Single-Incision Pediatric Endosurgical Nissen Fundoplication

Abstract

Single-incision pediatric endosurgery (SIPES) is gaining popularity for routine ablative operations such as appendectomy and cholecystectomy in a number of centers. We have employed this technique for Nissen fundoplication for the first time as a major reconstructive procedure. This study describes the technical evolution of SIPES fundoplication at our center, discusses the challenges, and evaluates the outcome. After IRB approval was obtained, data were prospectively collected on all SIPES fundoplications performed in our hospital from September 2009 through August 2010. The surgical techniques, operative times, blood loss, complications, conversion rates, and outcomes were recorded. SIPES fundoplication was attempted in 10 children (ages 3 months to 11 years, median 21 months; weight 3.45-51 kg, median 9 kg). Fundoplication was performed as the sole procedure in 4, and combined with a gastrostomy in 6 patients in which case the gastrostomy was used as an additional trocar site. On average, total operative time was 104 ± 31 minutes, and reached a baseline around 90 minutes after five procedures. The mean estimated blood loss was 6 ± 5 mL, and postoperative length of stay 2.6 ± 1.4 days. Different trocars, liver retraction methods, and suturing techniques were employed. Extracorporeal knot tying was used in six operations. There were no intraoperative complications, but unplanned additional trocars or access sites were added in 2 cases, leaving 3 patients in which the procedure was carried solely through the umbilicus. Reflux symptoms subsided in all patients, but 1 patient had recurrence at 12 months postoperative and underwent conventional laparoscopic redo-fundoplication. Laparoscopic Nissen fundoplication can be accomplished successfully and safely using single-incision endosurgery in children with good antireflux efficacy and without leaving any appreciable scar. Extracorporeal knot tying appears to be superior to other methods. So far, the failure rate is not higher than in conventional laparoscopic Nissen fundoplication.