Abstract
I began to realize its importance when I first started doing laparoscopy. I did my first minimally invasive operation in 1989. It was a laparoscopic cholecystectomy. After doing a few, it became evident to me that this was really a much better way to remove the gallbladder.
We then realized that if we could safely remove the gallbladder laparoscopically, why could we not do other operations laparoscopically? So we progressed to appendectomy, and around 1992, or so, some of us started doing the laparoscopic fundoplication.
An interesting thing occurred during the learning curve, for me at least, in that I thought it would be better to perform a laparoscopic fundoplication on older children first to learn the technique, and then utilize it in younger children. When I was at Vanderbilt, I went to our GI [gastroenterology] colleagues, and I talked to them about doing laparoscopic fundoplications in older kids. They were really glad to refer patients because they thought it was a good open operation, but they did not like the large incision.
I started doing them in older kids because I thought it would be easier. It is important to remember that, back then, we did not have a Harmonic® scalpel, a LigaSure™, or anything like that. We had clips and ties. So I started putting endoscopic clips on the omentum and short gastric vessels. As you know, in an older child, there is a lot of adipose material in the short gastric vessels, and I sometimes struggled being able to identify the vessels clearly.
I would put clips on the vessels and cut, and there would be a lot of bleeding because I did not get the clip on the vessel because we could not see it very well in the older kids.
After doing this, 8 or 10 times, I figured out it would be better to do these operations when the patients were younger. Today, you would think that concept is a no-brainer. However, early in my experience, it seemed that it would be better to do a 50-kg adolescent rather than a 5-kg infant. But now we obviously do a lot in babies, and there is not much blood loss at all.
Another interesting fact to note is that the Harmonic scalpel was designed for a laparoscopic fundoplication. That is why the blade curves to the left, so the surgeon can use it along the greater curvature of the stomach. Now, it is obviously used for a lot of other things.
I did a few fundoplications before my first splenectomy, but not many. I think I did the first laparoscopic splenectomy, at least as reported in the literature, in 1993.
While I was in Nashville, I was personally helped by one of the real pioneers, Doug Olson, who, along with Eddie Joe Reddick, wrote the first papers in the late 1980s on laparoscopic cholecystectomy.
But what took it to the next level for me—that is, being able to do fundoplications and adrenals and things like that—was the fact that the first MIS fellow started at Vanderbilt on the adult side. The MIS surgeons at Vanderbilt thought it was very important to have these fellows participate in some pediatric cases because they thought it would add to the fellowship and make the fellowship more enticing.
I think either our second or third fellow was Ronnie Clements. Ronnie is a superb surgeon, and he is currently the Director of Bariatric Surgery at Vanderbilt. He is the one who really helped me learn how to do fundoplications, adrenals, and spleens because he was doing them in adults, and he showed me how they were positioning the patients, port placement, and things like that.
I have not used extracorporeal suturing on many patients. I learned intracorporeal knots early on, and kept with that technique.
Yes, I started with intracorporeal knots because some of the adult surgeons were tying this way. Also, as you know, it is easy to throw the knot extracorporeally, but it is difficult to get it down the cannula and then get it secured. Additionally, if you are putting four or five knots down, with the knot pusher sliding off the suture each time, and you are putting several sutures in, it takes time. So it became more efficient to tie intracorporeally.
That's an interesting question. As you recall, the only fellows that were around me when I was at Vanderbilt were the MIS fellows I was telling you about.
Also, the general surgery residents were not that facile in the early 1990s with laparoscopy. We had, as I recall, second- and third-year residents, and they had not learned much MIS. In hindsight, this was probably a benefit to me because I had to do most of the cases myself.
However, in 1999, when I came to Children's Mercy Hospital in Kansas City, there were pediatric surgery fellows who had finished their general surgery training and had learned how to do MIS. It was probably about this time that I felt much more comfortable teaching them the intricacies of pediatric MIS.
I think laparoscopic fundoplication is a great operation and is curative of the patient's symptoms, assuming that the wrap stays intact and remains in the abdomen. It is an operation that is reproducible and safe, the patient goes home the next day, and his or her symptoms resolve.
