Complications of laparoscopic and thoracoscopic surgery

Our group has been very interested in transmigration of the fundoplication wrap as, in our experience, over 90% of the patients requiring a re-do fundoplication require it because of transmigration rather than the wrap falling apart. Between 2000 and 2002, we mobilized the esophagus extensively in order to create what we felt was an adequate length of intra-abdominal esophagus. In doing so, however, we found a 12% incidence of transmigration of the fundoplication wrap postoperatively. In 2002, we changed to minimal mobilization of the esophagus as well as placement of esophagocrural sutures to help obliterate this potential space for transmigration of the wrap. These two maneuvers resulted in a reduction in our transmigration rate to 5%. This was presented at APSA in 2006 and subsequently published in Journal of Pediatric Surgery (42:25-30, 2007). Thus, we feel that minimal mobilization around the esophagus and keeping the phrenoesophageal barrier intact alongwith placement of four esophagocrural sutures at 8 o’clock, 11 o’clock, 1 o’clock, and 4 o’clock are all helpful maneuvers to reduce transmigration of the fundoplication wrap.