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© Springer Nature Switzerland AG 2019
D. J. Papandria et al. (eds.), Operative Dictations in Pediatric Surgery, https://doi.org/10.1007/978-3-030-24212-1_6
Esophagogastric Fundoplication
9. Grasp fundus and pass it posterior to the esophagus.
10. Create a short floppy wrap by placing inter- rupted sutures over the gastric tube or bougie.
11. If desired, place gastropexy sutures to pre- vent migration into the mediastinum.
Note These Variations
• A variety of liver or abdominal retractors may be used for exposure.
• Some surgeons prefer limited crural dissec- tion and minimal division of the short gastric vessels.
• The crura may not be reapproximated if there is no defect.
• Gastropexy sutures may be added to secure the fundus to the diaphragm.
• 3-mm or 5-mm ports and instruments may be used depending on the size of the child.
Template Operative Dictation (Open)
Preoperative Diagnosis Refractory gastro- esophageal reflux/feeding intolerance/parae- sophageal hernia/hiatal hernia
Postoperative Diagnosis Same as preoperative diagnosis
Findings See operative note
Procedure(s) Performed Esophagogastric fundoplication
Anesthesia General Specimen None Drains None Implants None
Estimated Blood Loss ___ mL
Indications This is a/an ___-day/week/month/
year-old male/female with severe reflux esopha- gitis/feeding intolerance/failure to thrive/parae- sophageal hernia/hiatal hernia. Medical management had failed and he/she was deemed to be a suitable candidate for esophagogastric fundoplication.
Procedure in Detail Following satisfactory induction of anesthesia, the patient was placed in supine and appropriately padded. Timeouts were performed using both pre-induction and pre- incision safety checklists with participation of all present in the operative suite. These confirmed the correct patient, procedure, operative site, and additional critical information prior to the start of the procedure. The abdomen was then prepped and draped in the usual sterile fashion.
A nasogastric/orogastric tube was placed to decompress the stomach. A midline upper abdominal/left subcostal skin incision was made.
The subcutaneous tissues were carefully dis- sected. The abdomen was inspected. A liver retractor was placed to elevate the left lobe of the liver anterosuperiorly and expose the esophageal hiatus. The left triangular ligament of the liver was taken down for additional exposure. Using electrocautery, the short gastric vessels were carefully ligated in order to mobilize gastric fun- dus and free it from its attachments to the spleen.
The stomach was then retracted caudally to pro- vide downward traction on the phrenoesophageal ligament. The gastrohepatic ligament was opened at the pars flaccida. A plane was dissected between the right and left diaphragmatic crura and the esophagus in order to develop a circum- ferential plane. Both the anterior and posterior vagus nerves were carefully identified and pre- served throughout the procedure. A vessel loop/
Penrose drain was placed around the esophagus incorporating the posterior vagus nerve. The dis- tal esophagus was mobilized to allow for suffi- cient intra-abdominal length. A small/large hiatal hernia was present and the contents were reduced. __ interrupted nonabsorbable sutures were placed posteriorly to reapproximate the right and left crura.
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The fundus was grasped and folded posterior to the esophagus. A “shoeshine” maneuver was performed to ensure adequate mobility of the fundus. The nasogastric/orogastric tube was exchanged for a ___ French bougie. A 360-degree fundoplication was created with ___ interrupted nonabsorbable sutures to create a ___-cm long fundoplication, incorporating the anterior wall of the esophagus on the two superior sutures. The wrap was noted to be floppy without any evidence of tension on the fundus or the sutures. The nasogastric tube/
orogastric tube/bougie was removed. The fun- doplication was tacked to the diaphragmatic crus using ___ interrupted nonabsorbable sutures to prevent the wrap from migrating into the mediastinum.
The abdomen was then inspected and hemo- stasis was ensured. The liver retractor was removed. The fascia was closed with running/
interrupted ___ suture. The skin incision was closed with absorbable suture in layers and a dressing was applied.
Upon completion of the procedure, a debrief- ing checklist was completed to share information critical to the postoperative care of the patient.
The patient tolerated the procedure well, was extubated in the operating room, and was trans- ported to the post-anesthesia care unit in stable condition.
