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Laparoscopic Fundoplication with Double Sided Posterior Gastropexy: a Different Surgical Technique

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Laparoscopic Fundoplication with Double Sided Posterior Gastropexy: a Different Surgical Technique View metadata, citation and similar papers at core.ac.uk ORIGINAL RESEARCH brought to you by CORE provided by Elsevier - Publisher Connector International Journal of Surgery 10 (2012) 532e536 Contents lists available at SciVerse ScienceDirect International Journal of Surgery journal homepage: www.theijs.com Original research Laparoscopic fundoplication with double sided posterior gastropexy: A different surgical technique Fahri Yetis¸ira,*, A. Ebru Salman b,Dogukan Durak a, Mehmet Kiliç c a Ataturk Research and Training Hospital, General Surgery Department, Turkey b Ataturk Research and Training Hospital, Anesthesiology and Reanimation Department, Turkey c Yildirim Beyazit University, General Surgery Department, Turkey article info abstract Article history: Background: Laparoscopic Nissen Fundoplication has become the gold standard surgical procedure for Received 18 April 2012 management of gastroesophageal reflux disease. Nissen fundoplication provides an effective barrier Received in revised form against reflux. The aim of this study was to evaluate early postoperative outcomes of a different surgical 3 August 2012 technique, laparoscopic fundoplication with double sided posterior gastropexy. Accepted 6 August 2012 Methods: Data of 46 patients who underwent laparoscopic fundoplication with double sided posterior Available online 21 August 2012 gastropexy between February 2010 and December 2011 were collected. Surgically, after Nissen fundoplication was completed, 2e4 sutures were passed through the uppermost parts of the posterior Keywords: Gastropexy and anterior wall of the gastric wrap and then passed gently 1 cm above the celiac artery from the denser fi Nissen fundoplication bers of uppermost part of the arcuate ligament. Demographic data, preoperative and postoperative Gastroesophageal reflux assesments of sympthomatic and functional outcomes of patients were recorded. Length of hospital stay, Hiatal hernia operative time, early postoperative complications and complications at 1 year follow up, early recurrence rate were also recorded. Results: This technique resulted in good symptomatic and clinical outcomes. Only one patient out of 45 patients was reoperated. The early recurrence rate was 2.2%. Conclusion: Laparoscopic Nissen fundoplication with double sided posterior gastropexy may prevent paraesophageal herniation. It is a reasonably feasible and effective method in surgical management of GERD. Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. 1. Introduction life but, new postoperative complaints may occur up to 25% of e cases.4 7 Gastroesophageal reflux disease is one of the most prevalant Several modifications have been proposed to original technique gastrointestinal disorders of the Western world, affecting up to 20% since the results of LNF are not always as good as expected. Several of the population.1,2 Laparoscopic Nissen fundoplication (LNF) has techniques combined with LNF such as cruroplasty with polyglactin become the gold standard surgical procedure for the treatment of or vicryl mesh, fibrin glue, hepatic shoulder technique, anterior or e gastroesophageal reflux disease (GERD) with or without hiatal posterior gastropexy have been used with various success.3,8 11 hernia.3 Antireflux surgery is the only choice of treatment that may Recently new operative techniques combining the LNF with prevent the need for long term medical therapy by correcting the posterior gastropexy have been defined in order to lessen the e pathophysiology leading to reflux.1 Hence, excessive transient postoperative failure of LNF.11 13 lower esophageal sphincter (LES) relaxation is the most likely The aim of this article is to present the early postoperative mechanism.1 outcomes of patients undergoing laparoscopic fundoplication with Nissen fundoplication involves wrapping the fundus around double sided posterior gastropexy. LES, thereby increasing basal LES pressure and decreasing episodes of transient LES relaxations. Laparoscopic surgery may provide 2. Material methods a significant improvement in patients’s symptoms and quality of 46 consecutive patients with GER disease underwent laparoscopic fundoplica- tion with double sided posterior gastropexy in our institution between February 2010 and December 2011. The patients with typical symptoms of GERD and mucosal * Corresponding author. Tel.: þ90 536 297 48 88. injury detected by endoscopy were included into the study. Ph monitoring was used E-mail address: [email protected] (F. Yetis¸ir). only in patients with diagnostic uncertainity or when the diagnosis cannot be 1743-9191/$ e see front matter Ó 