MIS revisional surgery for gastro-esophageal reflux disease: how I do it

Abstract

: Minimally invasive surgery to control gastro-esophageal reflux disease (GERD) was introduced in 1991, and quickly became mainstream as an excellent option for patients with breakthrough symptoms on maximal medical therapy. However, a small subset of patients will be unhappy with the result of laparoscopic fundoplication, and will present for consideration of a laparoscopic revisional procedure. A failed fundoplication may result in one of three situations: (I) true recurrent reflux symptoms, often due to an anatomical cause; (II) residual “reflux” symptoms post laparoscopic fundoplication, often due to symptoms mistakenly attributed to reflux; and (III) new symptoms post laparoscopic fundoplication, such as bloating, increased flatulence and dysphagia. With an increased morbidity and mortality rate for laparoscopic revisional fundoplication, it is critical to select the right patient for a redo procedure. Mandatory investigations when dealing with a presentation of recurrent reflux symptoms, include: endoscopy (ideally performed by the responsible surgeon), 24-hour pH study (if no evidence of reflux on endoscopy), esophageal manometry, and barium swallow. In this paper, we discuss our definition of a failed fundoplication, we outline our operative approach to a minimally invasive revisional fundoplication, and we discuss our postoperative management. With these steps, 86% of patients undergoing a laparoscopic revisional fundoplication in our institution are satisfied with the result.