Watson fundoplication in children: a comparative study with Nissen fundoplication

Background

Nissen fundoplication is the gold standard antireflux procedure in children. In 1996, one pediatric surgeon adopted the anterior fundoplication described by Watson in 1991. This procedure is reported to achieve good reflux control while permitting burping, active vomiting, and reducing gas bloat. An audit project was undertaken to compare the clinical outcome of children undergoing Nissen and Watson fundoplication.

Methods

The case notes of 144 children undergoing open fundoplication between February 1995 and February 2002 were reviewed retrospectively.

Results

Results of 72 boys and 59 girls comprising 76 Nissen and 55 Watson fundoplications were assessed. In each group, one death occurred within 1 month of operation. Chest infections occurred in 6.6% (Nissen) and 1.8% (Watson), and wound infections in 2.6% and 1.8%, respectively. Dysphagia was recorded in 7.9% of Nissen and 1.8% of Watson fundoplications. Follow-up data were analyzed in 70 children with Nissen and 48 children with Watson fundoplication. When overall clinical outcome was assessed for those patients with a minimum follow-up of 1 year, 85.1% Nissen and 88.2% Watson were judged good/excellent; 14.9% Nissen and 11.8% Watson were judged poor/bad.

Conclusion

Watson fundoplication can safely be performed in children with comparable clinical outcome to Nissen fundoplication.     

The first decade's experience with laparoscopic Nissen fundoplication in infants and children

Background/Purpose

Fundoplication for gastroesophageal reflux disease is a common procedure performed in infants and children. This report describes over a 10-year experience with more than 1000 consecutive laparoscopic Nissen fundoplications.

Methods

Ages ranged from 5 days to 18 years and weight from 1.2 to 120 kg. The procedures were performed using a 5 trocar technique and with 5- or 3-mm instruments depending on the size of the patient. Of 1050 fundoplications, 1048 were completed successfully through laparoscopy.

Results

Average operative time dropped dramatically from 109 minutes for the first 30 cases compared with 38 minutes for the last 30. Intraoperative and postoperative complications were 0.26% and 4.0%, respectively. Average time to discharge post fundoplication was 1.1 days. The wrap failure rate is 4.0%.

Conclusions

This study shows in a large operative experience for 10 years that laparoscopic fundoplication is safe and effective in the pediatric population. Clinical results are comparable to the traditional open fundoplication but with a significant decrease in morbidity and hospitalization.     

The respiratory advantage of laparoscopic Nissen fundoplication

Background/purpose

Laparoscopic Nissen fundoplication is replacing the open approach in the treatment of children with gastroesophageal reflux. The postoperative respiratory advantages seem obvious but remain unproven. The authors hypothesized that laparoscopic Nissen fundoplication provides postoperative respiratory advantages in neurologically normal children as well as those with mental retardation or profound neurologic impairment.

Methods

The charts of all laparoscopic Nissen fundoplications over a 4-year period were reviewed. Sixty-one laparoscopic procedures were compared with the most recent 61 consecutive open Nissen fundoplications. The following variables were reviewed: age, weight, gender, preexisting comorbidities, operating time, postoperative pulmonary complications, and length of stay. Categorical data were compared for significance utilizing χ² cross tabulation. Variables representing numerical data were compared by t test.

Results

Although there appeared to be a trend toward sicker patients in the open group, the laparoscopic group showed significantly improved rates of extubation, shorter recovery room stays, shorter durations of chest physiotherapy, fewer intensive care unit admissions, more rapid resumption of baseline feedings, and overall decreased length of stay (P < 0.05). Pulmonary benefits also were noted in the neurologically impaired population when analyzed separately.

Conclusions

Laparoscopic Nissen fundoplication confers a definable benefit with a significant pulmonary advantage in both neurologically normal children and those with neurologic impairment.     

A comparison of laparoscopic and open Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit population

Introduction

The aim of this study was to compare outcomes after laparoscopic and open techniques for Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit (NICU) population.

Methods

The medical records for NICU inpatients who underwent laparoscopic and open Nissen fundoplication and gastrostomy placement from August 2002 to August 2008 were reviewed after Institutional Review Board approval. Each technique was compared with regard to operative time, estimated blood loss, postoperative 24-hour narcotic requirements, time to goal feeds, and complication rates. Analysis of variance was used to determine statistical significance. Data are quoted as mean ± SEM.

