Open Laparotomy for Reoperative Fundoplication

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The most common approach for reoperative anti-reflux surgery is revision fundoplication via laparotomy, or the so-called open technique. Once in the operating room, the patient is placed in the supine position. The abdomen is prepped and draped in a sterile fashion. An upper midline incision is performed and extensive adhesiolysis may be necessary. Use of meticulous technique is important to minimize gastrotomies, enterotomies, or esophagotomies. If created, they are repaired primarily and, if at all possible, are subsequently contained within the wrap. A lighted bougie or endoscope can aid in the identification of the hiatal structures. The first step is to dissect the liver off the anterior surface of the stomach and wrap. Identification of either the right or left crus as an initial step is very helpful in confirming the location of dissection and in helping to identify the wrap. Dissection of both crura should continue until the wrap is completely dissected free. Retroe sophageal dissection is then performed with care taken not to injure the aorta. A Penrose drain can be placed around the esophagus to aid in mobilization.

The cause of technical failure is then assessed. Possible causes include wrap migration or her-niation, wrap failure with either a too loose or too tight wrap, paraesophageal hernia formation, and slipped fundoplication onto the stomach body (see Chapter 8). The wrap is taken down completely and both vagal nerves are identified and spared. If the short gastric vessels had not previously been divided, this is performed before wrap formation. It may be necessary to dissect the fundus off the spleen if the short gastric vessels have already been divided. If a paraesophageal hernia is the cause of failure, the hernia sac is excised.

Before creating the fundoplication, it is imperative that the GE junction is well within the abdomen. At least 5 cm of esophagus above the GE junction is mobilized. After releasing tension on the stomach, the GE junction must remain below the diaphragm without retracting into the mediastinum. If this is not possible with esophageal mobilization, an esophageal lengthening procedure such as the Collis gastroplasty is performed.2,11 Additionally, as Hunter et al.15 detail, a Collis gastroplasty may be indicated in patients who appear to have adequate esophageal length, but have herniated their wrap more than once. A Collis gastroplasty is performed by placing a GIA stapler at the angle of His and creating a longitudinal staple line that effectively recreates the GE junction further distally on the stomach (Figure 11.1). The wrap is then performed at the new GE junction while ensuring adequate intraabdominal length.

Regardless of the cause of failure, the hiatus is closed posteriorly with nonabsorbable sutures in all patients. The revision fundoplication is performed over a 56- to 60-French bougie to ensure a "floppy" wrap. Partial or total fundoplication is selected based on preopera-tive manometric studies. Patients with poor esophageal motility are considered for a partial or Toupet fundoplication in order to decrease the risk of postoperative dysphagia. If esophageal motility is adequate, the preferred operation is the Nissen fundoplica-tion. In patients with paraesophageal hernias, surgeons may prefer a Toupet wrap because that will better anchor the GE junction in the

REOPERATION FOR FAILED ANTI-REFLUX SURGERY

REOPERATION FOR FAILED ANTI-REFLUX SURGERY

Toupet Wrap

Figure 11.1. Collis gastroplasty.A,An area for the initial gastro-tomy is selected that is adjacent to the indwelling bougie and 3 cm from the esophagogastric junction. B, A through-and-through gastrotomy is performed with an EEA stapler.C, A linear cutting stapler is positioned through the gastrotomy and is fired parallel to the lesser curve of the stomach to complete the gastroplasty. (Zucker KA. Surgical Laparoscopy. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 2000:462.)

