Laparoscopic Pediatric Fundoplication
Gastroesophageal fundoplication currently is one of the three most common major operations performed on infants and children by pediatric surgeons. With the advent of laparoscopic surgery, the number of gastroesophageal fundoplications has virtually exploded. Morbidity always was substantial with this operation, and laparoscopy has not changed this.
In recent years, laparoscopic Nissen fundoplication has been performed with increasing frequency in pediatric patients with symptomatic GER because it causes minimal trauma to the abdominal wall and supposedly eases patient recovery. Initial experience demonstrates that Nissen fundoplication can be accomplished successfully and safely using the laparoscopic approach in very small babies suffering from severe GER. Infants and children who are candidates for the antireflux procedure differ in many aspects from the adult population. In adults, GER is typically associated with hiatal hernia and is usually unrelated to any other abnormality. In children, on the other hand, there is usually no hiatal hernia, but clinically significant GER is often associated with neurological impairment, metabolic abnormality, or some other severe underlying disease. Therefore, even after successful surgical resolution of GER, these babies often remain very sick due to their primary disease.
Many children undergoing antireflux operation are at increased risk because of chronic parenchymal lung damage due to recurrent episodes of pneumonia and because they are often severely malnourished. Operative risk is especially high in children with familial dysautonomia. Concomitant impairment of gastrointestinal motility is also unique to the pediatric population. In particular, impairment of the swallowing mechanism and delayed gastric emptying should be taken into account by the surgeon. Hence, when the swallowing mechanism is impaired, gastrostomy should be constructed for postoperative feeding or fluid administration to prevent persistent aspirations. Likewise, the surgeon should consider pyloroplasty when there is preoperative evidence of delayed gastric emptying. In this case, it is usually preferable to do an open procedure, although a pyloroplasty can be accomplished through a small laparotomy incision at the end of the laparoscopic procedure. There are several technical concerns in laparoscopic Nissen fundoplication that are unique to infants and small children. Because the operating space is very small, it is necessary to use specially designed short instruments and to handle them with great care. To prevent dislocation, the trocars need to be secured to the skin by stitches.
The pneumoperitoneum should be maintained at pressures as low as 10 mm Hg. Elevation of pressure may cause difficulty in ventilation, with resultant hypercarbia. It is sometimes necessary even in the pediatric age group to increase the pneumoperitoneum pressure temporarily, for example during suturing, and to immediately deflate the abdomen if expiratory CO2 increases or any difficulty in ventilation is encountered. At the same time, the minimal fat around the esophagus in these small babies and the absence of hiatus hernia make the definition of the dissection planes clearer. Thus, the dissection itself, including mobilization of the esophagus, identification of the vagus nerves, and construction of the fundic wrap are easier in small children than in adults. Furthermore, it is usually unnecessary to divide the short gastric vessels to achieve a tension-free wrap. Small children who need an antireflux operation often suffer from chronic lung disease, which makes them especially susceptible to postoperative lung complications. The laparoscopic approach seems to minimize these complications. The minimal trauma to the upper abdominal wall in this approach results in less impairment of respiration and thus minimizes the need for narcotics and sedatives postoperatively is pediatric patients. Recent reports suggested that recovery was smoother following laparoscopic antireflux operations than after open procedures, with comparable short-term results. Laparoscopic Nissen fundoplication is feasible and safe in very small children and infants and that it appears to offer some advantages over the standard open technique.