Fundoplication Operative Note (Laparoscopic)

Date of Procedure: [Date] [Start time – End time]

Facility/OR: [Facility name and OR number]

Service: [Foregut Surgery / General Surgery]

Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant names and roles]

Anesthesia: [General endotracheal / other] (Note difficult airway or adjuncts if clinically relevant)

Case Classification: [Elective / Urgent / Emergent]; [Laparoscopic / Robotic-assisted / Converted to open]; [Primary / Redo] (If conversion occurred, document rationale)

Diagnoses

Preoperative Diagnosis:

• [GERD characterization, e.g., medically refractory, chronic]
• [Hiatal/paraesophageal hernia type (I–IV) and size if known]
• [Aspiration or extra-esophageal manifestations] (Include only if relevant)
• [Esophagitis or Barrett's status] (Include if known)
• [Prior anti-reflux procedure and failure mode] (Include only for redo cases)

Postoperative Diagnosis:

• [Confirmed diagnoses based on intraoperative findings]
• [Hiatal hernia type and size confirmed]
• [Short esophagus: identified / excluded]
• [Prior wrap/mesh status] (Include only for redo cases)

Procedures Performed

• [Procedure 1]
• [Procedure 2]
• [Procedure 3]

(Use precise titles: laparoscopic hiatal hernia repair with posterior cruroplasty, Nissen fundoplication (360°), Toupet fundoplication (posterior 270°), Dor fundoplication (anterior partial), intraoperative EGD, mesh reinforcement of hiatus, Collis gastroplasty, gastropexy, gastrostomy/jejunostomy)

Indications

[Justification for surgery including symptom profile, failure or intolerance of medical therapy, and summary of objective testing (EGD, pH/impedance, manometry, barium/UGI, hernia size). For redo cases, note prior surgery and failure mode. If specific test values are unavailable, state "per preoperative evaluation."]

Perioperative Elements

• Consent: [Informed consent obtained] (Note specific risks discussed in high-risk scenarios)
• Antibiotic Prophylaxis: [Agent and timing / per protocol]
• VTE Prophylaxis: [Mechanical / Pharmacologic / Both]
• Positioning: [Supine with split-leg / Lithotomy]; [Reverse Trendelenburg: yes / no]
• Time-out: [Performed] (Include only if explicitly stated)
• Counts: [Correct / Discrepancy and resolution] (Include only if explicitly stated)

Operative Findings

• [Hiatal hernia: presence, type (I–IV), size in cm, contents]
• [Hernia sac: presence, reducibility, degree of mediastinal herniation]
• [Esophagus: appearance, mobilization adequacy, short esophagus assessment]
• [Vagus nerves: visualized and preserved] (Include only if specifically identified)
• [Adhesions: none / mild / moderate / severe]
• [Prior mesh or wrap status] (Include only for redo cases)
• [Fundus and short gastric vessel status]
• [Other notable findings]

Operative Technique

(Describe what was actually performed in chronological past tense)

Access and Exposure

[Method of peritoneal entry: Veress / optical trocar / Hasson]. [Port configuration: number, sizes, locations]. [Insufflation pressure]. [Liver retraction method]. [Gastric decompression if used].

Hiatal Dissection and Esophageal Mobilization

[Dissection of phrenoesophageal membrane]. [Hernia sac management: reduced / excised / left in situ]. [Extent of mediastinal and circumferential dissection]. [Pleural entry or capnothorax and management] (Include only if occurred). [Intra-abdominal esophageal length assessment]. [Short esophagus determination and Collis gastroplasty decision with rationale].

Cruroplasty

[Closure orientation: posterior / anterior / combined]. [Suture material and type]. [Number of sutures; pledget use]. [Bougie in place during closure: yes / no; size if used]. [Relaxing incision] (Include only if performed). [Esophagopexy sutures] (Include only if placed).

Mesh Reinforcement

(Include only if mesh was used or explicitly considered but not used)

[Indication: large defect / poor tissue quality / redo / tension]. [Mesh type: synthetic / biologic; brand]. [Size and configuration: U-shape / keyhole / onlay]. [Fixation method].

Fundus Mobilization

[Short gastric vessels: divided / preserved]. [Extent of mobilization]. [Hemostasis method].

Fundoplication

Wrap type: [Nissen 360° / Toupet posterior 270° / Dor anterior partial / Other]

Bougie/calibration: [Used / Not used]; [Size in French]; [Type: esophageal bougie / OG tube]; [Any difficulty or mucosal trauma]

[Wrap length in cm]. [Tension: loose-floppy / snug]. [Number of sutures and material]. [Esophageal wall incorporation: yes / no]. [Orientation verification method]. [Anchoring sutures to crura or gastropexy] (Include only if placed).

(Required elements: Wrap type and bougie/calibration status must be explicitly documented)

Intraoperative Endoscopy

(Include only if performed)

[Findings: wrap appearance from lumen, GEJ patency, mucosal integrity]. [Interventions performed].

Feeding Tube

(Include only if placed)

[Indication]. [Type: gastrostomy / jejunostomy]. [Size]. [Technique and confirmation]. [Fixation].

Closure

[Hemostasis confirmed]. [Fascial closure for ports ≥10 mm]. [Skin closure method]. [Local anesthetic at port sites] (Include only if used).

Specimens

(Omit section if no specimens, or state "None" per institutional preference)

• [Specimen description and destination]

Implants

(Include only if implants were used)

• [Implant type, size, brand; lot/serial as required]

Drains and Tubes

• [Drain type and location]
• [NG/OG tube: in place / removed]
• [Foley catheter status]
• [Feeding tube type and external marking] (Include only if placed)

Case Data

Estimated Blood Loss: [mL]

Fluids/Urine Output: [Fluids; Urine output] (Include for complex or lengthy cases)

Complications

[None] (State only if dictation explicitly confirms no complications)

[Complication and management: pleural entry, esophageal/gastric injury, bleeding, conversion to open, deviation from planned procedure with rationale]

Disposition

[Extubation: extubated in OR / intubated to ICU]. [Hemodynamic status]. [Destination: PACU / ICU]. [Immediate diet/NGT plan].

Surgeon Signature

[Surgeon name, credentials]

Signature: ________________________________

Date/Time: [Date and time]

[Trainee attestation] (Include if applicable per institutional policy)