1. How I Do It Laparoscopic 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 - CMH Jan 2000 – March 2002 130 Pts No Esophagus – Crural Sutures Extensive Esophageal Mobilization Mean age/weight 21 mo/10 kg Mean operative time93 minutes Transmigration wrap15 (12%) Postoperative dilation0 APSA 2006 Accepted, J Pediatr Surg

6. Current Thoughts 1.Less mobilization of esophagus 2.Keep peritoneal barrier b/w esophagus & crura

7. Current Thoughts 3.Secure esophagus to crura at 8, 11, 1 and 4 o’clock

8. Personal Series - CMH April 2002 – December 2004 119 Pts Esophagus – Crural Sutures Minimal Esophageal Mobilization Mean age/weight 27 mo/11 kg Mean operative time102 minutes Transmigration wrap6 (5%) Postoperative dilation1 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 Group I Jan 00-March 02 117 Pts Group II April 02-Dec 04 102 Pts P Value Mean Age (mos)10.2610.950.650 Mean Wt (kg)7.03 7.170.801 Gastrostomy47%46%0.893 Neuro Impaired71%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

11. Patients Less Than 24 Months Group I Jan 00-March 02 104 Pts Group II April 02-Dec 04 93 Pts P Value Mean Age (mos)6.998.150.175 Mean Wt (kg)6.326.460.759 Gastrostomy46% 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

12. Group II 119 Patients Esophago-Crural Sutures # PatientsTransmigration% 2 silk sutures20525% (9, 3 o’clock) 3 silk sutures4312.3% (9, 12, 3 o’clock) 4 silk sutures5600% (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 Fundoplication Operative Technique 21/273 Pts No mesh (13) 4 recurrences Surgisis (8) 0 recurrences J Pediatr Surg 42: 1298-1301, 2007