Robotic redo fundoplication for incompetent wrapping after antireflux surgery: A case report

Abstract

INTRODUCTION

Incidence of gastroesophageal reflux disease (GERD) is high. antireflux surgery with specific indications could be an option. Nissen fundoplication is the most popular surgical procedure for GERD, and recent results using laparoscopy have reported excellent short- and mid-term results. Regarding surgical outcome of antireflux surgery, the rate of complications has been reported as below 2.4%, but rare cases still require reoperation.

PRESENTATION OF CASE

A 53-year old male patient underwent laparoscopic Nissen fundoplication three years ago owing to gastroesophageal reflux disease (GERD) troubled by dysphagia and heartburn However, despite undergoing surgery, his symptoms did not show improvement .A robotic redo fundoplication was planned. The patient recovered uneventfully, and the esophagography on postoperative day four revealed improvement of previous upward contrast reflux and distension of the distal esophagus during swallowing had disappeared. Dysphagia and heartburn had still not occurred at one year follow-up.

DISCUSSION

Redo antireflux surgery for postoperative stricture is not an easy procedure due to postoperative adhesion and anatomical change. Robotic surgery may be more helpful for precise dissection of the adhesion site by a previous operation and robotic suturing for re-fundoplication was more effective.

CONCLUSION

Re-do fundoplication using a robot, which is a complicated procedure compared with primary anti-reflux surgery would be a general procedure in the near future.

1. Introduction

Incidence of gastroesophageal reflux disease (GERD) is high, and has shown an increasing trend worldwide.¹ Untreated GERD can lead to persistent symptoms and severe complications, like Barrett esophagus and esophageal carcinoma. Although the first treatment of choice for GERD is a proton pump inhibitor, antireflux surgery with specific indications could be an option.² The most popular surgical procedure for antireflux is Nissen fundoplication, and recent results using laparoscopy have reported excellent short- and mid-term results accompanied by reduced post-operative pain and shortened convalescence.^3–7

Regarding surgical outcome of antireflux surgery, the rate of complications like esophageal perforation and pneumothorax has been reported as below 2.4% in a high volume center.⁸ Although most complications could be managed by conservative treatment postoperatively, rare cases still require reoperation. Postoperative stricture of the esophagogastric junction following fundoplication could also be treated with conservative care or gastrofiberscopic dilatation; however, refractory cases should be treated by revision of wrapping. Revision of fundoplication is not easy to perform due to postoperative adhesion and the possibility of esophageal perforation during dissection.^9–12 Here, we report on robotic surgery using the Da Vinci system for revision of post-fundoplication stricture.

2. Presentation of case

A 53-year-old male patient who had undergone laparoscopic Nissen fundoplication three years ago visited our clinic for persistent progressive dysphagia, heartburn, and weight loss after surgery. He had difficulty in swallowing anything. For investigation of the cause of symptoms, the patient was tested with several studies. The esophagogram demonstrated that the esophagogastric junction was narrowed with distension and followed by the reflux of swallowed contrast from the stomach to the distal esophagus (Fig. 1). In addition, esophagogastroduodenoscopy revealed several continuous linear erosions above the occupying EG junction, and the cardiac fold was deformed by the previous fundoplication (Fig. 2). Esophageal manometry showed that the motility of the esophagus was normal. Based on these findings, revision of wrap by fundoplication using robotics was planned. Under general anesthesia, the patient was in a spine position for the robotic operation. Five trocars (two 12 mm, three 8 mm) were inserted into the abdominal wall, and the exact position of the trocars is described in Fig. 3. After docking of the trocars with the robotic arms, the previous operation site in the abdominal cavity was examined. We found that the esophagus was dilated, with heavy adhesion around the fundoplication. In addition, we found very short width of wrapping caused by previous incomplete suturing (Fig. 4A). However 36Fr bougie was easy to pass through the esophagogastric junction, which meaned anglulation was developed by the incomplete wrapping. Adhesion was dissected carefully using a harmonic scalpel and the stomach wrapping was resected using an endoscopic stapler, GIA 60 mm (Fig. 4B). Once the esophagus and the fundus of the stomach were fully mobilized, both diaphragmic crus were sutured (Fig. 4C) and new wrapping was made using another part of the fundus. Re-fundoplication was completed by three laparoscopic stitches with Vicryl #3-0, identifying the intact esophagogastric junction with a 36Fr bougie. We then fixed the esophagus to the diaphragm and sutured the previous stomach parallel to the longitudinal axis of the esophagus (Fig. 4D). The patient recovered uneventfully, and was able to tolerate a regular diet. In the esophagography on postoperative day 4, the reflux of contrast noted during preoperative study showed improvement, and distension of the distal esophagus during swallowing was not shown (Fig. 5). The patient was discharged on postoperative day 6. The patient did not complain of symptoms of dysphagia and heartburn during the first year of follow-up study.

