Mark L. Wulkan, M.D.

Assistant Professor of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, Atlanta, GA., Children's Healthcare of Atlanta at Egleston

 

Beware Delayed Gastric Emptying

GES studies may not be accurate in children with GERD.

 

Trocar Placement

Always strive to have a 60-120 degree angle between your right and left working ports to facilitate suturing. Good trocar placement can make the difference between an easy case and a challanging one.

 

 

Dilator placement

No one wants to see the esophageal dilator with the laparoscope! Place the dilator prior to starting the case. Ask the anesthesiologist to move it in and out of the GE junction as necessary.

 

The Dissection

Ligate the short gastric vessels and mobilize the fundus posteriorly in order to form a floppy wrap. Dissect the esophageal hiatus and gain adequate intra-abdominal esophageal length.

 

The Wrap

Keep it short and loose. A 360 degree 1-2 cm wrap will stop GER and have cause minimal dysphagia.

 

Post-op Care

Place the patients on a soft mushy diet for 4-6 weeks. Most normal patients will cheat by 2-3 weeks if they are doing ok. Slowly advance the diet after that. Some patients will have prolonged dysphagia due to swelling at the GE junction. Resist the temptation to do something. This will usually resolve by 6-8 weeks. Dilation may be necessary.

 

Give of caloric needs to patients with a GT by overnight continuous feeds. This is to prevent gagging and gastric over distention.

 

Treat gagging aggressively. Teach mom to vent the GT when necessary. It may be desirable to continue Reglan, if it is helpful.

 

Do not stop omeprazole immediately. Wean it over a few days. There is a large increase in gastric acid when omeprazole is stopped abruptly. While this is usually not a problem, some patients may have some discomfort secondary to gastritis.

 

Complications of Fundoplication

Minimally Invasive Surgical Techniques in Re-operative Surgery for Gastroesophgeal Reflux disease in Infants and Children: Sanda Tan, Ph.D. and Mark L. Wulkan, M.D., American Journal of Surgery, in press

 

Background: Fundoplication is commonly performed in children suffering from complications of gastroesophageal reflux disease (GERD). Recently, laparoscopic fundoplication has become the standard of care for GERD in children. Published reports show that 2.3% to 14% of children will require re-operation after failed fundoplication. The purpose of this study is to show the feasibility of minimally invasive surgical (MIS) techniques to treat children after failed fundoplication.

 

Methods: A retrospective chart review was performed for all patients who underwent laparoscopic redo fundoplication at Children's Healthcare of Atlanta at Egleston from July 1998 to July 2000. The patients records were reviewed for age, diagnosis, type and time of initial operation, type and time of redo operation, operative time for redo operation, and complications.

 

Results: Seventeen children (age 3 months to 18 years) had operations for failed fundoplication attempted using minimally invasive surgical (MIS) techniques. Six of these children were referred after their initial operation performed elsewhere. Nine (53%) were neurologically impaired. Ten (59%) have respiratory complications of gastroesophageal reflux disease (GERD). The initial procedures were as follows: One open Nissen fundoplications, two open Thal fundoplications, thirteen laparoscopic Nissen fundoplications, and one laparoscopic Toupet fundoplication. The re-operative procedures performed were revision of fundoplication and hiatal hernia repair (13) or hiatal hernia repair only (4). Two patients had concurrent gastric emptying procedures. One procedure was converted to open due to technical reasons. One patient developed a pelvic abscess secondary to leakage around the gastrostomy tube. One child had erosion into the esophagus of a Dacron® patch that was used to close a large hiatal defect. Thirteen patients began feeding by the first post-operative day.

 

Conclusion: We conclude that MIS techniques can be applied to re-operative surgery for the treatment of GERD with an acceptable complication rate in this difficult group of patients. Re-operative patients appear to have the same benefits from MIS as patients undergoing their initial procedure.

 

Table 1. Clinical Data of children who underwent laparoscopic redo-fundoplication.