Results

Fifty-seven NICU patients underwent fundoplication and gastrostomy placement (25 laparoscopic and 32 open). The time to goal feeds was significantly shorter for the laparoscopic group (4.3 ± 0.4 vs 6.1 ± 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 ± 0.05 vs 0.55 ± 0.08 mg/kg, P = .007). Operation times (111 ± 5 [open] vs 113 ± 5 minutes, P = .76) and estimated blood loss (13 ± 2 [open] vs 11 ± 1 mL, P = .33) were comparable for both groups.

Conclusion

Laparoscopic and open techniques for Nissen fundoplication with gastrostomy placement are safe and appropriate treatment methods with equivalent operating times for the treatment of gastroesophageal reflux in the NICU population.     

Use of esophagocrural sutures and minimal esophageal dissection reduces the incidence of postoperative transmigration of laparoscopic Nissen fundoplication wrap

Objectives

Herniation of the fundoplication wrap through the esophageal hiatus is a common reason for surgical failure in children who have undergone laparoscopic Nissen fundoplication. Extensive mobilization of the gastroesophageal junction in combination with decreased adhesions after laparoscopy may contribute to the development of this complication. In an attempt to decrease the incidence of wrap migration, we changed our technique to minimal mobilization of the intraabdominal esophagus and to placement of esophageal-crural sutures. In this study, we investigate the impact of these modifications on outcome.

Methods

A retrospective analysis was performed on all patients undergoing laparoscopic fundoplication by the senior author (GWH) from January 2000 through December 2004. Those undergoing operation with extensive esophageal mobilization and without esophagocrural sutures (January 2000 to March 2002) (group I) were compared with those in whom there was minimal esophageal dissection with placement of these esophagocrural sutures (April 2002 to December 2004) (group II).

Results

Two hundred forty-nine patients underwent laparoscopic Nissen fundoplication during the study period. One hundred thirty patients were in group I, and 119 patients were in group II. The rate of transmigration decreased from 12% in group I to 5% in group II (P = .072). The relative risk of transmigration with extensive esophageal mobilization and without the esophagocrural sutures was 2.29.

Conclusions

This retrospective study has shown that placement of esophagocrural sutures and minimization of the dissection around the esophagus results in a more than 2-fold reduction in the risk of wrap transmigration after laparoscopic Nissen fundoplication.     

Laparoscopic Nissen fundoplication without division of short gastric vessels in children

Purpose

It has been suggested that routine division of short gastric vessels (SGVs) results in a more “floppy” Nissen fundoplication leading to improved outcomes, that is, less dysphagia and lower incidences of recurrent gastroesophageal reflux disease (GERD). The aim of this retrospective study was to assess whether laparoscopic Nissen fundoplication without division of SGVs (Rossetti modification) (laparoscopic Nissen-Rossetti fundoplication [LNRF]) is associated with acceptable clinical outcome in children.

Method

The charts of 368 children who underwent LNRF between January 1996 and September 2004 by 1 primary surgeon were retrospectively reviewed. Children were divided into 2 groups: LNRF + gastrostomy (A) and LNRF alone (B). Mean follow-up period of all groups was 4.2 years.

Results

Laparoscopic Nissen-Rossetti fundoplication was completed in 99% (365/368). Mean operating time for group A was 74 minutes and 61 minutes for group B. None in group A required postoperative esophageal dilatation, and 9 in group B (22.5%) required 12 dilatations; 3.6% developed recurrent GERD, 3.7% in group A and 2.5% in group B.

Conclusion

Laparoscopic Nissen-Rossetti fundoplication can be performed with acceptable long-term outcome in children, especially in the majority also requiring chronic gastrostomy access. Short-term, reversible dysphagia may be seen in a small percentage of children having fundoplication alone.     

Outcomes after laparoscopic surgery in neonates with hypoplastic heart left heart syndrome

Background/Purpose

Laparoscopy has advanced the care of children for a variety of pediatric surgical diseases. However, complication rates for laparoscopic interventions in neonates with hypoplastic left heart syndrome (HLHS) have not been well described. The purpose of this study is to present the largest reported series of laparoscopic surgery performed in patients with HLHS.

Methods

We conducted a single-institution, retrospective chart review for all neonates with HLHS who underwent a laparoscopic procedure from September 2002 to March 2005. Data regarding patient characteristics, intraoperative monitoring, previous cardiac surgery, perioperative complications, and postoperative mortality were assessed.

