Postoperative complications were found to occur in approximately 8% of patients, with the rate of conversion to an open procedure of about 4%. The most common perioperative complication was early wrap herniation (1.3%), defined as occurring within 48 hours of surgery. This is one complication that may be more common with the laparoscopic than open approach. The explanation for this is unclear but may be related to the opening of tissue planes by the pneumoperitoneum and the reduced tendency for adhesion formation after laparoscopic compared to open surgery. In an attempt to eliminate this complication, most surgeons routinely perform a crural repair.
Both pneumothorax and pneumomediastinum have been reported. The occurrence of pneumothorax is related to breach of either pleural membrane, usually the left, during the hiatal dissection. Chest drain insertion is usually not required because accumulated carbon dioxide rapidly dissipates following release of pneumoperitoneum by a combination of positive pressure ventilation and absorption.
As with any laparoscopic procedure, instrumental perforation of the hollow viscera may occur. Early esophageal perforation may arise during passage of the bougie, during the retroesophageal dissection, or during suture pull-through. Late esophageal perforation is related to diathermy injury at the time of mobilization. Gastric perforations usually resulted from excessive traction on the fundus for retraction purposes. Recognition of the problem at the time of surgery requires repair, which may be performed either laparoscopically or by an open technique.
Hemorrhage during the course of laparoscopic fundoplication usually arises from the short gastric vessels or spleen. Rarer causes include retractor trauma to the liver, injury to the left inferior phrenic vein, an aberrant left hepatic vein, or the inferior vena cava. Cardiac tamponade as a result of right ventricular trauma has also been reported. Major vascular injury mandates immediate conversion to an open procedure to achieve hemostasis.