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Laparoscopic anti-reflux surgery

In our mind, and our recommendation, is that the same patients who are candidates for an open approach generally are candidates for the laparoscopic approach laparoscopic anti-reflux surgery, gastroesophageal reflux surgery, Nissen fundoplication. Refractory to medical treatment is a relative term. Of course, you can given a hundred pills a day to a patient, but everything is relative. Patients cannot afford to take the treatment anymore; we are seeing this more and more.

Relative contraindication is also relative. In fact, those indications have all been approached laparoscopically but the patient who has massive obesity might not even be a candidate for surgery. You have to question the wisdom of operating on a patient who weighs 250 pounds who needs laparoscopic surgery.

Re-operation: We tend to want to do the re-operation open. We tend to do that through the chest most of the time, although people have an excellent result with an open laparotomy. I know for a fact that some people have re-operated with good results laparoscopically, but we don't tend to do that in Rochester. However, we think that this will probably become a reality in more people, because there have been so many anti-reflux procedures done laparoscopically in the last five years and more people will come to re-operation eventually.

The true short esophagus is really rare. Because of medical treatment, the shortened, inflamed esophagus is not seen very commonly, but it happens. Typically, it happens in people who have a huge hernia. If you approach a patient with an intrathoracic stomach, a little old lady of 75, often the EG junction will be truly well above the diaphragm and those patients can present a problem. Actually, the definition of a short esophagus for the surgeon is one in which you cannot reduce the EG junction.

I will present here our experience with the learning curve and also our subsequent experience. We started doing the surgery in 1994 and this was our first attempt at 60 patients. The median age was 49 ; there were 38 men and 22 women. During this period, this was only 21% of our experience for anti-reflux surgery. At the same time, we had done 280 patients who underwent anti-reflux surgery, but only 21% were treated laparoscopically. Nowadays, this is closer to 50 to 60% of our patients who will have laparoscopy, and maybe 40% will have an open approach. The symptoms were quite typical, including heartburn, regurgitation, dysphagia, pain, aspiration and about 7% of the patients had been dilated previously. The duration of symptoms was 6 years median, from 7 months to 54 years.

The crura is dissected circumferentially completely; this is the left side being done. Following this, the crura is closed. We do calibrate the closure of the crura with a bougie; not everybody does that, but we think it is convenient to have an idea. I use a 50 French bougie here and we close the crura in everybody. It will lead to problems not to close the crura, even in patients who do not have a hernia, because you do dissect the area very well and if you do not have a hernia at this time, you will cause one if you do not close the crura to prevent anatomical recurrence.

Postoperatively, patients do not have a nasogastric tube. They have a PCA pump for pain control for 12 to 24 hours and their pain is not in the incision usually, but is in the chest. They complain of crushing pain in the chest because of the dissection and they complain of pain in their shoulder because of laparoscopic over-distention of the diaphragm by gas. This pain goes away in a few days and really, the pain in the incision is minimal. That is not to say that you will not have complications with the incision. At the beginning, when the ports were really large, more than 10 mm, there was a higher incidence of hernia in those incisions.