Results

Twelve patients with HLHS underwent a total of 13 operations during the study period (8 combined Nissen fundoplication and gastrostomy tubes, 3 isolated gastrostomy tubes, 1 Ladd procedure, and 1 combined Nissen fundoplication and gastrocutaneous fistula closure). All cases were completed laparoscopically. Patients had undergone palliative cardiac surgery but were not completely corrected; therefore, they were cyanotic. Perioperative complications were observed in 6 patients (3 gastrostomy tube site infections, 1 small bowel obstruction, 1 postoperative sepsis, and 1 urinary tract infection). There was no mortality in this series.

Conclusions

From this experience, it appears that laparoscopy can be performed safely and with satisfactory outcomes in patients with HLHS. However, a multidisciplinary approach, including the availability of a skilled and experienced cardiac anesthesia team, is believed to be critical to optimize outcomes in these critically ill children.     

The use of biosynthetic mesh to enhance hiatal repair at the time of redo Nissen fundoplication

Objective

There are a number of reports in the literature describing the need for a redo fundoplication in patients who have previously undergone open fundoplication. However, these data are not well characterized in our current era of laparoscopic surgery. The purpose of this report is to document the management of patients requiring a redo fundoplication who originally underwent a laparoscopic Nissen fundoplication.

Methods

After internal review board approval, the senior surgeon performed a retrospective chart review on all patients undergoing laparoscopic fundoplication between January 2000 and April 2006. Data collected included the patient's age, sex, neurologic impairment, need for gastrostomy, time interval between the initial and redo fundoplication, operative approach for the redo fundoplication, use of a biologic patch for the redo procedure, and length of follow-up.

Results

Two hundred seventy-three patients underwent laparoscopic Nissen fundoplication by the senior author during this time interval. Twenty-one patients have required a redo fundoplication and repair of the enlarged hiatus after laparoscopic fundoplication. No patient has undergone a redo procedure without the development of transmigration of the fundoplication wrap. A redo operation was performed without mesh in 13 patients, of which there were 4 recurrences (31%). The other 8 cases were repaired with Surgisis (Cook, Inc, Bloomington, Ind), and none of these have recurred, with a minimum of 11 months' follow-up and a mean follow-up of 26 months. In the 4 patients requiring a second redo procedure, the enlarged esophageal hiatus was reinforced with Surgisis, and none of these cases have recurred, with a minimum of 3 years' follow-up.

Conclusions

Our data support the use of a biosynthetic mesh to reinforce the crural closure during the repair of iatrogenic hiatal hernias in children.     

Complications of laparoscopic surgery in neonates and small infants

Purpose

The difficulty of performing laparoscopic surgery in small infants remains a common complaint of pediatric surgeons. The aim of this study was to evaluate the complications of laparoscopic surgery in small infants weighing less than 5 kg.

Methods

Since 1997, 154 infants weighing less than 5 kg underwent laparoscopic surgery (group S). During that same period, 96 infants weighing less than 10 kg (group M) and 335 children weighing more than 10 kg (group L) also underwent laparoscopic surgery. Intra- and postoperative complications were evaluated and compared between the 3 groups, especially in the 60 cases that underwent Nissen fundoplication. P < .05 was considered a significant difference.

Results

Complications such as gastrointestinal perforation and wound infection were observed in 15 (9.7%), 15 (15.6%), and 32 (9.6%) infants of groups S, M, and L, respectively. There were no significant differences in complication rates among the 3 groups. However, in Nissen fundoplication, 5 of 15 patients in group S had complications, thereby significantly increasing the complication rate as compared with group L (1 of 23, P = .04). Major complications in group S were gastrointestinal perforation and vagal nerve injury.

Conclusions

Laparoscopic surgery is feasible even in small infants. However, in Nissen fundoplication, special attention is necessary to avoid severe intraoperative complications.     

Population-based comparison of open vs laparoscopic esophagogastric fundoplication in children: application of the Agency for Healthcare Research and Quality pediatric quality indicators

Background/Purpose

Increasing national focus on patient safety has promoted development of the pediatric quality indicators (PDIs), which screen for preventable events during provision of health care for children. Our objective is to apply these safety metrics to compare 2 surgical procedures in children, specifically laparoscopic and open esophagogastric fundoplication for gastroesophageal reflux.

Methods

A retrospective analysis using 20 years of data from national representative state inpatient databases through the Healthcare Cost and Utilization Project was conducted. Patients younger than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for open or laparoscopic esophagogastric fundoplication were included. Pediatric quality indicators were linked to each patient's profile. Demographics, comorbidities, outcomes, and 8 selected PDIs between open and laparoscopic fundoplications were compared using Pearson χ² tests and t tests.

