Transcript Title

Laparoscopic Nissen
Fundoplication and
Gastrostomy – How I Do It
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas 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 side
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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 esophagocrural sutures
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Laparoscopic Fundoplication
Intraoperative Bougie Sizes
PAPS 2002
JPS 37:1664-1666, 2002
Laparoscopic Fundoplication
Creation of fundoplication over bougie
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Laparoscopic Fundoplication
Measuring fundoplication
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Laparoscopic Fundoplication
Fundoplication
suture line at 10
o’clock
Study Design
Retrospective
One Surgeon (GWH)
Jan 2000 – March 2002
Group I
• 130 patients
• Extensive esophageal
mobilization
• No esophago-crural sutures
Study Design
Retrospective
One Surgeon (GWH)
April 2002 – Dec. 2004
Group 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)
Results
Data Point
Group I
(130 pts)
21.1
Group II
(119 pts)
27.3
P
Value
.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
Pts with transmigration
wrap
0
ALL
Mean age (mo)
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 Fundoplication
Current 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
Preoperative Demographics
177 Patients
Age (yrs)
Weight (kg)
Neurologically
Impaired (%)
Operating Time
(Minutes)
Extensive Esophageal
Mobilization (N=87)
Minimal Esophageal
Mobilization (N=90)
P-Value
1.9 +/- 3.3
2.5 +/- 3.5
0.30
10.7 +- 11.9
12.6 +/- 18.2
0.44
51.7
54.4
0.76
100 +/- 34
95 +/- 37
0.37
APSA, 2010
J Pediatr Surg 43:163-169, 2011
Minimal vs Extensive Esophageal
Mobilization During Laparoscopic
Fundoplication
Results
177 Patients
Extensive
Esophageal
Mobilization (N=87)
Minimal Esophageal
Mobilization (N=90)
PValue
Postoperative Wrap Transmigration (%)
30.0%
7.8%
0.002
Need for Re-do Fundoplication (%)
18.4%
3.3%
0.006
APSA, 2010
J Pediatr Surg 43:163-169, 2011
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
www.cmhclinicaltrials.com
www.cmhmis.com