Managing Anaesthetic Challenges in Gastrofundoplication: A Case Report

Abstract

Introduction Esophagogastric fundoplication, a surgical procedure to treat reflux or hiatal hernia, presents significant challenges for anesthesiologists. Its complexity and patient-specific factors necessitate thorough airway assessment, intubation preparation, and continuous respiratory and hemodynamic monitoring to prevent complications [1,2]. Case Presentation A 55-year-old man underwent elective laparoscopic diaphragmatic hernia repair under general anesthesia for a grade II–III axial gastric hernia (ASA III). Intraoperatively, he developed severe complications, including hemodynamic instability, cyanosis, pneumothorax, pneumomediastinum, and subcutaneous emphysema. These were likely due to increased intra-abdominal pressure, pleural injury, or esophageal fragility from prior surgeries and adhesions. Postoperatively, persistent vasopressor requirements and respiratory acidosis necessitated ICU admission without extubation. Three days later, his condition worsened, and imaging revealed gastric perforation with ongoing pneumothorax, leading to emergency relaparoscopy (ASA IV E). Intraoperative challenges included CO₂ retention and hypoxemia, requiring intensified hemodynamic support with norepinephrine and 100% FiO₂. Extensive adhesions and tissue compromise likely contributed to these complications, prolonging the ICU stay. Discussion Intraoperative complications in esophagogastroduodenal surgery require careful preparation and continuous monitoring by the anesthetic team. A meticulous preoperative evaluation—including assessments for dysphagia, gastric regurgitation, and aspiration risk—is critical [3,4]. Intraoperatively, careful positioning, nasogastric tube insertion, and vigilant respiratory monitoring (via pulse oximetry, capnography, and gas exchange analysis) are essential to detect and manage pulmonary complications such as barotrauma, pneumothorax, or subcutaneous emphysema. Although hypotension is a rare laparoscopic complication, typically caused by high intra-abdominal pressure, early use of norepinephrine can stabilize hemodynamics when fluid therapy is inadequate [5–8]. Conclusions This case underscores the necessity of a robust anesthetic strategy for difficult situations to maintain patient stability during and after surgery.