1. 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

2. Patient Positioning Patient placed at foot of operating table
Foot of table removed or lowered
Monitor above head of bed

3. Personnel Position Surgeon at foot of bed Assistant to the right
Scrub nurse to the left

4. 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)

5. Laparoscopic Fundoplication
Ligation/division short gastric vessels
Please use this link if you experience problems viewing the video above.

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

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

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

9. Laparoscopic Fundoplication
Placement of esophago-crural sutures

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

11. Laparoscopic Fundoplication Intraoperative Bougie Sizes
PAPS 2002
JPS 37: , 2002

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

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

14. Laparoscopic Fundoplication
Fundoplication suture line at 10 o’clock

15. Study Design Retrospective One Surgeon (GWH)
Jan 2000 – March 2002
Group I
130 patients
Extensive esophageal mobilization
No esophago-crural sutures

16. Study Design Retrospective One Surgeon (GWH)
April 2002 – Dec. 2004
Group II
119 patients
Minimal esophageal mobilization
Esophago-crural sutures placed

17. 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 months
Minimum - 14 months
Mean time from initial operation to recurrence was 456 days (range days)

18. Results
The relative risk of transmigration of the wrap is 2.29 times greater for Group I than for Group II

19. Laparoscopic Fundoplication Current Technique - 2010
Please use this link if you experience problems viewing the video above.

20. 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

21. 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)
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: , 2011

22. 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: , 2011

23. Current Study Analysis (80% power, α- 0.05) – 110 patients
Minimal esophageal dissection in all patients
4 esophago-crural sutures vs. no sutures

24. No Esophago-crural Sutures
Please use this link if you experience problems viewing the video above.

25. 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

26. Know Location of LGA

27. 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

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

29. 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. 29