How I Do It

Laparoscopic Fundoplication

George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital

Kansas City, MO

Laparoscopic Fundoplication

The Use of Stab IncisionsProcedure (n) Used/case Saved/case Nissen (209) 1 4

Nissen (14) 2 3

Heller Myotomy (7) 2 3

Appendectomy (102) 2 1

Meckel’s Diverticulum (2) 2 1

Pyloromyotomy (77) 1 2

Cholecystectomy (31) 2 2

Pullthrough (20) 2 1

Splenectomy (21) 2 2

Adrenalectomy (6) 2 2

UDT (15) 1 2

Varicocele (5) 1 2

Ovarian (2) 1 2

Totals (511) 714 1337 PAPS 2003

JPS 38:1837-1840, 2003

Cost Savings from Stab IncisionsProcedure (n) Step Pt./Instit. Savings ($) Ethicon Pt./Instit. Savings ($) Nissen (209) 117,040 / 51,832 76,912 / 4,276 Nissen (14) 5,880 / 2,604 3,864 / 1,722 Heller (7) 2,940 / 1,302 1,932 / 861 Appy (102) 14,280 / 6,324 9,384 / 4,182 Meckel’s (2) 280/ 124 184 / 82 Pyloric (77) 21,560 / 9,548 14,168 / 6,314 Chole (31) 8,680 / 3,844 5,704 / 2,542 Pullthrough (20) 2,800 / 1,240 1,840 / 820 Spleens (21) 5,880 / 2,604 3,864 / 1,722 Adrenal (6) 1,680 / 744 1,104 / 492 UDT (15) 4,200 / 1,860 2,760 / 1,230 Varicocele (5) 1,400 / 620 920 / 410 Ovarian (2) 560 / 248 368 / 164 Total = 511 $187,180/$82,894 $123,004/$54,817

PAPS 2003JPS 38:1837-1840, 2003

Personal Series - CMHJan 2000 – March 2002

130 PtsNo 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

Current Thoughts

1. Less mobilization of esophagus

2. Keep peritoneal barrier b/w esophagus & crura

Current Thoughts

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

Personal Series - CMHApril 2002 – December 2004

119 PtsEsophagus – 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

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.

Patients Less Than 60 MonthsGroup I

Jan 00-March 02

117 Pts

Group II

April 02-Dec 04

102 Pts

P Value

Mean Age (mos) 10.26 10.95 0.650

Mean Wt (kg) 7.03 7.17 0.801

Gastrostomy 47% 46% 0.893

Neuro Impaired 71% 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

Patients Less Than 24 MonthsGroup I

Jan 00-March 02

104 Pts

Group IIApril 02-Dec 04

93 PtsP Value

Mean Age (mos) 6.99 8.15 0.175

Mean Wt (kg) 6.32 6.46 0.759

Gastrostomy 46% 46% 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

Group II119 Patients

Esophago-Crural Sutures

# Patients Transmigration %

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)

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

Intraoperative Bougie Sizes

PAPS 2002

JPS 37:1664-1666, 2002

Re-Do FundoplicationOperative Technique

21/273 Pts

• No mesh (13) 4 recurrences

• Surgisis (8) 0 recurrences

J Pediatr Surg 42: 1298-1301, 2007J Pediatr Surg 42: 1298-1301, 2007