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijsu.2012.08.001 ORIGINAL RESEARCH F. Yetis¸ir et al. / International Journal of Surgery 10 (2012) 532e536 533 confirmed with endoscopy. The patients not contacted for follow up were excluded hospital stay was 2.72 Æ 1.4 days. There was no in hospital from the study (Fig. 1). mortality. There was no conversion to open surgery. Postoperative All patients had upper abdominal ultrasonography, esophagogastroduodeno- dysphagia was not seen in any patient at 1 year follow up. The mean scopy with or without biopsy. Upper gastrointestinal contrast study was performed to 71.1% of patients and pH monitorization to 44.4% of patients. follow up time was 12.2 Æ 4.3 months. Only one patient with Visick Surgery: Five ports were placed. The first one, 5 mm, was inserted above the score >3 underwent endoscopy and slipped LNF was seen. After umbilicus at a location according to the distance between xiphoid and umbilicus to confirming the slipped LNF laparoscopically, first fundoplication enter the telescope (30 ). Four of the ports were inserted under direct vision. The and gastropexy was opened. Slipped LNF was disappeared and second and fourth trocar was placed in the right and in the left midclavicular line respectively. The third and fifth trocar was inserted in the right and in the left fundoplication with posterior gastropexy was repeated on surgical anterior axillary line respectively. The operation table was placed in a reverse revision 4 months after the first surgery. 44 patients have a Visick trandelenburg position to allow the abdominal organs fall away from the dia- score 2.44 (97.8%) patients documented that their symptoms had phragm. All patients underwent laparoscopic fundoplication with double sided improved. Patient satisfaction rate was 92.6 Æ 9.2%. posterior gastropexy. The operations were always performed by the same surgical team. After retraction of the liver and complete mobilization of the gastroesophageal junction and gastric fundus, short gastric vessels were cut. A tunnel was performed 4. Discussion at the posterior part of the esophagogastric junction. All these steps were performed with ultrasonically activated coagulation shears. (Harmonic Ace; Ethicon Endo- Proton pump inhibitors (PPI’s) are the most frequently surgery Inc., Smithfield, RI, USA) Intraabdominal gas pressure was maintained at fl e prescribed medical treatment of gastroesophageal re ux disease it a level less than 12 mmHg. Routine hiatal repair was applied in all patients with 2 4 15 2/0 sutures (Ti-cron, Covidien). After hiatal hernia repair and retraction of the heals the esophagitis in 90% of cases. However, medical gastroesophageal junction with a penrose tube, which was passed around the lower management cannot solve the mechanical cause of the disease, esophagus, a grasper forceps was inserted behind the lower esophagus through the symptoms may recur in 80% of cases within 1 year of drug with- posterior esophageal window to grasp the fundus 5 cm lateral to the gastroesoph- drawal.16 Furthermore, study results have revealed that PPIs are ageal junction. Fundus was passed back and forth to be certain that it was slack and fl had no twist. This part of the fundus, passed behind the esophagus, was used for associated with osteoporosis-related fractures, rebound re ux, creation of the wrap of the fundoplication. Fixation of the fundoplication was per- refractory hypomagnesemia, pharmacologic interaction with ASA formed by (Ti-cron, Covidien) a suture passed through the lips of the wrap and and clopidogrel with long term use. This raises the question esophageal musculature, 2 cm above the gastroesophageal junction, located 1.5e whether side effects of conservative treatment may overweight the 2 cm above the anatomic cardia (Fig. 2). benefits versus antireflux surgery.17 After fundoplication completed, the gastroesophageal junction was retracted with a penrose tube. 2e4 sutures (Ti-cron, Covidien) were passed through the Nissen fundoplication which is based on wrapping last part of uppermost parts of the posterior and anterior wall of the gastric wrap and then the esophagus using the gastric fundus, is the worldwide used passed gently 1 cm above the celiac artery from the denser fibers of uppermost part surgical technique in the treatment of GERD. Inadequate fundo- ’ 14 of the arcuate ligament, similar to Vansant s gastropexy (Figs. 3 and 4) All plication or paraesophageal herniation may cause postoperative concomitant abdominal diseases except ventral hernia were treated before fundo- failure of LNF up to 25% of cases.4 Symons et al. have emphasized plication (Table 1). Demographic characteristics of patients, preoperative signs at admission, that laparoscopic revision surgery have a greater risk of conversion, operation time, length of hospital stay, early postoperative complications
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