Robotic-Assisted Laparoscopic Nissen Fundoplication with Gastrostomy Preservation in Neurologically Impaired Children

Abstract

Robotic fundoplication has equivalent safety profiles, hospital stay, and time to alimentation, compared to laparoscopic fundoplication, but is not indicated for routine repair due to higher cost, decreased availability, and longer procedure time. Robotic surgery does offer key advantages over standard laparoscopy by employing internally articulating arms, a stable camera platform, and three dimensional imaging. Children presenting for initial or redo fundoplication after feeding gastrostomy are a subset of patients that may benefit from the robotic approach. Minimal dissection of the phrenoesophageal ligament, in combination with four anchoring sutures from the esophagus to the crura, has been shown to lead to less wrap herniation in children. This technique is particularly difficult in standard laparoscopy without dislodgement of the gastrostomy, particularly if there are abundant adhesions or a replaced left hepatic artery to preserve. In this article, we present 15 children with neurologic impairment and previous gastrostomy who underwent Nissen fundoplication, using the da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA). All patients underwent a floppy Nissen fundoplication after crural closure and placement of four anchoring stitches to the crura. Six patients (40%) had redo Nissens and 5 (33.3%) had replaced left hepatic or accessory arteries that were preserved. Seven patients underwent repair of a hiatal hernia and 2 had biologic mesh placed. There were no conversions to open or intraoperative complications. One child had a revision of the gastrostomy site, because the prior percutaneous endoscopic gastrostomy had been placed through the transverse mesocolon. There were only a few minor postoperative complications. All children were doing well at latest follow-up (average, 32 months). The da Vinci surgical robot can be used to safely perform fundoplications in patients with gastrostomy tubes. The articulating instruments allow for the optimal placement of four crural tacking sutures, while preserving the gastrostomy, even in the presence of a replaced left hepatic artery.

A literature review of the outcomes after robot-assisted laparoscopic and conventional laparoscopic Nissen fundoplication for gastro-esophageal reflux disease in children

“…The included studies did not separate their results regarding those children with or without gastrostomies. It is therefore not possible from these data to evaluate whether a gastrostomy affects the above mentioned parameters, but previous reports claim that it is not a practical obstacle for performing a fundoplication .…”

The learning curve of robot-assisted laparoscopic fundoplication in children: a prospective evaluation and CUSUM analysis

“…We are unable to affirm this with supportive data; however, Lehnert et al have previously demonstrated that hiatal dissection is able to be undertaken 34% faster ( p < 0.05) with robotic assistance than in conventional laparoscopy. In this context, it is also our impression that the advanced technical features of robotic assistance become more apparent and valued in cases that are more complex, such as those involving previous fundoplication, abnormal anatomy and pre‐existing gastrostomy .…”

Current Trends in Pediatric Robotic Surgery

“…A recent article reported robotic-assisted laparoscopic Nissen fundoplication in neurologically impaired children and found that although robotic-assisted fundoplication is not yet indicated for routine fundoplication it does have benefits in children with previous gastrostomy, adhesion from previous abdominal surgery or failed primary fundoplication. Robotic fundoplication has also successfully been reported by others [77][78] . In 2007, a case report was published on the robotic repair of a bochdalek congenital diaphragmatic hernia in a small neonate 79 .…”