PURPOSE: Transthoracic Belsey fundoplasty is associated with lower incidence of gas bloat and dysphagia compared to the Nissen wrap. However Belsey Mark IV fundoplasty has rarely been considered in patients with gastroesophageal reflux disease due to the fact that it is performed via thoracotomy. Minimally invasive techniques for performing the complex procedure through via chest or abdomen have not been successful. The 3-D visualization, greater dexterity, more accurate dissection of the da Vinci surgical robot may facilitate a laparoscopic approach to the Belsey Mark IV procedure.
METHODS: From 1/04 to 8/07, 73 patients (39 men, 34 women, mean age 38 +/−9 years) with gastroesophageal reflux disease underwent robotic transabdominal Belsey fundoplasty. All patients underwent preoperative manometry and 24 hour pH study. The procedure was performed through five laparoscopic ports. The hiatus was closed anteriorly and posteriorly. The esophagus was intussuscepted into the stomach 2 cm for 270 degrees. Results were assessed by preoperative and postoperative endoscopy, UGI study, subjective symptom assessment and objective assessment of clinical reflux by Viscik grading.
RESULTS: Preoperative indications were intractability (68), pulmonary complications (5). Median operative time 3 hours. Median hospitalization 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). 59 patients scored 0 and were completely free of reflux symptoms. 69 patients (94%) had transient postoperative dysphagia which resolved by the third week. There was no gas bloat or long term dysphagia. Postoperatively 67 patients (91%) were Viscik grade 1 or 2. Recurrent hiatal hernia was seen in 4 (5%) patients who subsequently required an open repair.
CONCLUSION: Robotic laparoscopic Belsey fundoplasty is safe, associated with short hospitalization, and excellent results.
CLINICAL IMPLICATIONS: The use of the robot facilitates a minimally invasive transabdominal approach to the Belsey fundoplasty with low incidence of gas bloat and dysphagia.
DISCLOSURE: Eric Strother, No Financial Disclosure Information; No Product/Research Disclosure Information