 

Patient number and gender

Age of first operation in months

Age at second operation in months

Time gap in months

Neurolo-gical deficit

Respiratory problems

Premat-urity

Type of initial operation

 

1*	F	?	36	?	Y	Y	Y	Open Thal
2	M	31	32	0.6	Y	N	Y	Lap. Nissen
3	F	1	9	8	Y	Y	N	Lap. Nissen
4	F	192	216	24	N	Y	N	Lap Nissen
5*	M	12	21	9	N	Y	Y	Lap. Nissen
6	M	67	72	5	Y	Y	N	Lap. Nissen
7	M	1.5	3	1.5	N	N	N	Lap. Nissen
8	F	4	18	14	N	Y	Y	Lap. Nissen
9	M	10	16	6	N	N	Y	Lap. Nissen
10	F	10	18	8	Y	Y	Y	Lap. Nissen
11*	M	?	181	?	Y	N	N	Lap. Toupet
12*	M	0	108	108	Y	N	N	Open Toupet
13	M	24	72	48	N	Y	N	Lap. Nissen
14*	F	8	36	28	N	N	N	Open Nissen
15*	F	6	30	24	N	Y	N	Open Thal
16	M	36	40	4	Y	Y	N	Lap. Nissen
17	F	24	31	7	Y	N	Y	Lap. Nissen

* Patients who were referred after their initial operation performed elsewhere.

 

Table 2. Surgical procedure and operative findings.

Patient number and gender

Wrap failure?

Hiatal hernia repair

Operative Time (hr)

Type of second surgery

Complications and comments

 

1	F	Y	N	1.75	Lap Nissen
2	M	N	Y	1.96	Lap Nissen	Extension of fundoplication
3	F	N	N	1.75	Lap Nissen	Reinforcement of fundoplication; Pt developed Pneumonia post-operatively
4	F	Y	N	2.65	Lap Nissen	Post-op dilation required
5	M	Y	Y	2.02	Lap Nissen	Exploratory lap 6 months later due to remnants of device left from previous repair in the lumen of esophagus
6	M	N	N	2.08	Lap Toupet	Conversion for esophageal dysmotility and dysphagia
7	M	N	N	1.16	Lap Nissen	Extension of fundoplication
8	F	N	Y	1.5	Lap Hiatal Hernia repair	Hiatal hernia repair twice
9	M	Y	N	5.92	Open Nissen	Scarring from previous Dacron patch
10	F	Y	N	1.72	Lap Nissen
11	M	Y	Y	2.58	Lap Nissen
12	M	Y	Y	3.58	Lap Nissen	Leak around the G-tube
13	M	N	Y	2.25	Lap Nissen	Reinforcement only
14	F	Y	N	2.83	Lap Nissen	Leak around G-tube leading to abscess and later exploratory laparotomy
15	F	Y	N	3.33	Lap Nissen
16	M	N	Y	1.08	Thoracic Hiatal Hernia Repair
17	F	N	Y	3.05	Lap Hiatal Hernia/Lap Antroplasty	Hiatal hernia repair, wrap intact

 

References:

1. Georgeson KE. Laparoscopic fundoplication and gastrostomy. Sem Lap Surg 1988;5:25-30.

2. Tovar JA, Olivares P, Diaz M, Pace RA, Prieto G, Molina, M. Functional results of laparoscopic fundoplication in children. J Pediatr Gastroenterol Nutr 1988;26:429-31.

3. Rothenberg SS. Experience with 220 consecutive laparoscopic Nissen fundoplication in infants and children. J Pediatr Surg 1998;33:274-78.

4. Esposito C, Montupet P, Amici G, Desruelle P. Complications of laparoscopic antireflux surgery in childhood. Surg Endosc. 2000 Jul;14(7):622-4.

5. Kubiak R, Spitz L, Kiely EM, Drake D Pierro A. Effectiveness of fundoplication in early infancy. J Pediatr Surg 1999;34:295-99.

6. Curet MJ, Josloff RK, Schoeb O, Zucker KA. Laparoscopic reoperation for failed antireflux procedures. Arch Surg 1999;134:559-63.

7. Pointner R, Bammer T, Then P, Kamolz T. Laparoscopic refundoplications after failed antirefulx surgery. Am J Surg 1999;178:541-44.

8. Hunter JG, Smith CD, Branum GD, Waring JP, Trus TL, Cornwell M Galloway K. Laparoscopic fundoplication failures: Patterns of failure and response to fundoplication revision. Ann Surg 1999;230:595-604.

9. van der Zee DC, Bax NM, Ure BM. Laparoscopic refundoplication in children. Surg Endosc. 2000 Dec;14(12):1103-4.

10. Vecchia LKD, Grosfeld JL, West KW, Rescorla FJ, Scherer III LR, Engum SA. Reoperation after Nissen fundoplication in children with gastroesophageal reflux: Experience with 130 patients. Ann Surg 1997;226:315-23.

