Schematic of patient positioning.
(a) Schematic of trocar placement, (b) Picture of trocar placement.
This technique has been developed over the last 2 decades with minor revisions to improve outcome [7–9]. The left lobe of the liver is retracted superiorly to expose the gastroesophageal junction through the right upper quadrant port. Although a self-retaining retractor may be used, a babcock retractor with a locking in-line handle can be placed on the diaphragm to expose the hiatus. With the stomach retracted towards the left by an assistant through the left upper quadrant port, the gastrohepatic ligament is divided (Fig. 22.3). The stomach is then retracted to the right and the short gastric vessels are divided either with electrocautery or a sealer device in older children (Fig. 22.4). Short gastric mobilization is necessary to achieve a tension-free wrap. A retro-esophageal window is then created bluntly from the right side with care not to injure the posterior vagus nerve (Fig. 22.5). The right crus should be dissected so that the gastroesophageal junction can be clearly identified and an adequate length of intra-abdominal esophagus is confirmed. A crural repair is then performed in all cases to decrease the risk of hiatal hernia formation post-operatively (Fig. 22.6). The stomach is brought through the retro-esophageal window and a shoeshine maneuver is performed to assure that the stomach is not twisted (Fig. 22.7). The fundoplication wrap is then performed with three sutures (Fig. 22.8). The most superior suture incorporates a small piece of anterior esophagus and right crus to help secure the wrap. The two more inferior sutures incorporate just anterior esophagus. The wrap should be about 2–3 cm and be oriented at the 11 o’clock position. In addition, it is important for the wrap to be above the gastroesophageal junction.
The stomach is retracted to the left by the assistant and the retrohepatic ligament is visualized for division.
The stomach is being retracted to the right and the short gastric vessels are being divided with electrocautery.
A retro-esophageal window is bluntly being created from the right side. Arrow indicates the posterior vagus nerve.
After the right crus was dissected and adequate intra-abdominal length was ensured, a crural stitch is placed with a braided nonabsorbable suture.
The stomach is brought through the retro-esophageal window and a shoeshine maneuver is performed.
The fundoplication is created with three 2–0 ethibond sutures. The wrap should be approximately 2–3 cm, floppy, and oriented at 11 o’clock.
If there is a large defect or recurrent hiatal hernia, the crural repair should be performed with pledgets and horizontal mattress sutures. An orogastric tube is usually sufficient to complete the wrap particularly in smaller infants. However, a bougie may be placed before the fundoplication wrap is performed to avoid creating too tight a wrap around the distal esophagus. Ostlie et al. have published a table of appropriate bougie sizes for infants weighing less than 15 kg . If a gastrostomy is required, the trocar site in the left upper quadrant is used for the button site. A number of techniques may be used to create the gastrostomy .
Divide the short gastric vessels to create a tension-free wrap
Mobilize an adequate length of intra-abdominal esophagus
Perform a crural repair in all cases to avoid hiatal hernia formation
Create a 360-degree wrap, approximately 2–3 cm in length, and oriented at the 11 o’clock position
Dissection should not be extended into the mediastinum or through the phrenoesophageal ligament in order to decrease the risk of creation of a hiatal hernia
For patients who had a gastrostomy button placed at the time of fundoplication, feeds can be started either on the first postoperative day or that evening and advanced as tolerated. If no gastrostomy was placed, clear liquids may be started 4–6 h postoperatively. Patients are then kept on a soft diet for approximately 2 weeks to avoid complaints of dysphagia due to post-operative edema around the fundoplication.