Mechanisms of gastric and esophageal perforations during laparoscopic nissen fundoplication

Objective The purpose of this study was to determine possible mechanisms of 17 gastric and esophageal perforations that occurred during laparoscopic Nissen fundoplication. Methods Specific details of each perforation relating to mechanism of injury, surgeon experience, diagnosis, treatment, and outcome were obtained. For each perforation, an attempt was made to accurately determine the mechanism of perforation. Results Three mechanisms accounted for the 17 perforations, the majority of which occurred within the first ten laparoscopic Nissen fundoplications performed by the surgeon. Ten perforations resulted from injuries related to improper retroesophageal dissection, five occurred during passage of the bougie dilator or nasogastric tube, and two occurred after surgery secondary to suture pull-through. Six patients received a delayed diagnosis, which adversely affected outcome. Most of the perforations were successfully managed by primary closure and wrap to include the repair. Morbidity was significantly increased for perforations recognized late. One death, attributed to sepsis, occurred in association with a delay in diagnosis. Conclusions Gastric and esophageal perforations are serious complications of the new laparoscopic method of Nissen fundoplication. The mechanisms of these complications are specifically related to limitations of the laparoscopic technique. Prevention of these potentially lethal complications requires a full understanding of the detailed anatomy of the gastroesophageal region and awareness of the recognized mechanisms of perforation.