Farid Gharagozloo, Marc Margolis, Barbara Tempesta.
George Washington University Medical Center, Washington, DC, USA.
Background:
Belsey Fundoplasty is associated with lower incidence of gas bloat and dysphagia compared to the Nissen wrap. However Belsey Mark IV fundoplasty has been rarely considered in patients with gastroesophageal reflux disease due to the fact that it is performed through a thoracotomy. Minimally invasive techniques for performing this complex procedure through the chest or the abdomen have not been successful. We reasoned the the 3-D visualization, greater dexterity and more accurate dissection which are provided by the daVinci surgical Robot may facilitate a laparoscopic approach to the Belsey Mark IV procedure
METHODS:
From 1/04 to 12/07, 78 patients (42men, 36women, mean age 41+/- 9 yrs.) with gastroesophageal reflux disease underwent robotic laparaoscopic Belsey fundoplasty. All patients underwent preoperative manometry and 24hr pH study. The procedure was performed through five laparoscopic ports. The hiatus was closed anteriorly and posteriorly. The esophagus was intussuscepted into the stomach by 2 cm for 270 degrees. Results were assessed by preoperative and postoperative endoscopy, UGI study, a subjective questionnaire and objective symptom assessment by Viscik grading of clinical state of reflux.
RESULTS:
Indications were intractability (68), pulmonary complications (10). Median operative time was 3 hours. Median hospitalization was 1 day. Two patients had intraoperative pneumothorax which did not affect the conduct of the procedure.There were no postoperative complications. Mean follow up was 28 months. Subjective symptomatic improvement judged by clinical scoring of reflux( maximum 12/patient) decreased from 8.6 +/- 0.6 to 0.6 +/- 0.2 ( p< 0.05). 62 patients scored 0 and were completely free of reflux symptoms. 73 patients (94%) had transient postoperative dysphagia which resolved by the third postoperative week. There was no gas bloat or long term dysphagia. Postoperatively 71 patients (91%) were Viscik Grade 1 or 2. Recurrent hiatial hernia was seen in 4 (5%) patients who subsequently required an open repair.
CONCLUSIONS:
Based on this preliminary experience robotic laparoscopic Belsey fundoplasty is feasible. Although greater follow up and experience are necessary, Robotics may facilitate the minimally invasive approach to a complex procedure which may be associated with less gas bloat and less dysphagia than the conventional laparoscopic fundoplication.
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