Template Operative Dictation (Laparoscopic)
Preoperative Diagnosis Refractory gastro- esophageal reflux/feeding intolerance/parae- sophageal hernia/hiatal hernia
Postoperative Diagnosis Same as preoperative diagnosis
Findings See operative note
Procedure(s) Performed Laparoscopic esopha- gogastric fundoplication
Anesthesia General
Specimen None Drains None Implants None
Estimated Blood Loss ___ mL
Indications This is a/an ___-day/week/month/
year-old male/female with severe reflux esopha- gitis/feeding intolerance/failure to thrive/parae- sophageal hernia/hiatal hernia. Medical management had failed and he/she was deemed to be a suitable candidate for laparoscopic esoph- agogastric fundoplication.
Procedure in Detail Following satisfactory induction of anesthesia, the patient was placed in supine/low lithotomy position at the foot of the table and appropriately padded. Timeouts were performed using both pre-induction and pre- incision safety checklists with participation of all present in the operative suite. These con- firmed the correct patient, procedure, operative site, and additional critical information prior to the start of the procedure. The abdomen was then prepped and draped in the usual sterile fashion.
A nasogastric/orogastric tube was placed to decompress the stomach. A skin incision was made at/above the umbilicus for placement of a 5-mm port. The abdomen was insufflated and a 5-mm, 30-degree laparoscopic was placed. There were no noted injuries from initial port place- ment. Three additional 5-mm ports were placed, including two operating ports in the right and left upper quadrants along the mid-clavicular lines, and a retracting port in the left mid-abdomen.
{If Nathanson liver retractor used} In the mid- line of the epigastrium, a skin incision was made for a Nathanson liver retractor. The liver retractor was placed to elevate the left lobe of the liver and expose the esophageal hiatus.
{If flexible liver retractor used} In the right anterior axillary line, a skin incision was made for a snake liver retractor. The liver retractor was placed to elevate the left lobe of the liver and expose the esophageal hiatus.
6 Esophagogastric Fundoplication (Open and MIS Approaches)
The short gastric vessels were carefully divided using a vessel sealing device/hook elec- trocautery to mobilize gastric fundus. The stom- ach was then retracted caudally to provide downward traction on the phrenoesophageal liga- ment. The gastrohepatic ligament was then opened at the pars flaccida. A plane was dissected between the right and left diaphragmatic crura and the esophagus in order to develop a circum- ferential plane. Both the anterior and posterior vagus nerves were carefully identified and pre- served throughout the procedure. A vessel loop/
Penrose drain was placed around the esophagus incorporating the posterior vagus nerve. The dis- tal esophagus was mobilized to allow for suffi- cient intra-abdominal length. A small/large hiatal hernia was present and the contents were reduced. ___ interrupted nonabsorbable sutures were placed posteriorly to reapproximate the right and left crura.
The fundus was grasped and folded posterior to the esophagus. A “shoeshine” maneuver was performed to ensure adequate mobility of the fundus. The nasogastric/orogastric tube was exchanged for a ___ French bougie. A 360-degree
fundoplication was created with ___ interrupted non-absorbable sutures to create a/an __-cm long fundoplication, incorporating the anterior wall of the esophagus on the two superior sutures. The wrap was noted to be floppy without any evi- dence of tension on the fundus or the sutures. The nasogastric tube/orogastric tube/bougie was removed. The fundoplication was tacked to the diaphragmatic crus using ___ interrupted non- absorbable sutures to prevent the wrap from migrating into the mediastinum.
The abdomen was then inspected and hemo- stasis was ensured. The liver retractor was removed under vision. The ports were removed and the abdomen desufflated. The umbilical fas- cial defect was closed with interrupted absorb- able sutures. Skin incisions were closed with absorbable sutures and a dressing was applied.
Upon completion of the procedure, a debrief- ing checklist was completed to share information critical to the postoperative care of the patient.
The patient tolerated the procedure well, was extubated in the operating room, and was trans- ported to the post-anesthesia care unit in stable condition.
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© Springer Nature Switzerland AG 2019
D. J. Papandria et al. (eds.), Operative Dictations in Pediatric Surgery, https://doi.org/10.1007/978-3-030-24212-1_7