Entrapment of a nasopharyngeal temperature probe: an unusual complication during an apparently uneventful elective revision laparoscopic Nissen fundoplication.

ABSTRACT

We report the first case of nasopharyngeal temperature probe entrapment during an apparently uneventful elective revision laparoscopic Nissen fundoplication that precipitated a continuous quality improvement project at our institution. We describe changes in our clinical practice that resulted from this occurrence and envision these modifications will have a positive influence on patient care.