Surgical Considerations

  • Indicated for the treatment of severe GERD

  • The anterior and posterior wall of the stomach are sutured together around the lower esophagus to reinforce the closing function of the LES (lower esophageal sphincter).

  • May be performed open or laparoscopic.

  • Duration: 1-2 hours

  • Position: supine

  • Antibiotic: Usually Cefoxitin 40mg/kg or Cefazolin 30mg/kg- ask surgeon

  • EBL: Usually < 20ml

  • Equipment: standard monitors, urinary catheter, NG/OG tube to decompress the stomach, suction

Patient Considerations

  • Disease Specific Considerations: Patients may have active and uncontrolled GERD

Case Planning

  • Specific or Unique Room Set-Up Requirements

    • Airway: ETT

    • Drugs/Infusions: Consider non-depolarizing neuromuscular blockade if laparoscopic

    • Monitors: standard

    • Blood Availability: Not required

    • PICU Bed Availability: If patient is neonate with an open procedure, consider the possibility of post-operative ventilation

Anesthetic Considerations

  • Induction: Consider RSI if uncontrolled GERD

  • Positioning: supine, bed not turned

  • Maintenance:

    • Volatile Anesthetic

      • Avoid nitrous oxide

    • Consider non-depolarizing neuromuscular blockade

    • Monitor ETCO2 and prevent hypercarbia from absorbed CO2 due to the insufflation.

    • Be reminded that stimulation of the Vagus nerve (CN X) can cause a vagal response resulting in bradycardia.

    • Confirm ETT placement with position changes.

    • NG/OG tube if requested by surgeon

  • Emergence: Awake extubation

  • Intraoperative Considerations:

    • May be asked to place a bougie down the esophagus.

      • DO NOT force the bougie. If there is any resistance, inform the surgeon and allow him/her to insert it. We don’t want to cause a perforation of the esophagus.

  • Emergence/Disposition: Awake Extubation v. Return to NICU/PICU Intubated

  • Post-Op Pain Management:

    • NSAIDS if ok with Surgeon

    • Acetaminophen (Oral or IV)

    • IV Narcotics

    • Consider regional/neuraxial anesthesia if open procedure

  • Case-Specific Complications:

    • Perforated esophagus

    • Hemorrhage,

    • Esophagus sliding out of the wrap leading to decreased LES tone

    • Continued GERD

    • Referred shoulder pain from insufflation

    • PONV in children >3yo


Jaffe, R. and Samuels, S. (2009). Anesthesiologist’s Manual of Surgical Procedures. 4th ed. Philadelphia: Lippincott Williams & Wilkins.