High success rates (>90%) in relieving symptoms.

⭐ The most common reason for persistent dysphagia after Heller myotomy is an incomplete myotomy, particularly inadequate extension onto the gastric cardia or too tight fundoplication wrap.

Lap PPU & Bariatric Bits - Ulcers & Weight Wins

• Lap PPU Repair (Graham Patch)
  • Indication: Perforated peptic ulcer (PPU), commonly duodenal.
  • Diagnosis: Pneumoperitoneum (X-ray/CT). Free air under diaphragm.
  • Procedure: Laparoscopic omental (Graham) patch over perforation.
  • Benefits: ↓pain, ↓hospital stay, ↑earlier recovery & return to work.
• Bariatric Surgery
  • Indications: BMI ≥ 40 kg/m², or BMI ≥ 35 kg/m² with major comorbidities (e.g., T2DM, OSA, HTN).
  • Common Procedures:
    • Lap Sleeve Gastrectomy (LSG): Restrictive. Removes ~80% of stomach along greater curvature.
    • Roux-en-Y Gastric Bypass (RYGB): Restrictive & malabsorptive. Small gastric pouch (~30ml) + biliopancreatic & Roux limb.
  • ⚠️ Key Risks: Anastomotic leaks, DVT/PE, nutritional deficiencies (Fe, B12, Ca, Vit D), dumping syndrome (esp. RYGB), internal hernias (RYGB).

> ⭐ Sleeve gastrectomy is currently the most performed bariatric procedure worldwide due to its relative simplicity and good outcomes.

High‑Yield Points - ⚡ Biggest Takeaways

• Laparoscopic Nissen fundoplication: gold standard for GERD; watch for dysphagia, gas bloat.
• Laparoscopic Heller's myotomy (+ partial fundoplication): treatment of choice for achalasia cardia.
• Pneumoperitoneum (CO2): causes shoulder tip pain (phrenic nerve); risks gas embolism, hypercarbia.
• Laparoscopic omental patch repair: standard for perforated peptic ulcer.
• Laparoscopic gastrectomy: for early gastric cancer, offers MIS benefits with comparable oncological outcomes.
• Key MIS benefits: ↓ pain, ↓ hospital stay, ↑ recovery speed, better cosmesis.