JSLS The Accuracy of Gastric Insufflation in Testing for Gastroesophageal Perforations during Laparoscopic Nissen Fundoplication David R. Flum, MD, Robert C. Bass, MD ABSTRACT Background: Laparoscopic Nissen fundoplication is an effective technique for the symptomatic relief of the man- ifestations of gastroesophageal reflux disorder but is associated with a 0.8-1% rate of gastroesophageal perfo- ration. Early detection and repair of these injuries is crit- ical to patient outcome, but occult injuries occur and may be missed. Gastric insufflation technique evaluates the integrity of the gastroesophageal wall after laparoscopic Nissen fundoplication. Gastric insufflation technique involves occlusion of the proximal stomach with a non- crushing bowel clamp while insufflating the submerged gastroesophageal junction. We conducted an animal study to assess the utility of gastric insufflation technique. Methods: Five pigs (mean weight, 40.4 kg) underwent testing of laparoscopic gastric insufflation technique. In four animals, laparoscopic Nissen fundoplication was performed and then gastroesophageal junction injuries were created (3-5 mm distraction-type wall injuries). Non-crushing bowel clamps provided occlusion of the pylorus and then the proximal stomach during gastroe- sophageal insufflation. The gastroesophageal junction was then submerged. In the fifth animal, gastric insuf- flation technique was repeated while calibrated injuries were created to determine the smallest detectable injury. An injury was considered detectable if rising air bubbles were noted from the submerged gastroesophageal struc- tures. Maximal luminal pressures needed to detect injuries were recorded with an in-line manometer. Results: In all animals, 5-7 mm injuries of the gastroe- sophageal junction were easily detected using gastric insufflation technique when the proximal stomach was occluded. When the pylorus alone was occluded, detec- tion of gastroesophageal injuries was inconsistent. Small Department of Surgery, Chinle Comprehensive Health Care Facility, Indian Health Service-Navajo Nation, Public Health Service, Chinle, Arizona (allauthors). Address reprint request to: David R. Flum, MD, PO Box 67, Chinle, Arizona 86503, USA. Telephone: (520) 674-7001, Fax: (520) 674-7008. © 1999by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc. injuries (<3 mm) of the esophagus were difficult to visu- alize with pyloric occlusion alone but were consistently detectable with proximal stomach occlusion at pressures less than 20 mm Hg. When the pylorus alone was occluded, the smallest detectable stomach perforation was a l6-gauge needle puncture while applying maximal gastric pressure (40-60 mm Hg) and a 2.5 mm linear injury when generating lower pressures (20 mm Hg). Conclusion: Proximal stomach occlusion and insuffla- tion appears to effectively detect esophageal injuries of likely clinical importance (>2.5 mm). Pyloric occlusion and insufflation reliably evaluates the anterior stomach for injury. Gastric insufflation technique is a useful method for detecting gastroesophageal injury after laparoscopic Nissen fundoplication. Key Words: Laparoscopy, Nissen fundoplication, Gastroesophageal injury, detection. INTRODUCTION Laparoscopic Nissen fundoplication (LNF) is an effective technique for the symptomatic relief of the manifesta- tions of gastroesophageal reflux disorder (GERD). In large reviews, laparoscopic Nissen fundoplication has been performed with limited morbidity and mortality.1 The most common complications include early (but usu- ally transient) dysphagia (20%), pneumothorax (2%)and esophageal or gastric perforation (1.1%).1 The morbidi- ty associated with this procedure is particularly relevant because although GERD is associated with significant patient complaints, it is usually not life threatening. For that reason, the acceptance of a surgical procedure for its resolution is critically dependent on a low rate of com- plications. While postoperative dysphagia is the most common of these complications, it is usuallyself-limited. Conversely, intraoperative perforation of either the stom- ach or the esophagus is much less common, but its con- sequences are quite significant. When detected at the time of the procedure, gastroe- sophageal (GE) perforation is associated with limited morbidity and is unlikely to result in patient death.2 JSLS (1999)3:267-271 267