INTRODUCTION
Most infants spit up milk after feedings, sometimes in a spectacular fashion. This post-prandial regurgi- tation is rarely associated with any serious conse- quences to the baby and is usually outgrown by 1 year of age.
Pathologic gastro-oesophageal reflux (GER) in in- fants is associated with potentially serious complica- tions including failure to thrive, recurrent apnea and aspiration of gastric contents. Older children can al- so present with reactive airways disease, chronic si- nusitis and peptic oesophagitis.
A careful history is invaluable in eliciting the symptoms of GER in children. Frequent regurgita- tion, asthma associated with recumbency and ex- treme irritability are all potential signals of GER.
Further workup should include an upper gastrointes- tinal study to rule out other anatomic causes of re- gurgitation and to detect the presence of a hiatus hernia. A 24-h pH probe study is considered the gold standard for detecting pathological GER in children.
A negative pH probe study does not rule out sympto- matic GER due to the common occurrence of non-ac-
id reflux in paediatric patients. Upper gastrointesti- nal endoscopy is occasionally useful in defining the presence of oesophagitis secondary to GER. Gastric emptying studies are not usually useful in the work- up for GER in children.
Proton pump inhibitors and promotility agents are useful therapeutic modalities for most children with pathologic GER. Even those patients who do not fully respond to medical management should be treated for 8 weeks before surgical therapy is consid- ered, unless the patient is experiencing life-threaten- ing symptoms.
Antireflux surgery is indicated in patients with in- adequate response to medical management or in children who cannot be weaned from medical man- agement. Antireflux surgery is also appropriate in children with the complication of peptic oesopha- gitis presenting with a stricture or Barrett’s oesopha- gus. Those infants with life-threatening events de- spite optimal medical management are also candi- dates for immediate surgery.
Reflux and Hiatus Hernia
Keith E. Georgeson
The intubated patient is positioned at the end of the operating table. The knees are flexed and the feet cushioned. The patient is taped to the table so he/she will not slide when placed in the reversed Trendelen- burg’s position. The operator stands at the end of the table, which is positioned low enough for easy ma- nipulation of the laparoscopic instruments. A large Maloney bougie is passed through the mouth into the
stomach. The dilator should be large enough to fully distend the distal oesophagus for safer peri-oesopha- geal dissection. The patient’s head should be posi- tioned so that the anaesthetist has access to withdraw and advance the dilator as needed throughout the course of the operative procedure. The patient is prepped from nipples to groin.
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Figure 6.1
Five trocars are inserted in the abdominal wall. Un- like adult patients, who have a precisely defined posi- tion for each trocar, children have more variation in body habitus and liver position so the placement of the trocars must be tailored to the individual patient.
The initial trocar placement is through the centre of the umbilicus in the midline. Each trocar site should be infiltrated prior to the placement of the trocar with a local anaesthetic. The incision in the umbili- cus should be the same size as the trocar. The umbil- ical scar does not stretch well. An extremely tight tro- car will cause ischaemic injury to the skin of the um- bilicus if the skin incision is not large enough to ac- commodate the trocar. The incision should be made through the central portion of the umbilicus. The peritoneal cavity is usually easily entered through the umbilicus because the layers of the abdomen are scarred together at this point. Once the peritoneal cavity is opened with a no. 11 blade, a curved mosqui- to clamp is introduced into the peritoneal cavity with the tip upward pointing away from the abdominal viscera. The clamp is pushed inward to dilate the um- bilical opening allowing easier access to the perito- neal cavity. A radially expanding disposable 5-mm trocar with a fitted Veress needle is then passed into the peritoneal cavity while pulling upward on the umbilical skin. The trocar should be advanced at a 30º angle and its tip kept as close to the parietal peri- toneum of the anterior abdominal wall as possible to avoid injury to intra-abdominal or retroperitoneal
structures. The Veress needle inside the expandable sheath is then removed and the trocar cannula in- serted through the plastic sheath expanding the tro- car and fixing it to the abdominal wall due to its snug fit. Suture fixation is sometimes necessary in smaller infants with a thin abdominal wall. A 30º 4-mm scope is advanced through the umbilical trocar after a pneumoperitoneum has been instilled. This scope is then used for surveillance during the placement of the other four trocars. The second trocar is placed in the right upper quadrant. This trocar should be posi- tioned at the inferior margin of the liver border in the right anterior axillary line. The articulated re- tractor is passed toward the left upper quadrant and tightened to form its working position. It is then se- cured to the frame of the operating table by way of a retractor holder. The third, fourth and fifth trocars are then placed under laparoscopic surveillance. All but the umbilical trocars are reusable 3- or 4-mm tro- cars except in patients over 20 kg when a larger liver retractor is passed through a 5-mm trocar.