But, at least in my patients, we were having difficulty with migration of the fundoplication wrap into the chest. Because of this complication, it was an operation that had great results, but also had a re-do rate of 12%–15%. So, I thought it was really important to try to figure out how we could reduce that rate of re-do fundoplication to certainly less than 5%, and as low as possible.
No and yes. Prior to the development of the trial, I did some other things first. I will never forget that in 2003, I was seeing a patient in the clinic who needed a re-do fundoplication, and I was thinking, “There has got to be a better way. There has got to be a way to prevent the need for a re-do fundoplication.” The laparoscopic re-do fundoplication and hiatal hernia repairs are hard operations, and I was committed to figure out a way to prevent the need for a second operation.
It struck me that all of the re-dos were because the wrap had migrated into the chest. We needed to do something to keep the wrap anchored in the abdomen, and that was to do as little dissection as possible, and also to secure the esophagus to the diaphragmatic crura using esophagocrural stitches to obliterate any space that might allow the wrap to transmigrate.
During that same time Mac Harmon, who is now the Surgeon-in-Chief in Buffalo, NY, and I would see each other several times a year, and he told me that he did minimal dissection around the esophagus. I thought, “Well, maybe I ought to try that.” Decreasing the dissection, in conjunction with the esophagocrural sutures, led to a retrospective analysis in 1995. This analysis showed that we were able to drop the re-do rate from 15% to 6% or 7%. That was a really good success story.
The randomized trial was conceived when Keith Georgeson was a visiting professor with us. We were in the operating room with our pediatric surgery fellow at the time, Shawn St. Peter. We were discussing the changes that we had made in terms of less dissection and use of the esophagocrural sutures. Keith made the statement that he was not sure that the less dissection and the sutures were that helpful, but they certainly were helpful to some extent. And so I think I said, “Why don't we do a prospective randomized trial between your group of surgeons and our group of surgeons, and let's see what the answer is?” And he said, “That is a great idea. Let's do it.”
My aha moment was when I saw the results of the retrospective review of my patients after modifying the technique. They were my own patients. One cohort was from about 2000 to 2002, and there were about 140 patients, and then we changed the technique to very little esophageal mobilization and use of esophagocrural sutures. For the next 2 years I did about 130 patients and reduced the need for re-do fundoplication from 12% to 5%. To me, that was the aha moment. I was pretty convinced that esophageal dissection and mobilization, along with the esophagocrural sutures, were much better than the previous technique using a good amount of esophageal mobilzation.
In pediatric surgery, we have generally taken adult instruments and adapted them to our use. I think the biggest development for pediatric surgery has been the development of the Storz Clickline's set of 3-mm instruments. Storz has always been a good partner for pediatric surgery, and it has created a line of instruments that are 3 mm in diameter that were really made for the pediatric surgeon.
I think these instruments were developed around 2005, and showed that you could build a sturdy set of instruments that could be continually used and that would be very effective for pediatric surgery. I think that was a very important innovation.
There was another company called Jarit, which I liked because they created a 3-mm needle holder for us that was a self-righting needle holder. I have always liked that particular needle holder. They developed it in the early 2000s, as well, and that was really the first really good 3-mm needle holder. Prior to that, there really was not a good needle holder for use in kids.
Right. I think we started doing that around 2000 or 2001, and I decided to do the stab incisions because we really did not have good 3-mm cannulas. There were a few cannulas, but they were expensive to use. The impetus really was to save on costs, because there is an expense involved with using five 3-mm disposable cannulas for a fundoplication.
One thing led to another, and because we were using the stab incisions for pyloromotomy, and we were using the same-size instruments, it seemed natural to just extend their use to other operations, especially fundoplication. It's nice to see that a lot of people have now adapted this technique.
Another significant advancement came when Storz decided to make shorter 3-mm instruments. Instead of the standard 20-cm-length instruments, Storz made us 10- and 14-cm instruments. And I always get a kick out of hearing the story from the folks in Germany, in Tuttlingen, where Mrs. Storz would close the factory for a week or two and just make these special instruments at the 10-cm length and 14-cm length. She has a great commitment toward pediatric surgery.