Fig. 1.

(A) Esophagogram showed narrowing of the EG junction with distended distal esophagus 2 min after contrast ingestion, (B) clearing of contrast 5 min after ingestion, and (C) reflux of contrast from stomach to esophagus 7 min after ingestion.

Fig. 2.

(A) Endoscopy showed several continuous erosions above the esophagogastric junction and (B) cardiac fold was deformed by the previous fundoplication.

Fig. 3.

Trocars’ positions.

Fig. 4.

(A) Narrow wrapping by the previous operation, (B) resection of the wrapping with linear stapler, (C) suturing both diaphragmic crus and (D) refundoplication suturing.

Fig. 5.

Esophagogram showed smooth passage of the contrast through the EG junction, and previously noted upward contrast reflux did not appeared. Distension of the distal esophagus during swallowing also showed improvement.

3. Discussion

Postoperative stricture after Nissen fundoplication for treatment of GERD was one of the most disturbing problems. Redo antireflux surgery for postoperative stricture is not an easy procedure due to postoperative adhesion and anatomical change. Here, we first performed robotic redo antireflux surgery to solve this problem.Satisfactory outcomes of antireflux surgery for patients with GERD have been reported in 85–90% of patients.¹⁰ However, the remaining 10–15% of patients may have persistent reflux symptoms, recurrence, or complications.¹¹ Most of these patients received conservative treatment or endoscopic interventions. However, only 4–6% of patients with refractory symptoms or anatomical abnormality required reoperation.^13,14

In this case, the patients complained of postoperative dysphagia immediately after initial Nissen fundoplication. The common cause of that symptom is a wrap that is too tight or a stricture refractory. Although conservative treatment or endoscopic dilatation would be applied for these patients, about 10–15% of cases require surgical revision.¹⁵ However, due to the higher rate of complications, like gastric or esophageal perforation, stricture of the re-made wrap, and bleeding during dissection of the fundus, the decision to perform redo antireflux surgery should be made cautiously.

Some reports on reoperation by open laparotomy have been previously published.^12,15,16 As laparoscopic surgery has developed, reports of laparoscopic reoperation have increased.^13,17 While laparoscopic reoperation has the benefits of early recovery, less pain, and a shorter hospitalization, overcoming the learning curve technically and approaching the operative field in cases of patients with postoperative adhesion is difficult. However, recent extension of minimal surgery and laparoscopic fundoplication of primary surgery can lead to laparoscopic redo operation.

Along with being a minimally invasive technique, several technical points are critical to reduction of the rate of complication in redo fundoplication. Intraoperative endoscopy will aid surgeons in identification of the anatomical location of the distal esophagus and prevention of unexpected perforation of the esophagus or the stomach. In addition, the perforation would be easily detected. Tight wrapping, which became the cause of re-do fundoplication in our case, should also be avoided. The bougienage during this operation will aid in confirming that there is sufficient space in the esophagogastric junction during the re-do operation. In addition, adequate vertical lengthening of the wrap using about three to four stitches can also prevent reoperation due to postoperative stricture. In our case, bougienation and robotic suturing lead to a successful surgical outcome.

Comparing robotic surgery with the laparoscopic approach, it allows for more precise manipulations and increased dexterity by downscaling the surgeon's motion. It liberates the surgeon from the restraints of entrance ports, conferring improved ergonomic positioning. Visualization is improved with robotic surgery, because it allows a true three-dimensional view. Although there was no randomized trial, the feasibility of robotic surgery for treatment of GERD had already been reported when it was compared with open or laparoscopic surgery.¹¹ Because redo fundoplication requires a more complicated procedure, robotic surgery may be more helpful for precise dissection of the adhesion site by a previous operation. In our operation, adhesion of the previous fundoplication site was easily dissected without injury to the wall of the esophagus and the stomach by the robotic device. In addition, robotic suturing for re-fundoplication was more effective, in spite of the fibrosis of the fundus by the previous operation.

4. Conclusion

Robotic surgery has several limitations, like high cost; however, it has a very promising future. With further development of automatization and miniaturization features, robotic surgery may prove more efficient than conventional laparoscopy.¹⁸ Because the procedure is more complicated, the usefulness of the robotic procedure will receive greater emphasis. Therefore, re-do fundoplication using a robot, which is a complicated procedure compared with primary anti-reflux surgery would be a general procedure in the near future.

Conflict of interest statement

The authors of this manuscript disclose that they do not have any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.

Funding

None.

Ethical approval

A written informed consent was obtained by the patient for publication of this report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author's contributions

Sang-Uk Han was actively involved in the clinical and operative care of the patient and Drafted the article. Author for correspondence. JunYoung Kim, YongKwan Cho and Vu Duc Thu performed the literature review. Yi Xuan and Hoon Hur drafted the article, acquired the figures and revised the manuscript. All authors read and approved the final manuscript.