Introduction: Nissen Fundoplication is an effective treatment of gastroesophageal reflux disease. Recurrent reflux symptoms may occur due to the mechanical failure of the fundoplication. Patients who fail medical management will require surgical revision.
The safety and efficacy of laparoscopic reoperation for the recurrent hiatal hernia or slipped fundoplication depend on the surgeon’s skills and experience. The laparotomy approach is advised by some investigators due to these technical difficulties.
The purpose of this study is to introduce the robotic approach as a potential safe and effective technique for the failed fundoplication.
Materials and Methods: Twelve consecutive patients presented to the University of Kansas with recurrent gastroesophageal reflux following previous Nissen fundoplication. Eight patients were females while four patients were males. The mean age was 45.7+ 3.8 years. The main symptoms were refractory gastroesophageal reflux in all patients and dysphagia in 2 patients. Two patients had recurrent slipped Nissen following previous 2 laparoscopic repairs. All patients failed medical management with proton pump inhibitors (Usually double dose therapy). Esophageal manometry, esophageal pH monitoring, barium swallowgram and/or gastric emptying scintigraphy (GES) were performed preoperatively.
The Da Vinci robot was used to perform the entire steps of the procedures in all patients.
The hiatal repair was performed either primarily or using the Crura Soft Bard mesh® if the primary repair was not satisfactory. Eleven patients had Nissen (360°) fundoplication while one Patient had a Toupet 270 degree fundoplication. One patient required Leigh-Collis gastroplasty.
Results: Robotic assisted laparoscopic repair was successful in all patients. No operative mortality. The mean operative time was 203.9 + 32.1 minutes. Type III slipped Nissen was detected in three patients while Type IV fundoplication hiatal hernia was identified in nine patients. Primary repair of the hiatal defect was performed in three patients while mesh was used in nine patients. Pleural injury occurred in one patient. Pneumothorax resolved spontaneously. Robotic primary repair of gastric fundus tear was performed in 2 patients. The tears occurred during the fundoplication takedown. No blood transfusion was required. Mean hospital stay was 1.7 + 0.7 days. Mean follow up is 22.4 + 6.9 months. Two patients had temporary postoperative dysphagia. All patients discontinued PPIs postoperatively. No recurrence of gastroesophageal reflux symptoms.
Conclusion: Recurrent gastroesophageal reflux due to failed fundoplication can be repaired successfully and safely using the Da Vinci telesurgical system. It provides the surgeon with the necessary accuracy and degrees of freedom required for a safe procedure.
Program Number: P565