Ian Finlay, Consultant Upper GI, Bariatric, Laparoscopic and General Surgeon
Royal Cornwall Hospitals NHS Trust
Patient Selection
- Standard day case criteria
- Hiatus hernia containing less than half of stomach
Anaesthetic Techniques
- Standard day case protocol GA:
- Rapid sequence ET induction with propofol, rocuronium, fentanyl
- Maintenance with sevoflurane (avoid nitrous oxide), or propofol TIVA if higher PONV risk
- 3 anti-emetics given intraoperatively (ondansetron, dexamethasone, cyclizine or droperidol) with fourth as reserve for use in recovery if needed
Surgical Technique
- Patient legs straight and apart, slightly head up, surgeon between legs with assistant on patient's left
- 1 x 12mm camera port, 3 x 5mm working ports, suture passed via camera port. Diamondflex liver retractor via right side 5 mm port
- 12mmHg CO2, dissection with Lotus ultrasonic energy device
- 360o Nissen or 180o anterior fundoplication as per surgeon's preference
Peri-operative Analgesia
- Fentanyl titrated intra operatively (250 – 500mcg)
- 20ml of 0.5% levobupivacaine to port sites at end of case
- Avoid morphine, fentanyl in recovery, Oramorph only if required
Take Home Medication
- Prochlorperazine 3mg buccal tablets - 1-2 twice daily for 2 days PRN
- Over the counter soluble paracetamol and ibuprofen - pre op' purchase advised
Organisational Issues
- Patients advised pre op' that day case procedure normal practice
- First on list to allow longer recovery before discharge
- Telephone call from Specialist Nurse first day essential for reassurance
Common Pitfalls
- Day one increase in dysphagia (inform of this pre op')
- Pain worse if analgesia taken PRN instead of regularly
Anticipated Day Case Rates