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How I Do It Laparoscopic Fundoplication

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. PAPS 2003 JPS 38:1837-1840, 2003. Cost Savings from Stab Incisions. PAPS 2003 JPS 38:1837-1840, 2003.

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How I Do It Laparoscopic Fundoplication

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  1. How I Do ItLaparoscopic Fundoplication George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO

  2. Laparoscopic Fundoplication

  3. The Use of Stab Incisions PAPS 2003 JPS 38:1837-1840, 2003

  4. Cost Savings from Stab Incisions PAPS 2003 JPS 38:1837-1840, 2003

  5. Personal Series - CMHJan 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

  6. Current Thoughts • Less mobilization of esophagus • Keep peritoneal barrier b/w esophagus & crura

  7. Current Thoughts • Secure esophagus to crura at 8, 11, 1 and 4 o’clock

  8. Personal Series - CMHApril 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

  9. 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.

  10. Patients Less Than 60 Months The relative risk of transmigration of the wrap is 2.03 times greater for Group I than for Group II

  11. Patients Less Than 24 Months The relative risk of transmigration of the wrap is 1.94 times greater for Group I than for Group II

  12. Group II119 PatientsEsophago-Crural Sutures # PatientsTransmigration% 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)

  13. 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

  14. Intraoperative Bougie Sizes PAPS 2002 JPS 37:1664-1666, 2002

  15. Re-Do FundoplicationOperative Technique21/273 Pts • No mesh (13) 4 recurrences • Surgisis (8) 0 recurrences J Pediatr Surg 42: 1298-1301, 2007

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