Download - How I Do It Laparoscopic Fundoplication
How I Do It
Laparoscopic Fundoplication
George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital
Kansas City, MO
Laparoscopic Fundoplication
The Use of Stab IncisionsProcedure (n) Used/case Saved/case Nissen (209) 1 4 Nissen (14) 2 3 Heller Myotomy (7) 2 3 Appendectomy (102) 2 1 Meckel’s Diverticulum (2) 2 1 Pyloromyotomy (77) 1 2 Cholecystectomy (31) 2 2 Pullthrough (20) 2 1 Splenectomy (21) 2 2 Adrenalectomy (6) 2 2 UDT (15) 1 2 Varicocele (5) 1 2 Ovarian (2) 1 2 Totals (511) 714 1337 PAPS 2003
JPS 38:1837-1840, 2003
Cost Savings from Stab IncisionsProcedure (n) Step Pt./Instit. Savings ($) Ethicon Pt./Instit. Savings ($) Nissen (209) 117,040 / 51,832 76,912 / 4,276 Nissen (14) 5,880 / 2,604 3,864 / 1,722 Heller (7) 2,940 / 1,302 1,932 / 861 Appy (102) 14,280 / 6,324 9,384 / 4,182 Meckel’s (2) 280/ 124 184 / 82 Pyloric (77) 21,560 / 9,548 14,168 / 6,314 Chole (31) 8,680 / 3,844 5,704 / 2,542 Pullthrough (20) 2,800 / 1,240 1,840 / 820 Spleens (21) 5,880 / 2,604 3,864 / 1,722 Adrenal (6) 1,680 / 744 1,104 / 492 UDT (15) 4,200 / 1,860 2,760 / 1,230 Varicocele (5) 1,400 / 620 920 / 410 Ovarian (2) 560 / 248 368 / 164 Total = 511 $187,180/$82,894 $123,004/$54,817
PAPS 2003JPS 38:1837-1840, 2003
Personal Series - CMHJan 2000 – March 2002
130 PtsNo 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 - CMHApril 2002 – December 2004
119 PtsEsophagus – Crural Sutures
Minimal Esophageal Mobilization
Mean age/weight 27 mo/11 kgMean operative time 102 minutesTransmigration 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 MonthsGroup I
Jan 00-March 02
117 Pts
Group IIApril 02-Dec 04
102 Pts
P Value
Mean Age (mos) 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
Wrap Transmigration
14 (12%) 6 (6%) 0.159
The relative risk of transmigration of the wrap is 2.03 times greater for Group I than for Group II
Patients Less Than 24 MonthsGroup I
Jan 00-March 02
104 Pts
Group IIApril 02-Dec 04
93 PtsP 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
Wrap Transmigration 13 (12%) 6 (6%) .226
The relative risk of transmigration of the wrap is 1.94 times greater for Group I than for Group II
Group II119 Patients
Esophago-Crural Sutures# Patients Transmigration %
2 silk sutures 20 5 25%(9, 3 o’clock)
3 silk sutures 43 1 2.3%(9, 12, 3 o’clock)
4 silk sutures 56 0 0%(8, 11, 1, 4 o’clock)
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 2002JPS 37:1664-1666, 2002
Re-Do FundoplicationOperative Technique
21/273 Pts
• No mesh (13) 4 recurrences
• Surgisis (8) 0 recurrences
J Pediatr Surg 42: 1298-1301, 2007J Pediatr Surg 42: 1298-1301, 2007