Trocar site 3 is used for the endoscope and is also the prospective gastrostomy site during gastrostomy button placement. Trocar sites 2 and 4 are the work- ing ports for the operating surgeon. Trocar site 5 is the initial entry point and is also used for surveil- lance during placement of the other 4 ports. When the endoscope is moved to port 3 to perform the op- eration, port 5 is used for intraperitoneal access by the surgeon’s assistant.
Figure 6.2
Figure 6.1
1
2
3
4
5 Figure 6.2
Figure 6.3
The intraperitoneal dissection is begun by opening the upper part of the hepatogastric ligament. The dissection is performed sharply. The hepatic branch- es of the vagus nerve are divided. The small vessels to the liver are also divided using electrocautery. Care is taken to avoid transecting the left hepatic artery, which can be found in this ligament in a very small number of patients. The dissection is carried up to the hiatus in an avascular plane. The phreno-oesoph- ageal ligament is opened between the oesophagus and the right crus. The peri-oesophageal plane should be entered cleanly to avoid excessive bleeding
and to facilitate a faster operation. The dissection is continued in this plane bluntly and sharply over the top of the oesophagus and down the left side. The an- terior vagus nerve is usually tightly adherent to the muscle of the oesophageal wall. However, occasional- ly the nerve falls away and is only loosely associated with the oesophageal wall. Linear structures along the anterior oesophageal wall should be carefully evaluated before dividing them. The cleavage between the oesophagus and left crus should be car- ried posteriorly until the fundus of the stomach is encountered.
Figure 6.4
The short gastric vessels are divided routinely. Divid- ing these vessels allows for much better visualization of the left crus and also contributes to a better geom- etry of the fundoplication wrap. In most patients, the vessels are divided with a hook electrocautery. In large or obese patients an ultrasonic scalpel is useful
in dividing the short gastric vessels. The gastrosplen- ic ligament is opened at the mid portion of the spleen. The dissection is carried cephalad from this point. Most patients have both an anterior and poste- rior leaflet of the gastrosplenic ligament. Vessels run in both leaflets.
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Figure 6.3
Figure 6.4
Figure 6.5
The left crus should be followed as it courses toward the right side behind the oesophagus. Dissection is performed from both sides. The fundus is pulled down using a grasper through the umbilical port site, which allows excellent visualization of the left crus.
For visualization of the right crus, the grasper is pulled downward and toward the splenic flexure of the colon. By dissecting both sides alternately using the left crus as a guide, a window is safely formed be- hind the oesophagus. The tissues tethering the oe- sophagus to the crura are further divided circumfe- rentially to lengthen the intra-abdominal portion of the oesophagus. The posterior vagus is vulnerable and should be identified and preserved. An instru- ment passed through the umbilical trocar is used to retract downward on the gastro-oesophageal junc- tion while lengthening the intra-abdominal oesoph- agus. Circumferential dissection around the oesoph- agus is continued as far into the mediastinum as nec- essary to provide at least 2.5 cm of oesophagus in the abdomen with no downward tension on the oesoph- agus. If less than 2.5 cm of oesophagus remains in the abdomen after releasing the downward tension on the oesophagus, consideration should be given to lengthening the abdominal oesophagus by tubulariz- ing the upper stomach. As much as possible, the fas- cia covering the crura should be left intact. Care should also be taken to avoid entry into the plural cavity on either side. If a hole is made in the pleura it should be enlarged to avoid the development of a tension pneumothorax caused by a one-way ball- valve effect. The pneumothorax can be evacuated by needle thoracentesis at the end of the operation.
