laparoscopic nissen fundoplication and gastrostomy – how i do it george w. holcomb, iii, m.d., mba...
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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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