Results

Of 33,533 patients identified, 28,141 underwent open and 5392 underwent laparoscopic fundoplication. Comorbidities occurred more frequently in open surgery. In-hospital mortality, length of stay, and hospital charges were less in laparoscopic surgery. Of the 8 PDIs evaluated, decubitus ulcer (P = .04) and postoperative sepsis (P = .003) had decreased rates with laparoscopic surgery compared with open.

Conclusion

Laparoscopic fundoplication for gastroesophageal reflux in children can be performed safely compared with the open approach with equivalent or improved rates of PDIs.     

Splenic torsion requiring splenectomy six years following laparoscopic Nissen fundoplication

Background:

Laparoscopic Nissen fundoplication has become a mainstay in the surgical treatment of gastroesophageal reflux disease, as it has proved to be a durable, well-tolerated procedure. Despite the safety and efficacy associated with this procedure, surgeons performing this advanced laparoscopic surgery should be well versed in the potential intraoperative and postoperative complications.

Methods:

A case is presented of a rare complication of splenic torsion following laparoscopic Nissen fundoplication. Diagnostic evaluations and intraoperative findings are discussed.

Results:

We present an otherwise healthy 41-year-old woman who underwent a laparoscopic Nissen fundoplication 6 years earlier at another medical center and presented with worsening chronic left upper quadrant abdominal pain. She was diagnosed with torsion of the splenic vascular pedicle, resulting in heterogenicity of perfusion with associated hematoma requiring open splenectomy.

Conclusion:

Surgeons should be aware of splenic torsion as a potential, albeit rare, complication related to laparoscopic Nissen fundoplication.     

Effectiveness of alimemazine in controlling retching after Nissen fundoplication

Background

Retching, an early component of the emetic reflex, is a common and distressing symptom in children after Nissen fundoplication. Alimemazine (trimeprazine, Vallergan; Castlemead, Herts, UK) is a phenothiazine derivative histamine₁ antagonist, which anecdotally relieves the retching symptoms.

Material and Methods

A prospective, double-blind, randomized, crossover, placebo-controlled study of 15 neurologically impaired children with retching after Nissen fundoplication over a period of 1 year (December 2002-December 2003). Patients were randomly allocated to receive 1 week each of alimemazine and placebo with crossover. A diary was maintained of retching episodes 1 week before, during, and 1 week after the trial. Dosage of alimemazine used was 0.25 mg/kg 3 times a day (maximum, 2.5 mg per dose). Statistical analysis was done using a paired Student's t test, where P value of less than .05 was considered significant. Results are presented as mean ± SD.

Results

Twelve parents completed the diaries (9 open, 3 laparoscopic Nissen fundoplication). Median age of the child was 36 months (8-180 months), median duration of retching was 4.5 months (1-52 months), and mean number of retching episodes per week was 60 ± 29.40. Mean number of retching episodes with alimemazine was 10.42 ± 9.48 vs 47.67 ± 27.79 with a placebo (P < .0001). No adverse effects were reported in those cases that completed the study.

Conclusion

At low dose, alimemazine (Vallergan) is a safe and effective drug in the management of retching after Nissen fundoplication.     

Impact of surgery on immunologic function: comparison between minimally invasive techniques and conventional laparotomy for surgical resection of colorectal tumors

Background

Surgical trauma suppresses host immune function, potentially creating an environment vulnerable to tumor cell growth. This study compared immune function after laparoscopy, minilaparotomy, and conventional colorectal tumor resections.

Methods

Seventy-one patients underwent surgery (20 laparoscopy, 21 minilaparotomy, and 30 conventional). Blood samples were taken before surgery and at 3 hours, 24 hours, and 5 days after surgery. White blood cell constitution was determined using monoclonal antibodies. Levels of TH1 cytokines interferon-γ, tumor necrosis factor-α, and interleukin (IL)-2 and TH2 cytokines IL-10, -4, and -6 were measured in plasma and from supernatants of activated peripheral blood mononuclear cells.

Results

At 5 days after surgery, lymphocyte counts remained low in the conventional and minilaparotomy groups (P = .001 and P = .008) but had resolved in laparoscopic patients. Three-hour postoperative serum IL-6 concentrations were lower in laparoscopic than in conventional patients (P = .028). Production of TH1 cytokines 3 hours after surgery were significantly increased in laparoscopic patients (interferon-γ P = .018, tumor necrosis factor-α P = .011, and IL-2 P = .037).