 

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2. Laparoscopic Gastrostomy

SYLLABUS NOT AVAILABLE

Juda Z. Jona, M.D.

Evanston Northwestern Healthcare

2650 Ridge

Evanston, Illinois 60201

 

 

A. Diagnostic Phase

    1. Clinical Presentation

        a. The earlier the diagnosis - the better.

        b. Avoiding enterocolitis - important!

        · c. "No nursery d/c without spontaneous stooling!"

     2. Radiology

        a. KUB - screening only.

        · b. Contrast enema unprepped unevacuated colon

        c. Short falls of x-ray:

        · Diagnostic in 90%+ improves with age

        · Transition zone localization +/-

        d. Start Rx - rectal tube for irrigations

     3. Pathology

        a. Suction mucosal biopsy.

        b. "Not too high - not too low

            just right.." 1 - 2cm.

        c. Biopsy 2-3 specimens

        d. Full thickness biopsy seldom used

 

B. In Hospital Care:

    1. Colonic washout (irrigation) - not an enema!!

    · 2. Frequency: 3-4/d. more if distended

    3. Adjust frequency to baby's need.

    · 4. Warm N/S or R/L - not water!!

    5. Train parents in irrigations, catheter insertion

    6. Don't persist with irrigations if not effective

    · 7. Colostomy - rarely used: Perforation

        Inability to decompress

        Op for bowel obstruction

         · - Pitfall or Peril

 

C. Timing of post natal d/c:

    1. Baby is gaining weight

    2. Irrigations are going o.k.

    3. Parents comfortable.

    If not: 1. consider colostomy

                2. Plan primary pull through

 

Advantages of delayed pull through:

    1. Permits patient to stabilize and gain weight (0.5-1kg)

    2. Parents/baby bonding

    3. Colon decompressed

    4. Scheduling is elective

 

D. Laparoscopic Operative therapy: I. Preparations

    1. Routine preop care

    2. Positioning of patient: (slide)

        a. At the foot of the bed and across.

        · b. Anesthesia: safety is imperative!

        Tunneled access to patient

        Full monitoring - CO2

        Warming

        c. Surgeon: direct vision. Pt. head6 to perineum 6 monitor

        d. Foley catheter or just decompress

    3. Laparoscopy and instrumentation

        a. Keep it simple - world-wide acceptance

        · b. Port sites camera - RUQ

        Grasping - LUQ

        Dissector/clipping - RLQ

        May consider 4th port for long segment H.D.

        c. pneumoperitoneum at 10-12 cm H20

D. Laparoscopic Operative Therapy: II. Abdominal Phase

    · 1. Inspection - Establish transition.

    2. S/M biopsy if uncertain - some do it routinely

    3. Establish window in sigmoid mesentary

    4. Clip-ligate sup. hemorrhoidal vessels

    5. Dissection Swenson's style - near the bowel

    · 6. Avoid injuries to: right ureter, bladder and small bowel

    · 7. Continue dissection as long as comfortable

D. Operative Technique: III. Perineal Phase  

    1. Good exposure of anal canal

    2. Mucosectomy to start 1cm in

    3. Keep plane in submucosa

    4. Penetrate muscularis into pelvic cavity

    5. Assess and/or divide muscular cuff posteriorly

D. Operative Technique: IV. Pull Through

    1. Confirm ganglionated bowel with F.S.

    2. Four quadrants anastomosis

        Single layer vicryl

        Full thickness bites - both sides

    3. No need for protective colostomy

D. Operative Technique: V. Variations

    1. Conversion to open technique:

        a. Uncontrolled bleeding (0)

    b. Injury to other organs (0)

        c. Difficult dissection

            Long segment (1)

            Total colon (1)

    d. Intolerance of pneumoperitoneum (0)

            Do perineal pull through or

            Standard laparotomy

    2. S/M Biopsy

        a. Some do it routinely - chance of spillage

        b. Minilap at the umbilicus (?)

        c. Most do not need it

 

E. Post -op care

    1. Nothing per rectum

    2. If needs irrigation - by surgeon only

    3. p.o. in 12-18 hours

    4. d/c if has spontaneous stooling

 

F. Follow-up

    1. First rectal exam/dilitation > 3 weeks

    2. Repeated dilitations - rare

    3. Enterocolitis - irrigations - rare

    4. Long term follow-up - excellent

 

