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 Please use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication Create retroesophageal window from patient’s left side Please use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication Ligation/division anomalous left hepatic a.? Minimal esophageal mobilization Please use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication Close crura posterior to esophagus Please use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication Placement of esophago-crural sutures

Laparoscopic Fundoplication Insertion of bougie after placement esophago-crural sutures Please use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication Intraoperative Bougie Sizes PAPS 2002 JPS 37:1664-1666, 2002

Laparoscopic Fundoplication Creation of fundoplication over bougie Please use this link if you experience problems viewing the video above.

Laparoscopic Fundoplication Measuring fundoplication Please use this link if you experience problems viewing the video above.

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 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 Please use this link if you experience problems viewing the video above.

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 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, 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) P-Value 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 Please use this link if you experience problems viewing the video above.

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 Please use this link if you experience problems viewing the video above.

QUESTIONS www.cmhclinicaltrials.com www.cmhmis.com 29 Finally, until a more efficacious, more cost effective and more efficient (with regard to health care providers and families) antibiotic regimen is identified, this study supports the use of single day dosing of ceftriaxone/metronidazole as the initial treatment regimen in children with perforated appendicitis. www.cmhclinicaltrials.com www.cmhmis.com 29