Conclusions

TH1 lymphocyte function is improved transiently and immune homeostasis restored earlier in patients undergoing laparoscopic colorectal cancer resection, which may influence disease recurrence.     

Pledgeted mattress sutures reduce recurrent reflux after laparoscopic Nissen fundoplication

Introduction

In response to a perceived increase in the incidence of recurrent reflux after adopting the laparoscopic Nissen fundoplication, we adjusted our technique to include the use of pledgeted, horizontal mattress sutures for crural closure and wrap construction.

Methods

We assessed the impact of this technical modification in children who underwent laparoscopic fundoplication between 1997 and 2007 at a large children's hospital. The medical history, indications, technical details, and outcomes were reviewed. Differences between groups were assessed with χ², logistic regression, and Kaplan-Meier analysis.

Results

A total of 384 subjects were identified. Neurologic deficits were present in 77%. The crural closure and wrap were constructed with simple sutures in 226 and with pledgeted, horizontal mattress sutures in 158. The cumulative incidences of recurrent reflux, gagging/retching, wrap failure on imaging studies, and reoperation were significantly greater with the use of simple sutures (P < .01, .03, < .01, and < .01, respectively). Kaplan-Meier analysis confirmed a significant difference in the probability of recurrent reflux with simple sutures despite a significant difference in postoperative follow-up. Operative time was the same with both methods.

Conclusions

The use of pledgeted, horizontal mattress sutures for crural closure and wrap construction in laparoscopic Nissen fundoplication may reduce the incidence of recurrent reflux.     

Early laparoscopic fundoplication and gastrostomy in infants with spinal muscular atrophy type I

Background/Purpose

Spinal muscular atrophy (SMA) in children leads to progressive muscle weakness, dysphagia, aspiration, and death. We hypothesized that early laparoscopic fundoplication and gastrostomy in infants with SMA type I could be performed safely perhaps leading to fewer aspiration events and improved nutritional status.

Methods

Children diagnosed with SMA type I from 2002 through 2005 were included (n = 12). All children underwent laparoscopic Nissen fundoplication with gastrostomy shortly after diagnosis. Postoperative respiratory management and discharge criteria were standardized.

Results

All patients were extubated immediately postoperatively. There were no significant complications. Average time to full feeding and inpatient length of stay were 42 ± 4.9 hours (range, 30-48 hours) and 78 ± 22.5 hours (range, 44-120 hours), respectively. Mean weight-for-length percentile was doubled at 1 year postoperatively (P = .03). The number of respiratory-related hospitalizations in the cohort decreased by almost 50% in the ensuing 12 months after surgery, although this did not reach statistical significance in this small cohort (P = .34).

Conclusions

Early laparoscopic fundoplication and gastrostomy is safe and is associated with improved nutritional status. A trend toward fewer significant long-term aspiration-related events was seen after fundoplication. To better assess the long-term benefits of performing an antireflux procedure in these high-risk patients, a larger prospective trial comparing current nutritional support practices is needed.     

Reliability of a procedural checklist as a high-stakes measurement of advanced technical skill

Background

The purpose of this study was to determine the reliability of a previously validated laparoscopic Nissen fundoplication procedural checklist as a measurement of advanced technical skill.

Methods

Five surgeons, using a 65-step procedural checklist, independently evaluated 2 video recordings of expert surgeon operative performances of a laparoscopic Nissen fundoplication. Results were analyzed for percent agreement and Fleiss kappa correlation for each operation independently and combined as a whole.

Results

Sixty-four of the 65 steps had 80% or higher percent agreement for both operative case A and B independently and when considered overall. The Fleiss kappa coefficients for operative case A (kappa = .95) and operative case B (kappa = .96) and overall (operative case A + B) (kappa = .95).

Conclusion

The percentage agreement and kappa coefficients for all 3 analyses indicate a high degree of reliability (>.80) that would support the use of this instrument for high-stakes assessment of a laparoscopic Nissen fundoplication.     

A reinforced suture line prevents recurrence after fundoplication in patients with familial dysautonomia

Background/Purpose

Long-term follow-up of fundoplication in patients with familial dysautonomia (FD) has revealed a high rate of recurrent gastroesophageal reflux. This may be because of the unique characteristics of patients with FD which include autonomic denervation accompanied by cyclic vomiting and retching. We reviewed our results with adaptations to the Nissen fundoplication to determine which would be most effective in preventing the need for reoperation.

