From the Guidelines
Laparoscopic redofundoplication is the recommended approach for repairing a failed previous fundoplication, involving several key steps to ensure a successful outcome. The procedure begins with placement of ports, typically including a camera port at the umbilicus and additional working ports in the right and left upper quadrants, as stated in the guidelines 1. After establishing pneumoperitoneum, the surgeon carefully dissects adhesions from the previous surgery to expose the hiatal region. The failed fundoplication is then completely taken down by dividing the wrap and freeing the gastroesophageal junction.
The hiatus is fully mobilized, with careful identification and preservation of the vagus nerves. The surgeon then performs a complete esophageal mobilization to ensure adequate intra-abdominal esophageal length, which may require mediastinal dissection, considering the possibility of a ‘short’ oesophagus in patients with EA-TEF who failed a previous operation 1. Any large hiatal hernia is repaired with non-absorbable sutures, potentially reinforced with mesh in selected cases.
The fundoplication is then recreated, typically as a Nissen (360-degree) or Toupet (270-degree) wrap, depending on the patient's specific condition and the reason for the initial failure, with the choice between total or partial fundoplication left to the preferences and expertise of surgeons 1. The wrap is secured with non-absorbable sutures, ensuring it is neither too tight nor too loose. A final check confirms proper wrap position and absence of obstruction before removing the instruments and closing port sites.
Some key considerations in the procedure include:
- The need for lengthening procedures of the oesophagus in patients with EA-TEF who failed a previous operation 1
- The potential for complications such as dysphagia, retching, and gas or bloating, particularly with complete Nissen fundoplication 1
- The importance of meticulous technique, as redofundoplication is technically more challenging than primary fundoplication due to scarring and altered anatomy from the previous surgery.
From the Research
Steps of Lap Redofundoplication
The steps involved in laparoscopic redo fundoplication are not explicitly outlined in the provided studies. However, the following points can be inferred about the procedure:
- Laparoscopic redo fundoplication is a feasible and safe procedure for patients with failed antireflux surgery, providing symptom relief and improved quality of life 2.
- The procedure can be performed laparoscopically, with a conversion rate to open surgery of around 6% 2.
- The steps involved in the original laparoscopic fundoplication procedure may include:
- Dissection of the esophageal hiatus
- Wrap creation and placement
- Crural repair
- Mesh placement (if necessary)
- Redo fundoplication may involve revising or redoing these steps to address the cause of the initial failure.
- The choice of approach (laparoscopic or open) and the specific steps involved may depend on the individual patient's anatomy and the reason for the initial failure.
Indications and Contraindications
The indications for laparoscopic redo fundoplication include:
- Recurrent symptoms after initial fundoplication
- Anatomic complications (e.g. wrap herniation)
- Failed antireflux surgery The contraindications for the procedure are not explicitly stated in the provided studies, but may include:
- Severe adhesions or scarring from previous surgery
- Large hiatal hernias
- Significant medical comorbidities
Outcomes and Complications
The outcomes of laparoscopic redo fundoplication include:
- Improved symptom scores and quality of life 3, 2
- Low recurrence rates (around 10%) 2
- Low complication rates (around 5%) 2 The complications of the procedure may include:
- Conversion to open surgery
- Major morbidity (e.g. bleeding, infection)
- Recurrence of symptoms or anatomic complications
- Adverse events (e.g. dysphagia, gas-bloat syndrome)