John G Linn, MD, Kyle A Perry, MD, W. Scott Melvin, MD. The Ohio State University Medical Center
INTRODUCTION: Laparoscopic Nissen fundoplication has become the standard surgical treatment for refractory gastroesophageal reflux disease (GERD). Though normally performed via four or five laparoscopic ports, the potential cosmetic and physiologic benefits of single and reduced port laparoscopy have generated significant interest. The evolution of specialized, flexible instrumentation facilitates port reduction, and we report our initial experience in a novel technique of reduced port Nissen fundoplication using the Spider Surgical System (Transenterix, Morrisville, NC) with short-term follow up.
METHODS: Patients were evaluated for antireflux surgery after demonstrating objective evidence of gastroesophageal reflux including radiographic, endoscopic, and manometric evaluation of the esophagus. Symptom severity was evaluated preoperatively using validated Anvari and Velanovich GERD symptom and quality of life indices. Patients were offered reduced incision laparoscopic fundoplication and entered into a prospective database for laparoscopic esophageal surgery. Using the Spider Surgical System, each patient underwent laparoscopic Nissen fundoplication using a reduced port technique. Operative and hospital data were collected. Short term follow up evaluation including repeat GERD symptom and quality of life scores were obtained.
RESULTS: A total of 5 patients underwent reduced port laparoscopic Nissen fundoplication. Age ranged from 29-67, and the mean body mass index was 27.8 g/m². One patient had previously undergone an endoscopic fundoplication. Operations were performed using midline insertion of the Spider Surgical System at or just above the umbilicus. Two flexible instruments and a laparoscope were introduced through the device, a needlescopic grasper was used for liver retraction, and an additional left upper quadrant working port was used for the ultrasonic energy device and intracorporeal suturing. Fundoplication was performed successfully in all patients without additional port placement. Mean operative time was 135 minutes. Gastric perforation occurred in one patient. This was recognized intraoperatively and repaired without complication. There were no other major complications. Mean length of stay was 1.2 days. Short term follow up at 6 weeks demonstrated improvement in mean symptom severity score (50—29) and quality of life score (44—17).
CONCLUSIONS: Use of a multiport device with flexible instrumentation facilitates the performance of reduced port laparoscopic Nissen fundoplication in this initial experience. This approach is feasible with the use of appropriate adjunctive measures. However, further advances in instrumentation may be necessary before complex laparoscopic operations can be safely performed in a single incision fashion.
Program Number: P251