How I Do It Laparoscopic Fundoplication George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO

Laparoscopic Fundoplication

The Use of Stab Incisions PAPS 2003 JPS 38: , 2003

Cost Savings from Stab Incisions PAPS 2003 JPS 38: , 2003

Personal Series - CMH Jan 2000 – March Pts No Esophagus – Crural Sutures Extensive Esophageal Mobilization Mean age/weight 21 mo/10 kg Mean operative time93 minutes Transmigration wrap15 (12%) Postoperative dilation0 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 - CMH April 2002 – December Pts Esophagus – Crural Sutures Minimal Esophageal Mobilization Mean age/weight 27 mo/11 kg Mean operative time102 minutes Transmigration wrap6 (5%) Postoperative dilation1 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 Months Group I Jan 00-March Pts Group II April 02-Dec Pts P Value Mean Age (mos) Mean Wt (kg) Gastrostomy47%46%0.893 Neuro Impaired71%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 Months Group I Jan 00-March Pts Group II April 02-Dec Pts P Value Mean Age (mos) Mean Wt (kg) Gastrostomy46% 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 II 119 Patients Esophago-Crural Sutures # PatientsTransmigration% 2 silk sutures20525% (9, 3 o’clock) 3 silk sutures4312.3% (9, 12, 3 o’clock) 4 silk sutures5600% (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: , 2002

Re-Do Fundoplication Operative Technique 21/273 Pts No mesh (13) 4 recurrences Surgisis (8) 0 recurrences J Pediatr Surg 42: , 2007