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Laparoscopic Nissen Fundoplication and Gastrostomy – How I Do It

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.

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Laparoscopic Nissen Fundoplication and Gastrostomy – How I Do It

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  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 37:1664-1666, 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 lineat 10 o’clock

  15. Study DesignRetrospectiveOne Surgeon (GWH)

  16. Study DesignRetrospectiveOne Surgeon (GWH)

  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 - 38 months • Minimum - 14 months • Mean time from initial operation to recurrence was 456 days (range 151-1155 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 FundoplicationCurrent 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 APSA, 2010 J PediatrSurg 43:163-169, 2011

  22. Minimal vs Extensive Esophageal Mobilization During Laparoscopic Fundoplication Results 177 Patients APSA, 2010 J PediatrSurg 43:163-169, 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

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