Laparoscopic Revision of Fundoplication

Operative access for technical failures of fundo-plications was originally described using an open abdominal technique or a thoracic approach. In the past 10 years, there have been multiple retrospective reviews of personal expe-

REOPERATION FOR FAILED ANTI-REFLUX SURGERY

Laparoscopic Liver Surgery

Figure 11.5. Port placement for laparoscopic reoperative fundoplication surgery. LR, liver retractor; S, telescope; SLH, surgeon's left hand; SRH, surgeon's right hand; ARH, assistant's right hand. (Reproduced with permission from Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991;1(3):138-143.)

Figure 11.5. Port placement for laparoscopic reoperative fundoplication surgery. LR, liver retractor; S, telescope; SLH, surgeon's left hand; SRH, surgeon's right hand; ARH, assistant's right hand. (Reproduced with permission from Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991;1(3):138-143.)

riences with laparoscopic reoperative fundopli-cation. The overall conclusion to date is that laparoscopic reoperation is safe and effective if performed by an experienced laparoscopic surgeon. In addition, most reports indicate that laparoscopic reoperative fundoplication is associated with fewer complications, shorter length of stay, and better patient satisfaction.

Laparoscopic refundoplication is performed with a five-trocar technique similar to the initial fundoplication procedure (Figure 11.5). Initial access to the abdomen is obtained either with an open technique with insertion of a Hasson trocar or placement of a Veress needle away from the original operative site,e.g.,the left subcostal region. Adhesiolysis is then performed as necessary to insert the subsequent ports. Initially, it may be necessary to place ports in non-traditional locations to aid in lysis of adhesions. The operating ports are then inserted once the abdominal wall is cleared of adhesions.

The type of device used for hemostasis is surgeon dependent. Ultrasonic shears can minimize heat conduction to surrounding tissue and reduce the risk of inadvertent enterotomies.

If cautery is used, one must clearly visualize adhesions and ensure that no conduction to surrounding tissue occurs. Some surgeons prefer sharp dissection with use of cautery only when hemorrhage occurs. Regardless of the hemosta-tic technique chosen, meticulous adhesiolysis is imperative to prevent gastrotomy or esophago-tomy. If created, these are repaired primarily and the operation can continue laparoscopically if deemed safe. If possible, the repair is included in the new wrap to protect it.

Once operative trocars are placed, adhesions from the left lobe of the liver to the fundoplica-tion are taken down. The liver retractor may need to be adjusted periodically to aid in the dissection. Once the liver is retracted,both crura are identified. To enable the identification and dissection of the esophagus, an endoscope or lighted bougie can be placed at the GE junction. After the crura are identified, the wrap is encircled with a Penrose drain to aid in retraction. Both vagal nerves are identified and spared if possible. The wrap is taken down either by removing the previous fundic sutures, or by stapling the fundo-fundic connection with the EndoGIA stapler. The anterior vagus is usually identified in the wrap. If the posterior vagus was included in the wrap previously, it is much easier to identify and spare. The short gastric vessels are divided with the ultrasonic shears if this was not previously performed. If the short gastric vessels were previously divided, the fundic adhesions to the spleen are carefully lysed.

A crural closure is performed in all patients (Figure 11.6). This is done with nonabsorbable suture and may be buttressed with pledgets or mesh. The data of Granderath et al.19-21 on the routine use of polypropylene mesh in crural closure for both primary and recurrent fundo-plication reveal that recurrent herniation is significantly lower in the mesh group (Figure 11.7). They reported 24 patients who underwent revisional fundoplication.19 All patients had hiatal disruption and all had been previously closed primarily. There were no intraoperative complications and only one patient had severe postoperative dysphagia that responded to dilation. A barium swallow test was performed at 1 year in 19 of the 24 patients, which revealed no hiatal recurrence. The remaining 5 patients were asymptomatic. They support the use of mesh in all patients undergoing fundoplication. This is

MANAGING FAILED ANTI-REFLUX THERAPY

Fundoplication With Mesh Wrap
Figure 11.6. Closure of the hiatus with crural sutures. Phillips EH, Rosenthal RJ. Operative Strategies in Laparoscopic Surgery. Springer-Verlag 1995,119.

also supported by Frantzides and Carlson22 in a prospective, randomized trial of 72 patients who had either suture cruroplasty or polytetrafluoroethylene mesh repair. This study determined that the frequency of recurrent hiatal hernia was significantly higher in the primary repair group (22%) versus the mesh group (0%). Carlson et al.23 had similar results in 31 patients who were randomized to simple suture closure versus mesh closure. Whereas some authors report mesh erosion into the esophagus, Granderath et al.19 state that mesh erosion is a very rare complication.

Failed Fundoplication
Figure 11.7. Mesh closure of the hiatus. (Reproduced with permission from Granderath et al.,18 Copyright ©2003, American Medical Association. All rights reserved.)