Figure 6.6
The crura are closed in every case by approximating them behind the oesophagus with non-absorbable sutures. Generous bites of crus are taken on both the left and right sides and are tied snugly. The aorta is located behind the posterior aspect of the left crus and should not be incorporated in the suture closing the crura. The author prefers to close the crura with the dilator withdrawn into the oesophagus. Great care should be taken to avoid closing the hiatus too tightly. If a large dilator is left in the intra-abdominal oesophagus, suture placement is more difficult and the hiatus is often left larger than it should be. With large hiatal defects, the hiatus may require both pos- terior and anterior closure. Once the hiatus is closed around the oesophagus, at least 2 cm or more of oe- sophagus is fixed in the abdomen utilizing three or four collar sutures. These sutures are usually placed at the 11, 7 and 3 o’clock positions on the oesophagus incorporating a portion of the oesophageal wall and coapting it to the associated crus. For large hiatus hernias it may take four or more collar sutures to ad- equately close the oesophageal hiatus.
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Figure 6.7
The mobilized fundus is pushed up beside the left side of the oesophagus. A grasper via the umbilical port is used to lift the oesophagus exposing the fun- dus behind the oesophagus. The fundus is grasped and pulled through the retro-oesophageal window.
The fundus is fluffed until a geometric symmetry is achieved. A “shoe shine” manoeuvre is used to con- firm the fundal wrap and to avoid attaching the fun- dus to the mid portion of the stomach.
Figure 6.5
Figure 6.7
Figure 6.6
Figure 6.8
The dilator should be repositioned into the stomach at this time. The left side of the fundus is then basted to the right side of the fundus with a single stitch that does not incorporate oesophageal tissue. The wrap should be loose and should encircle the oesophagus.
Two or three non-absorbable sutures are placed above and/or below the first stitch incorporating the
left and right sides of the fundal wrap and securing them to the oesophagus. The wrap should be no more than 1.5–2 cm in length and lie loosely around the oesophagus. A figure-of-eight suture is then placed near the bottom of the wrap as a second layer to secure the fundoplication and prevent wrap break- down.
Figure 6.9
Gastrostomy placement is performed in conjunction with fundoplication only in those patients who have swallowing disorders or severe failure to thrive. It is not used as a routine procedure to decompress the stomach after a fundoplication. The laparoscope is moved back to the umbilical port. A locking grasper is passed through the medial left upper quadrant tro- car site. This trocar is initially positioned with the in- tention of using this site as the gastrostomy site. The stomach is grasped near the greater curvature at the junction of the body and antrum. If a fundoplication
was not performed, the stomach should be grasped close to the lesser curvature. Using a large curved needle with a monofilament suture swaged to the needle, a U-suture is passed through the abdominal wall through the stomach taking a 1–0.5 cm bite of stomach and back through the abdominal wall. Pass- ing the suture into the gastric lumen does not seem to lead to complications. A second U-suture is passed parallel to the first 1.5 cm lateral to the first suture.
The grasper is then removed along with the trocar.
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Figure 6.8
Figure 6.9
Figure 6.10
The anaesthetist passes a single lumen orogastric tube into the stomach and inflates the stomach with 60–120 cc air. A hollow needle is passed through the medial left upper quadrant trocar site into the inflat- ed stomach. The passage of the needle into the lumen of the stomach should be visualized completely and should not occur on the blind side of the stomach. A J-wire is then passed through the needle into the
stomach and the needle removed over the J-wire. The tract is dilated with vascular dilators from a size 8- French up to a size 20-French. The 20-French dilator should be passed through the abdominal wall only and not into the stomach. The U-suture should be al- lowed to slacken during passage of the 20-French di- lators to avoid passing of the dilator into the stom- ach.
Figure 6.11
The gastrostomy button is stiffened by passing the 8- French dilator through it. The dilator and balloon button are passed over the guide wire. Gentle twist- ing of the balloon button while holding countertrac- tion on the U-suture allows the balloon button to slip into the stomach under laparoscopic surveillance.