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5. Perils And Pitfalls During Laparoscopic Repair Of High Imperforate Anus

Craig T. Albanese, MD

Associate Professor, Surgery, Pediatrics, Obstetrics, Gynecology & Reproductive Sciences; Department of Surgery, Division of Pediatric Surgery; The University of California, San Francisco

 

ANATOMY

1. Fistula to bladder neck, prostatic (most common) or bulbar urethra

2. High fistula (e.g. bladder neck) easier to dissect due to more acute anterior anglulation

3. Low fistula (e.g. bulbar urethra) more difficult to dissect due to common wall with urethra,
less angulation

4. No fistula rare, but associated with long common wall and Trisomy 21

5. Other anomalies: renal, vertebral, cardiac, esophageal, spinal cord, Hirschsprung's disease,
presacral mass

 

PREOPERATIVE EVALUATION

1. Other anomalies

2. Divided colostomy versus one stage procedure

3. Colostogram (via mucus fistula) versus cystoscopy

 

POSITIONING AND SKIN PREP

1. S upine, sideways on table

2. No IV's or monitors on lower extremities

3. Bladder catheter

4. Paint skin from nipples to toes, front and back (bovie pad high on back)

 

TROCARS AND VISUALIZATION

1. Three to four at a relatively high on the abdominal wall

2. 30° lens critical

3. Decompress distal colon

 

CAVEATS OF DISSECTION AND POTENTIAL PITFALLS

1. Begin rectal dissection at peritoneal reflection with bipolar scissors

Too close to bowel: colotomy

Too far away: nerve or ureter injury

2. Deeper pelvic dissection: retract bladder with transcutaneous suture or retractor

Inadequate retraction: ureter or vas deferens injury

Too much bladder compression: temporary neurogenic bladder

3. Identify tapering junction of rectum with urinary tract: aided by metal urethral sound or by lighted
urethral catheter; be aware of prostate, seminal vesicals, and vas deferens

4. Divide fistula flush with urethra using clip or ligasure

Urethral injury; heal with stricture

Prostatic injury; bleeding

Too far from urethral wall: diverticulum

5. Identify pelvic musculature ("sling shot" appearance); stimulate with endoscopic muscle stimulator

6. Small perineal incision aided by external perineal muscle stimulation

7. Pierce muscle complex with Veress needle guided by endoscopic visualization

May miss center of complex: continence issues

Too anterior: bladder or prostate injury

*Need two experienced surgeons during this step

8. Dilate tract to 7-10 mm with radially expanding access device

9. Pull bowel through complex from inside out with babcock clamp

Bowel torsion

Too tight a tract: ischemia

10. Perineal anoplasty; at least 16 sutures (interrupted)

Leak

Pull away from tension (short mucus fistula)

11. Suture rectum to presacral fascia while placing cephalad tension to lengthen skin-lined anal canal

Mucosal prolapse

12. Proximal diversion: controversial

No diversion: rash, possible leak with sepsis/abscess, difficulty decompressing rectum

Diversion: another anesthetic, later perineal "training"

13. Urethral catheter for 72 hours

Edema: urinary retention

 

LONGTERM ISSUES

Incontinence

Constipation

Neurogenic Bladder

Stricture of Neoanus

Prolapse of neoanus (mucosa or full thickness)

Perineal Rash

 

REFERENCES

1. Georgeson KE, Inge TH, Albanese CT: Laparoscopically assisted anorectal pull-through for high imperforate anus-A new technique. J Pediatr Surg 35:927-931, 2000

2. deVries PA, Pena A: Posterior sagittal anorectoplasty. J Pediatr Surg 17:638-643, 1982

3. Lambrecht W, Lierse W: The internal sphincter in anorectal malformations: Morphologic investigations in neonatal pigs. J Pediatr Surg 22:1160-1168, 1987

4. Albanese CT, Jennings RW, Lopoo JB, et al: One-stage correction of high imperforate anus in the male neonate. J Pediatr Surg 34:834-836, 1999

 

 

6. Laparoscopy for Inflamatory Bowel Disease

SYLLABUS NOT AVAILABLE

 

 

7. Laparoscopic Appendectomy

SYLLABUS NOT AVAILABLE

 

Albanese, Craig T.

Georgeson, Keith E.

Jona, Juda Z.

Rothenberg, Steven

Thompson, Raleight

Wulkan, Mark L.

Yeung, CK