I think the person who deserves all the credit in the world for the laparoscopic gastrostomy technique is Keith Georgeson. The technique that we currently use is the technique that he developed.
Back in the 1990s, it was very difficult to do a gastrostomy, and a lot of people would even do somewhat of an open-type gastrostomy even after doing a laparoscopic fundoplication. Then somebody came up with the T-fastener concept. For quite a while, that was the best we had; however, they could be really quite difficult to use correctly.
Fortunately, in the late 1990s, Keith came up with this idea of just putting transabdominal sutures through the abdominal wall and stomach and then back out through the abdominal wall. That was a game changer, in that the operation was made so much easier. It was a huge improvement over what was a very cumbersome technique.
Keith is known for a lot of innovation; some people may not know that that was his innovation. But it certainly is one of the more long-lasting innovations that he has developed.
No. That was just serendipity—a little luck and a little serendipity. I had been trained to use the bougie, and I feel it is important.
I thought the table would be helpful because I was concerned that when doing the fundoplication wrap, especially in these small babies, it was possible to obstruct the esophagus by making it too tight.
Honestly, the first 10 or 20 cases, we sort of eyeballed what size bougie we thought we should use. Almost all of our cases were under 15 kg. So, we created the table, and then we sort of validated it. But the table seems to be valid based on the fact that there is virtually no need for postoperative dilations if one uses the table.
One point should be emphasized: I think that the bougie sizes recommended in our table may, at times, be a little bit more generous than is actually needed. What that means to me is that if, during the operation, you cannot get the selected bougie across the esophageal hiatus, it is okay to downsize and put the next smaller one in there.
However, if you can get the fundoplication wrap performed over the selected bougie based on the table, you should not have any trouble with dysphagia. Dysphagia is always something that the gastroenterologists are worried about, and routinely talk to families about. I feel very confident in telling my families that that is not very likely to happen, at least in our experience.
I would comment on one great advancement and one concern. Currently, in Europe and other continents, there is a movement to do the so-called Nissen–Rossetti operation. With this modification, the short gastric vessels are not divided. I do not know why some surgeons use this modification. It only takes 5 minutes or so to divide the short gastrics, and there is no reason not to divide them. You are not going to hurt the vascularization of the stomach. Having done a few Nissen–Rossettis, it always seems like the wrap is under a lot of tension, and it never appears to be loose and floppy. So, I am a big believer in taking down some of the short gastric vessels, because I believe that it gives you less tension on the wrap.
The advancement I mention above is clearly the progression in technique toward less esophageal mobilization. As you know, less mobilization and dissection have been shown to be superior to maximal dissection in a prospective randomized trial. We have recently completed another prospective randomized trial comparing less esophageal mobilization and dissection (without esophagocrural sutures) versus less dissection and use of esophagocrural sutures. We are now in the period of getting a postoperative upper GI study at one year to complete the data collection.
Without a doubt, I can tell you that the need for re-do fundoplications in my hands, and in the surgeons' hands that have moved toward less esophageal mobilization and dissection, has markedly decreased over the last few years with the use of the less esophageal dissection.
That's a great point. We are now doing more gastrostomies alone (without fundoplication) than we used to do, because I think that we are becoming more savvy about knowing whether the child really needs a fundoplication, or can get by with just a gastrostomy.
It is really important not to put the gastrostomy too high on the greater curvature of the stomach, so that if you need to come back and do a fundoplication down the road, it won't be in the way. This is a key point.
The only thing I would add is that there are different approaches to this operation. For example, Steve Rothenberg and I differ on our initial approach. Steve starts along the lesser curvature and incises the gastrohepatic ligament first, and approaches the GE [gastroesophageal] juncture from the patient's right side first, and then goes to the patient's left side. I have always thought that it was better to go from the patient's left side (surgeon's right side) first, take down the short gastrics, and then address the gastrohepatic ligament side second. Just a difference in opinion.
Finally, I think it's important that one uses, at a minimum, a 45° telescope. Often in the small babies, a 70° scope is very helpful. More angulation from the telescope can often makes the operation easier. So I would just suggest that surgeons use as much angulation on the scope as possible.
Thank you, Dan.