Transcript Title

How I Do It
Laparoscopic Fundoplication
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, MO
Laparoscopic Fundoplication
The Use of Stab Incisions
Procedure (n)
Nissen (209)
Nissen (14)
Heller Myotomy (7)
Appendectomy (102)
Meckel’s Diverticulum (2)
Pyloromyotomy (77)
Cholecystectomy (31)
Pullthrough (20)
Splenectomy (21)
Adrenalectomy (6)
UDT (15)
Varicocele (5)
Ovarian (2)
Totals (511)
Used/case
1
2
2
2
2
1
2
2
2
2
1
1
1
714
Saved/case
4
3
3
1
1
2
2
1
2
2
2
2
2
1337
PAPS 2003
JPS 38:1837-1840, 2003
Cost Savings from Stab Incisions
Procedure (n)
Nissen (209)
Nissen (14)
Heller (7)
Appy (102)
Meckel’s (2)
Pyloric (77)
Chole (31)
Pullthrough (20)
Spleens (21)
Adrenal (6)
UDT (15)
Varicocele (5)
Ovarian (2)
Total = 511
Step Pt./Instit. Savings ($)
117,040 / 51,832
5,880 / 2,604
2,940 / 1,302
14,280 / 6,324
280/ 124
21,560 / 9,548
8,680 / 3,844
2,800 / 1,240
5,880 / 2,604
1,680 / 744
4,200 / 1,860
1,400 / 620
560 / 248
$187,180/$82,894
Ethicon Pt./Instit. Savings ($)
76,912 / 4,276
3,864 / 1,722
1,932 / 861
9,384 / 4,182
184 / 82
14,168 / 6,314
5,704 / 2,542
1,840 / 820
3,864 / 1,722
1,104 / 492
2,760 / 1,230
920 / 410
368 / 164
$123,004/$54,817
PAPS 2003
JPS 38:1837-1840, 2003
Personal Series - CMH
Jan 2000 – March 2002
130 Pts
No Esophagus – Crural Sutures
Extensive Esophageal Mobilization
Mean age/weight
21 mo/10 kg
Mean operative time
93 minutes
Transmigration wrap
15 (12%)
Postoperative dilation
0
APSA 2006
Accepted, J Pediatr Surg
Current Thoughts
1. Less mobilization of
esophagus
2. Keep peritoneal
barrier b/w
esophagus & crura
Current Thoughts
3. Secure esophagus to crura at 8, 11, 1 and 4 o’clock
Personal Series - CMH
April 2002 – December 2004
119 Pts
Esophagus – Crural Sutures
Minimal Esophageal Mobilization
Mean age/weight
27 mo/11 kg
Mean operative time
102 minutes
Transmigration wrap
6 (5%)
Postoperative dilation
1
APSA 2006
Accepted, J Pediatr Surg
The relative risk of wrap transmigration
in patients without esophago-crural
sutures and with extensive esophageal
mobilization was 2.29 times the risk if
these sutures were utilized and if minimal
esophageal dissection was performed.
Patients Less Than 60 Months
Mean Age (mos)
Group I
Jan 00-March 02
Group II
April 02-Dec 04
117 Pts
102 Pts
P Value
10.26
10.95
0.650
Mean Wt (kg)
7.03
7.17
0.801
Gastrostomy
47%
46%
0.893
Neuro Impaired
71%
61%
0.118
6 (6%)
0.159
Wrap
Transmigration
14 (12%)
The relative risk of transmigration of the wrap is
2.03 times greater for Group I than for Group II
Patients Less Than 24 Months
Group I
Jan 00-March 02
Group II
April 02-Dec 04
104 Pts
93 Pts
P Value
Mean Age (mos)
6.99
8.15
0.175
Mean Wt (kg)
6.32
6.46
0.759
Gastrostomy
46%
46%
0.999
Neuro
Impairment
73%
60%
0.069
6 (6%)
.226
Wrap
Transmigration
13 (12%)
The relative risk of transmigration of the wrap is 1.94
times greater for Group I than for Group II
Group II
119 Patients
Esophago-Crural Sutures
# Patients Transmigration
%
2 silk sutures
(9, 3 o’clock)
20
5
25%
3 silk sutures
(9, 12, 3 o’clock)
43
1
2.3%
4 silk sutures
(8, 11, 1, 4 o’clock)
56
0
0%
Prospective, Randomized Trial
• 2 Institutions: CMH, CH-Alabama
• Power Analysis: 360 Patients
• Primary endpoint-transmigration rate
(12% vs.5%-retrospective data)
• 2 Groups: minimal vs. extensive
esophageal dissection
• Both groups receive esophago-crural
sutures
Intraoperative Bougie Sizes
PAPS 2002
JPS 37:1664-1666, 2002
Re-Do Fundoplication
Operative Technique
21/273 Pts
• No mesh (13)
4 recurrences
• Surgisis (8)
0 recurrences
J Pediatr Surg 42: 1298-1301, 2007