Once the crura are reapproximated posteriorly, the endoscope is removed and a 56- to 60-French bougie dilator is placed. A Nissen fundoplication or Toupet fundoplication is then performed based on the preoperative manome-try as previously described. Some authors secure the Nissen fundoplication to the crura with collar sutures. There are no studies currently that evaluate recurrence based on securing the wrap to the crura. In contrast to the Nissen, the Toupet fundoplication is routinely secured to both crura. Finally, upper endoscopy is performed to evaluate the new wrap for leak. The liver retractor and all ports are removed under direct vision and the ports >5 mm are closed at the fascial level.

Most authors agree that laparoscopy is a safe and effective tool in reoperative surgery when performed by an experienced laparoscopist. Hunter et al.2,15 begin laparoscopically in all patients who underwent previous laparoscopic fundoplication and usually approach patients who have undergone previous open surgery either with a laparotomy or thoracotomy. Other authors attempt laparoscopy in all patients, but have a low threshold to convert to open laparo-tomy if adhesions preclude laparoscopic completion.15,6,24,25 Overall conversion rates vary from 9 to 60%. In the studies presented, recurrent symptoms were evaluated preoperatively as previously described. Among the technical causes of failure that were identified for the initial operation, crural failure with hiatal her-niation of the wrap was the number one cause of recurrent symptoms,1,15,24-26 followed by wrap failure, slipped Nissen, and a wrap that was too tight.27-29

When choosing the appropriate reoperation, one must consider the preoperative workup, which should clearly document the cause of the failure. Most authors agree that a tailored approach to each patient based on the cause of the recurrent symptoms is essential, rather than attempting the same operation in everyone.25 As is summarized in Table 11.1, most studies are small retrospective reviews of single surgeons' personal experience. However, in combining these data, of 505 total patients, 385 were completed laparoscopically for an overall conversion rate of 23.8%. The majority underwent Nissen fundoplication (56%), followed by Toupet partial fundoplication (17%), then miscellaneous operative procedures including

REOPERATION FOR FAILED ANTI-REFLUX SURGERY

Table 11.1. Results of laparoscopic reoperation after failed fundoplication.

Authors

Patients

Operative

Conversion

Morbidity

Length of

Follow-up

Success

(n)

Time (min)

Rate (%)

(%)

Stay (days)

(months)

Rate (%)

Awad et al.1

37

240

13.5

4

26.5

65

Curet et al.6

27

250

3.7

65.3

3.7

22

96

DePaula et al.30

19

210

5.2

15.8 intraop

3.1

13

84.3

15.8 postop

Dutta31

28

55.4

7.1

0

3

25.1

96.2

Floch et al.32

46

210

19.6

40.5

2.3

17.2

89

Granderath et al.33

51

L-80

0

11

12

96

O-245

Heniford et al.25

45

L 234

17.8

12.7

4.6

21.3

92.5

O 261

Horgan et al.34

31

307

9.7

32.3

4.1

25

87

Hunter et al.15

75

199

13.3

5

2.6

87

Kamolz et al.35

11

L 80

9.0

11

26

91

O 200

Khaitan et al.36

16

56.3

5.3

32.6

75

O'Reilly et al.37

8

25

50

2.2

12-42

100

Pointner et al.38

30

L 135

6.7

25

8

29

93

O 315

Serafini et al.39

28

L-184

10.7

16.2 intraop

5

20

89

O-216

37.8 postop

Soper and Dunnegan26

8

25.0

Szwerc et al.40

15

135

0

2.3

3

87

Watson and Krukowski41

11

141

9.0

20

3

29

91

Watson et al.42

27

L-80

22.2

0

3

12

92.5

O-105

Yau43

28

73.4

32.1

4

24

L = previous laparoscopic operation. O = previous open operation.

L = previous laparoscopic operation. O = previous open operation.

Collis gastroplasty and anterior fundoplication (12%) with 15% not reported. Operative times were significantly longer in the patients who had undergone previous open surgery than those who had undergone previous laparo-scopic surgery. Average length of stay for all studies except the Austrian group (government-mandated longer length of stay) was 4.4 days, which is shorter than reported in most open reoperative literature. Mean follow-up was 21.6 months with an average success rate of 90%. Success rates in most studies were based on patient satisfaction and not on scientific data. The relatively short average follow-up in most studies, although definitely a shortcoming, was not considered a problem because most recurrences occur in the first year. Complication rates were not consistently reported but ranged from 10 to 65% (Table 11.1). Previous open surgery was associated with a significantly higher complication rate than previous laparoscopic surgery. Common complications included pneumothorax, enterotomy, postoperative leak, dysphagia, and gas bloating. There were no operative mortalities reported in any of these studies. From these data, we conclude that laparoscopic refundoplication, especially in patients with previous laparoscopic repair, is associated with minimal morbidity, no mortality, a decreased length of hospital stay, and improved patient satisfaction compared with both open and thoracic reoperative surgery. Most authors agree that in the hands of an experienced laparoscopic surgeon, reoperative laparoscopy for failed fundoplication is safe and effective.

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Responses

  • Yohannes
    What is revision of fundoplication?
    8 years ago
  • tancredi lo duca
    What happens during revision fundoplication surgery?
    3 years ago
  • rosa
    What is the cpt code for laparoscopic revision of nissen fundoplication?
    9 months ago

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