Figure 11.1. Collis gastroplasty.A,An area for the initial gastro-tomy is selected that is adjacent to the indwelling bougie and 3 cm from the esophagogastric junction. B, A through-and-through gastrotomy is performed with an EEA stapler.C, A linear cutting stapler is positioned through the gastrotomy and is fired parallel to the lesser curve of the stomach to complete the gastroplasty. (Zucker KA. Surgical Laparoscopy. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 2000:462.)

sary is seeing the spleen pulled medially when the fundus is brought posteriorly to create the fundoplication. Once the fundus is adequately mobilized, it is passed posteriorly to the GE junction again. A 56- to 60-French bougie is passed down the esophagus and positioned across the GE junction. The anterior portion of the wrap is secured to the esophagus and the posterior portion of the wrap with two sutures approximately 1 cm apart, followed by a fundo-fundal suture at the level of the GE junction. Pledgets can be used to reinforce the sutures (Figure 11.3). There should be no tension on the wrap. This is assessed by passing an instrument between the wrap and the esophagus to see how much tension there is. The bougie is then removed. Given the difficult dissection that is typically experienced during reoperative surgery, intraoperative endoscopy with leak test should be performed at the conclusion of the operation. The leak test is performed by submerging the wrap under saline, insufflating at the GE junction with the endoscope, and observing for bubbles. If bubbles are seen, the enterotomy is sutured closed, and the leak test is repeated.

abdomen and may decrease the risk of recurrent herniation.

For a total fundoplication, the fundus is passed posteriorly around the esophagus. Performance of the "shoe-shine" maneuver, in which the fundus is grasped on either side of the esophagus and moved back and forth, ensures the appropriate amount of fundus is passed posteriorly and the wrap is in the correct orientation (Figure 11.2). The portion of the fundus now on the right of the GE junction is released. If the fundus retracts under the esophagus back to the left of the GE junction, there is excessive tension on the wrap and further attempts to mobilize the fundus need to be undertaken. Another sign that further mobilization is neces

Laparoscopic Nissen Signs
Figure 11.2. Performing a "shoe-shine"maneuver before suturing a Nissen fundoplication. (Reproduced with permission from Phillips EH,Rosenthal J,eds.Operative Strategies in Laparoscopic Surgery. New York: Springer-Verlag; 1995:121.)

MANAGING FAILED ANTI-REFLUX THERAPY

A partial posterior, or Toupet, fundoplication is indicated for patients who have inadequate esophageal motility. Patients with dysphagia from a fundoplication that is too tight may also benefit from a partial fundoplication if it is not possible to create a total fundoplication that is floppy secondary to scarring or ischemia. Although some authors recommend liberal use of a Toupet fundoplication, there are higher failure rates with a Toupet compared with a Nissen fundoplication.16,17 The Toupet is performed by wrapping the fundus posteriorly and securing the fundus to the esophagus and crura bilaterally. Two sutures are placed from the fundus to the crus on the right, and four fundus to esophagus sutures are placed, two on each side. Sutures along the esophagus are placed 1cm apart to create a 2-cm fundoplication (Figure 11.4).

If the patient had signs of vagal denervation preoperatively manifested by prolonged gastric emptying, then pyloric dilation, pyloroplasty, or pyloromyotomy should be performed to alleviate the symptoms of delayed gastric emptying. Rieger et al.18 caution against pyloroplasty because complication rates are significantly higher in these patients.

Pyloroplasty Complications
Figure 11.4. Completed Toupet fundoplication. (Zucker KA. Surgical Laparoscopy. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 2000:406.)
Floppy Fundoplication
Figure 11.3. Use of Teflon pledgets to reinforce a fundoplication. (Reproduced with permission from Phillips EH, Rosenthal J, eds. Operative Strategies in Laparoscopic Surgery. New York: Springer-Verlag; 1995:121.)

Siewert et al.5,11 summarized the morbidity and mortality data reported for open redo fundoplications. The authors identified a wide range of morbidity reported, ranging from 20 to 40% and a mortality rate of 2%. Good to excellent results were reported in 80-85% of selected patients undergoing reoperation for failed antireflux surgery. They reemphasized what Little et al.8 reported: that multiple operations significantly and adversely affect the success rate to the point that, after three operations, one should consider esophageal resection.

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Responses

  • mario
    DOES A NISSEN FUNDOPLICATION USE LAPAROTOMY?
    3 years ago

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