1. Day-case Laparoscopic Nissen Fundoplication
Mr Yuen Soon
Locum Consultant Surgeon
Oesophagogastric and Laparoscopic Surgery
Dr Antony Bateman
SHO Surgery
The Minimal Access Therapy Training Unit
The Royal Surrey County Hospital, Guildford

2. Day Case Lap Nissens
Evidence
Our Results
Past
Present
Our tricks

3. Previous reports Cohn et al. Todays Surg. Nurse 1997;19:27-30 (n=4)
Milford and Paluch Surg Endosc 1997;11: (61)
Trondsen et al. BJS 2000;87: (n=45)
Narain PK et al. J Laparoendosc Adv Surg Tech A 2000;10:5-11 (n=22)
Finley and McKernan Surg Endosc. 2001;15: (n=557)
Bailey et al. BJS 2003; 90: (n=20)
Ray Surg Endosc.2003;17: (n=310)
Victorzon et al. Scand J Surg 2006;95(3):162-5 (n=28)

4. Ng et al. ANZ J Surg 2005;75:

5. Ng et al. ANZ J Surg 2005;75:160-164 (Review)
“on the data considered the complication rates and readmission rates are comparable to inpatient procedures”
Ng et al. ANZ J Surg 2005;75: (Review)

6. Aim To assess the feasibility, the acceptability and the safety of
Day-case laparoscopic Nissen fundoplication

7. Patients 20 patients (12 males, 8 females)
Age: Median (Range) 47(25-69)
ASA I or II
Adequate home support
Counselled in out patient clinic
Written information sheet
Pre-assessment clinic
Admitted on day of surgery at 07.30

8. Anaesthetic technique
Standard anaesthetic, analgesia and anti-emetic protocol
Granesetron 1mg iv
Rocuronium (0.1mg/kg) iv
Propofol (8-12mg/kg/hour)/fentanyl (to a total of 30 m/kg) iv
Sevoflurane/nitrous oxide and fentanyl iv

9. Analgesia Diclofenac 100mg pr on induction
20ml 0.5% bupivicaine infiltrated
Cyclizine, Co-proxamol, morphine, tramadol
prn Co-Codamol 2 tablets, 4 hourly
Diclofenac 100mg, 8 hourly
Metoclopramide 10mg
Tramadol 100mg

10. Operative technique Standard 5 port approach
360o Nissen fundoplication over 54FR bougie “optional”
Selective division of short gastric arteries
Posterior crural repair

11. Post-operative care and assessment
Surgeon telephone number
District nurse visit
Visual analogue scores pain and nausea
Analgesia requirement and patient satisfaction at 2 week follow-up

12. Results
Median (range) anaesthetic and operating time 88 minutes (40-155)
All patients discharged on the day of surgery, 6hr 40m (4.5-9hrs)
None of the patients required readmission
One patient was assessed in casualty department the following morning
No post-operative complications at 2 weeks

13. Pain and nausea scores Hours post surgery 4 12 24 48
Pain 2 (0-9) 3 (0-9) 3 (0-8) 2 (0-5)*
Nausea 0 (0-10) 1 (0-9) 1 (0-8) 0 (0-10)
Median (range) *p=0.045

14. Analgesia and anti-emetics
13 patients used single analgesia (Co-dydramol or diclofenac) for between 2 and 7 days (median 2 days)
2 patients needed additional opiate analgesia (Tramadol) for 2 and 3 days
5 patients used no analgesia following discharge
None of the patients took anti-emetics at home

15. Follow up
All the patients were contacted by the surgeon on the night of discharge
6 patients were not contacted by a district nurse the following day

16. Patient satisfaction
All the patients were happy with the information that had been provided for them
All said that they would recommend the procedure as a daycase to a friend
17 patients expressed complete satisfaction and would be happy to undergo daycase laparoscopic surgery again

17. Conclusions
Laparoscopic fundoplication can be successfully undertaken as a day case
Patients find it acceptable
It appears to be safe
Adequate home support is necessary

18. What Next? Retrospective Study of Lap Nissen 2004-2006
Numbers of Day cases performed
Return Rates

19. Numbers

20. Day Case Defined as True Day Case Discharged in Morning Pre-ward round
Discharged in Morning Post Ward Round
Admitted to Main Hospital
Inpatient Procedure

21. Day Case

22. Age?

23. Date

24. Readmission 2 patients One at day 6 to A/E with Chest Infection
One at day 8 with abdominal pain and vomiting

25. Conclusion
93% of Lap Nissens completed as day case/ short stay patient
Not age dependent (p=0.25 Anova)
Not date Dependent (p=0.46 Anova)

26. Keys to successful day case
Patient
Surgical
Nursing

27. Patient Factors Patient selection Education/Counselling Expectation
Patient support
At home
At hospital

28. Surgical Factors Appropriate operation Good Anaesthetist
PONV
Analgesia
Training the “team”

29. Nursing Factors Dedicated ward Well defined pathway Enthusiastic team
Discharge criteria
Dietetic follow-up
Information sheets
Enthusiastic team

31. Long Term Clinical Outcome of 150 Consecutive Laparoscopic Nissen Fundoplications
The Minimal Access Therapy Training Unit
The Royal Surrey County Hospital, Guildford

32. Aims
To assess
The long term clinical outcome of 360o laparoscopic Nissen Fundoplication
The clinical outcome of a selective approach to division of the short gastric arteries

33. Operative Technique The Wrap 2cm Long 54F boogie
Fully mobilise the gastric fundus
Large window
Mobile wrap

34. Method 150 consecutive patients Single surgeon
March January 2000
Telephone Interview
Clinical Outcomes
Chi-squared test for statistics

35. Method Clinical Outcomes:Dysphagia
Ongoing dysphagia at follow up
De Meester grade of dysphagia
0 None.
1 Occasional transient sensation of food sticking.
2 Episodes of bolus obstruction requiring liquids to clear
3 Progressive dysphagia for solids requiring medical
attention or admission.

36. Method Clinical Outcomes: Symptom Recurrence
0 None.
1 Minimal.
Still much improved
on pre-operative state
2 Yes. Back to pre-operative state

37. Method Clinical Outcomes: Symptom Recurrence
Gas Bloat
Bowel Function
Patient Satisfaction

38. Methods Patient Information
Proven GORD (pH studies & upper GI Endoscopy )
Indication for Surgery
93 Failed Medical Therapy
40 Patient preference
7 complications of GORD
(6 Barrett’s, 1 stricture)

39. Methods Follow up Follow up rate 93% (140 of 150 patients)
Short gastric Time to Follow up
arteries divided Mean Range
Yes 30 pt 33 months 7-60m
No 110 pt 30 months 8-76m
Total 140 pt 31 months 8-76m

40. Results: Symptom Recurrence

41. Results: Symptom Recurrence

42. Conclusions 360o laparoscopic Nissen fundoplication Long term outcome
Low dysphagia rates
Low symptom recurrence rates
High Patient Satisfaction
A selective approach to division of the short gastric arteries does not affect clinical outcome