Laparoscopic Antireflux Procedures

Technique: Redo Laparoscopic Fundoplication

Experience, rigorous analysis and laparoscopic re-exploration of all our Laparoscopic Fundoplication failures taught us valuable lessons. It was initially believed a Laparoscopic Fundoplication fails because of post-operative torsion or a telescoping phenomenon. We now know it is most likely the failure of the diaphragmatic closure [or crural closure] which generates recurrent symptoms. Ninety eight percent of all our re-operated failures have an intact fundoplication. The fundoplication however migrates into the lower mediastinum via a newly formed hiatal hernia.

Torsion of the fundoplication occurs when a flawed previous posterior fixation was performed.

A total breakdown of the fundoplication is usually secondary to a previous technical error.

Lastly, it should be noted we have had no recurrence of re-inforced laparoscopic fundoplication which is a the reason why this technique is now routine on our surgical service.

Step 1: Verifying the Mechanism of Failure

An extensive dissection of the GE Junction should be performed. The inferior aspect of the left hepatic lobe is usually adherent to the fundoplication. The dissection should be performed with an ENDOSHEAR instrument or sharp scissors.

The failure of the previous crural closure may not be immediately apparent. For this reason, the entire anterior aspect of the  fundoplication should be dissected to expose the diaphagmatic cruras.

Step 2: Dissecting- mobilizing Previous Fundoplication

The anterior aspect of the diaphragmatic cruras should be visualized and dissected. The lateral aspect of the fundoplication is also dissected from the left hepatic lobe and the medial diaphragmatic crus.

The operator should measure the length of the fundoplication. In most cases it should be 2 cm to 2.5cm in length.

The anesthesiologist is asked to place a #50 French Bougie followed by a # 60 French Bougie.

Step 3: The Diaphragmatic Closure

The # 60 Bougie is in place and the cruras are slowly approximated anteriorly with interrupted silk sutures (7''-O Softsilk or Silk) placed with an ENDO STITCH* Instrument or a laparoscopic needle holder. This closure is completed after leaving a small window (.5 cm) between the last crural suture and the esophagus.

Step 4: Increasing the Length Fundoplication

We usually do not posteriorly dissect the fundoplication and increase the length of the fundoplication by 1 or 1,5 cm. This done by using the ENDOSTICH Instrument.

Step 5: Reinforcing the Fundoplication

A 1" x 2" SURGIPRO* Mesh is inserted in the intra-abdominal cavity. It is deployed over the Nissen Fundoplication and sutured with the ENDOSTICH* instrument with Softsilk.

The intra-abdominal cavity is irrigated and deflated. The trocars are removed. The trocar insertion sites are closed in the usual fashion.