Laparoscopic Nissen Fundoplication and Gastrostomy – How I Do It George W. Holcomb, III, M.D., MBA...

Laparoscopic Nissen Fundoplication and

Gastrostomy – How I Do It

George W. Holcomb, III, M.D., MBASurgeon-in-Chief

Children’s Mercy HospitalKansas City, MO

Patient Positioning

• Patient placed at foot of operating table

• Foot of table removed or lowered

• Monitor above head of bed

Personnel Position

• Surgeon at foot of bed

• Assistant to the right

• Scrub nurse to the left

Equipment

• 5 mm, 45o telescope

• 3 mm liver retractor (Snowden-Pencer)

• 3 mm instruments (Storz)

• 3 mm needle holder (Jarit or Storz)

• One 5 mm cannula in umbilicus (Step)

Laparoscopic Fundoplication

Ligation/division short gastric vessels

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Laparoscopic Fundoplication

Create retroesophageal window from patient’s left sidePlease use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication

• Ligation/division anomalous left hepatic a.? • Minimal esophageal mobilization

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Laparoscopic Fundoplication

Close crura posterior to esophagus

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Laparoscopic Fundoplication

Placement of esophago-crural sutures

Laparoscopic Fundoplication

Insertion of bougie after placement esophago-crural sutures

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Laparoscopic Fundoplication Intraoperative Bougie Sizes

PAPS 2002PAPS 2002JPS 37:1664-1666, 2002JPS 37:1664-1666, 2002

Laparoscopic Fundoplication

Creation of fundoplication over bougiePlease use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication

Measuring fundoplicationPlease use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication

Fundoplication suture line at 10 o’clock

Study DesignRetrospective

One Surgeon (GWH)

Jan 2000 – March 2002Group I

• 130 patients

• Extensive esophageal mobilization

• No esophago-crural sutures

Study DesignRetrospective

One Surgeon (GWH)

April 2002 – Dec. 2004Group II

• 119 patients

• Minimal esophageal mobilization

• Esophago-crural sutures placed

Patient Follow-up• Clinical follow-up

• Followed at 6 mo intervals

• All patients with transmigration presented with reflux symptoms – problem confirmed with UGI study

• Follow-up: Range - 14 – 76 months

Mean - 38 months

• Minimum - 14 months

• Mean time from initial operation to recurrence was 456 days (range 151-1155 days)

ResultsData Point Group I

(130 pts) Group II (119 pts)

P Value

Mean age (mo) 21.1 27.3 .236

Mean wt (kg) 10.0 11.6 .335

Mean op time (min) 93.4 102.4 .023

Mean length of fundoplication wrap (cm)

2.05 2.13 .074

Pts requiring gastrostomy 64 58 .999

Pts with esophago-crural sutures

0 ALL

Pts with transmigration wrap

15 (12%)

6 (5%)

.072

The relative risk of transmigration of the wrap is 2.29 times greater for Group I than for Group II

Laparoscopic FundoplicationCurrent Technique - 2010

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Prospective, Randomized Trial• 2 Institutions: CMH, CH-Alabama

• Power analysis using retrospective data (12% vs 5%) : 360 patients

• Primary endpoint -- transmigration rate

• 2 groups: minimal vs. extensive esophageal dissection

• Both groups received esophago-crural sutures

• Stratified for neurological status

• UGI contrast study one year post-op

• APSA, 2010

Minimal vs Extensive Esophageal Mobilization During Laparoscopic

Fundoplication

Extensive Esophageal Mobilization (N=87)

Minimal Esophageal Mobilization (N=90)

P-Value

Age (yrs) 1.9 +/- 3.3 2.5 +/- 3.5 0.30

Weight (kg) 10.7 +- 11.9 12.6 +/- 18.2 0.44

Neurologically Impaired (%)

51.7 54.4 0.76

Operating Time (Minutes)

100 +/- 34 95 +/- 37 0.37

APSA, 2010APSA, 2010J Pediatr Surg 43:163-169, J Pediatr Surg 43:163-169,

20112011

Preoperative Demographics177 Patients

Minimal vs Extensive Esophageal Mobilization During Laparoscopic

Fundoplication

Extensive Esophageal

Mobilization (N=87)

Minimal Esophageal Mobilization (N=90)

P-Value

Postoperative Wrap Transmigration (%)

30.0% 7.8% 0.002

Need for Re-do Fundoplication (%) 18.4% 3.3% 0.006

APSA, 2010APSA, 2010J Pediatr Surg 43:163-169, 2011J Pediatr Surg 43:163-169, 2011

Results177 Patients

Current Study

• Analysis (80% power, α- 0.05) – 110 patients

• Minimal esophageal dissection in all patients

• 4 esophago-crural sutures vs. no sutures

No Esophago-crural Sutures

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Tips/Tricks

• If liver is large, position cannula and telescope under it to help elevate the liver and improve visualization

• Know the position of the left gastric artery, and be sure you are cephalad to it when creating the retroesophageal opening

• Know the location of the vagus nerves

• Mark the site of the gastrostomy prior to insufflation, and use this site for one of the stab incisions

• There is no way to create a tension-free, loose “floppy” Nissen fundoplication without taking down the short gastric vessels

Know Location of LGA

Postoperative Management

• Clear liquids 4-6 hours following operation

• Advance to formula following morning

• Mechanical soft diet for 3 weeks for patients eating regular food

• If gastrostomy button inserted, begin half-strength half-volume 6 hours following surgery, and advance as tolerated

Laparoscopic Gastrostomy

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QUESTIONS

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