Multiple Failed Fundoplications are likely not amenable to Laparoscopic Repair
B L. Paton, Yuri W. Novitsky, Kent W. Kercher, B Todd Heniford; Dept. of Surgery, Carolinas Medical Center, Charlotte, NC
The laparoscopic approach to reoperative nissen fundoplication has proven to be feasible with excellent overall results. The minimally invasive approach to redo fundoplication however will not be possible for all patients. The aim of this study is to determine predictors of which patients will require an open redo fundoplication. Methods: From May 1997 to July 2005, at a tertiary referral center for complex laparoscopic procedures, the records of patients who underwent redo fundoplication were retrospectively reviewed. Results: Ninety patients (43 male: 47 female) with a mean age of 49 years (range 28-82) presented with recurrent symptoms after undergoing an antireflux procedure. Forty-eight patients had a previous open repair and forty-two patients had a previous laparoscopic repair. Seventeen patients included in the open group and eight patients in the laparoscopic group were undergoing their third or fourth fundoplication. Laparoscopic repair was attempted in seventy-four patients (82%); with twelve patients requiring conversion (13%). Sixteen patients (18%) underwent planned open repair. Of the patients who required conversion, eight had a previous open repair (with two patients having undergone three prior fundoplications) and four had previously undergone a laparoscopic repair (with two patients having undergone two previous fundoplications). Of the planned open group fifteen patients (93.8%) had previously had an open repair with two undergoing their third fundoplication attempt. Three patients had concurrent procedures including cholecystectomy and ventral hernia repair. Thirteen patients (27%) however who had a previous open repair were successfully treated with the laparoscopic approach. Of the twenty-five patients who were requiring their third or fourth fundoplication, only two patients were successfully repaired laparoscopically. Complications were higher for the open group and included an intraabdominal abscess, pneumonia, four wound infections, and one deep vein thrombosis. One patient in the laparoscopic group developed pneumonia. The mortality rate was 0%. Conclusion: Complex patients who have had multiple failed fundoplications are likely not candidates for laparoscopic repair. The laparoscopic repair is possible however for those who have had one previous open repair and though the procedure is technically challenging it does have a lower rate of complications.
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