The balloon should be inflated under direct visual- ization. The U-sutures are slackened at this point to make certain that the stomach is independently held against the abdominal wall by the inflated balloon button. The U-sutures are then tied over the wings of the balloon button. The laparoscope is passed through the lateral left upper quadrant trocar site to look at the gastrostomy button from a different angle to assure that it is properly positioned and remains inflated.
The liver retractor is removed using laparoscopic surveillance. The umbilical trocar is the first trocar to be removed after the pneumoperitoneum is evacuat- ed. The fascia of the umbilicus is closed using a groove director to protect the underlying bowel and omentum. A simple or figure-of-eight suture is used
to close the umbilical fascia. Once closure of the um- bilical fascia has been achieved, the pneumoperiton- eum is reinstated and the umbilical closure visual- ized from a lateral port site to confirm that the omen- tum has not been incorporated in the umbilical clo- sure. The other trocars are then removed. The fascia in these other trocar sites does not usually require closure. The skin is closed with subcuticular sutures and skin strips. The umbilical skin should be closed carefully with rapidly absorbable braided suture.
Careless closure of the umbilicus can result in granu- loma formation post-operatively.
The patients are fed clear liquids on the day of sur- gery. Pureed foods are useful for 3–4 weeks to avoid the dysphagia associated with oedema of the fun- doplication wrap. Discharge is 1–3 days after surgery.
Post-operative pain is controlled with intravenous ketorolac, scheduled acetaminophen and ibuprofen.
Narcotic agents are only used when necessary. The U-sutures in the gastrostomy are removed on the second post-operative day.
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Figure 6.10
Figure 6.11
CONCLUSION
Reflux control is excellent after fundoplication. Poor results are obtained in children whose pre-operative symptoms were unrelated to GER. Dysphagia can be symptomatic in up to 40% of children if they are allowed solid foods during the first few weeks of surgery. Long-term dysphagia occurs in less than 2%
of patients. Post-operative oesophageal dilatation should be avoided, as it is associated with breakdown of the fundoplication wrap and/or herniation of the stomach into the chest. Recurrent reflux at 2 years is less than 5% with little further recurrence after 2 years. Retching and choking are most commonly seen in neurologically impaired children. Those chil- dren with new onset retching after fundoplication are usually responding to overzealous feeding lead- ing to hypersatiety. Retching immediately after bolus feeding is often due to gastric distension or dumping
and can be ameliorated by dividing the feeding bolus into two parts given 30 min apart or by continuous drip feeding. Retching after the third or fourth bolus feeding of the day is often due to a low satiety set point and can be temporarily improved by anabolic steroids, which increases the child’s appetite. Gag- ging unrelated to feeding is often induced by a varie- ty of stimuli and is very difficult to treat. This global type of retching often results in breakdown of the fundoplication because of the chronic and forceful nature of the gagging.
Fundoplication is a highly reliable therapy in chil- dren with persistent or life-threatening GER. Lapar- oscopic fundoplication is superior to open fundopli- cation and should be in the repertoire of all paediat- ric surgeons who operate on children with GER.
SELECTED BIBLIOGRAPHY
Fonkalsrud EW, Ashcraft KW, Coran AG et al (1998) Surgical treatment of gastroesophageal reflux in children: a com- bined hospital study of 7,467 patients. Pediatrics 101 : 419–422
Georgeson KE (1998) Laparoscopic fundoplication and gas- trostomy. Semin Laparosc Surg 5 : 25–30
Rothenberg SS (1998) Experience with 220 consecutive lapar- oscopic Nissen fundoplication in infants and children. J Pe- diatr Surg 33 : 274–278
Sampson LK, Georgeson KE, Winters DC (1996) Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic fundoplication in children. Surg Endosc 10 : 1106–1110 Wulkan ML, Owings E,Georgeson KE (1998) Safety and effica-
cy of the 2 U-stitch gastrostomy tube. Surg Endosc 12 : 643
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