Methods

We reviewed the records of 108 patient with FD who underwent fundoplication by a single pediatric surgeon from November 1978 to July 1, 2004. Patients were divided into 4 groups based on the operative technique: standard Nissen fundoplication, Nissen with a posterior gastropexy, Nissen with posterior gastropexy and a superior anchoring suture, and Nissen with a reinforced suture line in addition to the previous modifications. Demographic data and surgical outcomes were abstracted.

Results

Patients who underwent a Nissen fundoplication with a reinforced suture line were significantly less likely to require a reoperation for recurrent reflux than any other patients (P = .05, Fisher's Exact test) despite the fact that they were younger than patients who underwent a standard Nissen alone.

Conclusion

The addition of a reinforced suture line to the standard Nissen fundoplication decreases the failure rate for patients with gastroesophageal reflux and FD. A reinforced suture line may be an attractive modification for patients where the fundoplication may be under continued physical stress caused by autonomic perturbations, or other conditions such as uncontrolled seizures or progressive neurologic decline.     

Implications of laparoscopy on surgery residency training

Background

With the advent of laparoscopy, many traditional junior-level cases now require advanced laparoscopic skill. We sought to ascertain the implications of laparoscopy on residency training through the use of a large national database.

Methods

American College of Surgeons National Surgical Quality Improvement Program data were gathered for patients undergoing elective open and laparoscopic inguinal herniorrhaphy, appendectomy, and partial colectomy during 2005 and 2006. Cases were stratified by resident level and compared using univariate analysis.

Results

A total of 14,729 cases were performed during the study period. For inguinal hernia repair, 72% of open repairs were performed by postgraduate year 3 residents or below versus 41% of laparoscopic repairs (P < .0001). Similarly, 61% of open appendectomies were performed by postgraduate year 3 residents or below compared with 48% of laparoscopic appendectomies (P < .0001). Forty-six percent of open colectomies were performed by postgraduate year 3 and postgraduate year 4 residents versus 33% of laparoscopic resections (P < .0001).

Conclusions

These data show an upward shift in cases traditionally performed by junior-level residents. The implications of this shift are unknown but may lead to decreased surgical experience during the early years of training.     

Surgical treatment of nonparasitic cysts of the liver: open versus laparoscopic treatment

Background

The aim of this study was to compare the immediately postoperative and follow-up results of open and laparoscopic surgery of hepatic cysts in a tertiary hepatobiliary referral center.

Materials and Methods

From March 1999 to February 2007, 59 patients underwent surgical treatment for nonparasitic liver cysts. Patients were assigned to the laparoscopic (n = 42) or open group (n = 17) for analysis.

Results

Three conversions to open procedures had to be performed in the laparoscopic group. One patient had to be reoperated because of a bile leakage in the laparoscopic group. Follow-up examination showed 2 recurrences in the laparoscopic and 3 in the open group. Three out of 17 patients in the open group had to be operated for incisional hernias. Time to previous activities was significantly shorter after laparoscopy.

Conclusions

Laparoscopic treatment of symptomatic nonparasitic liver cysts is superior concerning short- and long-term results in a vast majority of cases.     

Robotic fundoplication in children: resident teaching and a single institutional review of our first 50 patients

Background

Robotic surgery is a new technology that may eventually replace laparoscopy in treating many surgical issues in children. Resident education using robotic surgery has been a concern for many institutions. We present our first 50 consecutive robotic fundoplications in children and our teaching experience with this procedure.

Method

A 3-arm surgical robot was used to create a Nissen fundoplication with 1 additional port for liver retraction. Although there were exceptions, a 12-mm 3-dimensional camera was used in most patients greater than 10 kg, and a 5-mm 2-dimensional camera if less than 10 kg. Robotic instruments were either 8 or 5 mm. An accessory port was used for liver retraction. The console surgeon was either an attending surgeon or a fourth-year general surgery resident. The general surgery residents had limited prior minimally invasive experience consisting of cholecystectomies, appendectomies, and a few other procedures.

Results

Average age was 5.1 years (range, 1 month to 16 years). Average weight was 19.5 kg (range, 2.7-96.4 kg). No open conversions or intraoperative complications occurred. Postoperative complications included ileus (4%), dysphagia (4%), a G-tube site wound infection (2%), gas bloat syndrome (2%), and 1 wrap breakdown 3 years after the initial procedure (2%). Operative times for staff surgeons were down to 90 minutes after 5 fundoplications.

Conclusion

Robotic fundoplication is an acceptable method to perform minimally invasive antireflux surgery in children. Resident education and teaching can be readily accomplished using the robot and the learning curve is relatively short and steep.