LAPAROSCOPIC FUNDOPLICATION

Most reports on laparoscopic fundoplication are from large, tertiary r eferral medical centers. Presented here is an experience by a single s urgeon (M.E.F.) in community hospitals with 74 cases. All patients had esophagitis. All but two patients were Visick grade IV off medication . All patients had an incompetent lower esophageal sphicter. Four with abnormally low esophageal contractions underwent a Toupet procedure; the rest had a Nissen fundoplication. The largest estimated blood loss was 300 cc. One case (1.4%) had to be converted intraoperatively to a n open procedure because of bleeding from an iatrogenic liver lacerati on. There were two minor complications (a urinary tract infection and a pneumothorax) and one death (massive liver necrosis with an otherwis e unremarkable post mortem, thus it was felt to be due to anesthesia). The mean length of hospital stay was 2.8 +/- 0.21 days. Eighty-nine p ercent of the operations totally relieved reflux. Nineteen patients (2 6%) had mild, early postoperative dysphagia, gas bloat, and/or early s atiety. Four patients did not get any improvement in their reflux, thr ee still require chronic medication, and one underwent a redo open fun doplication. Three early patients had severe, new-onset postoperative dysphagia secondary to too tight a fundoplication. Attention must be f ocused on creating a loose wrap, a ''floppy'' Nissen by routine divisi on of the short gastric vessels and the use of a large dilator in the esophagus when the fundoplication is constructed. Laparoscopic fundopl ication is technically feasible, safe, and effective in a community ho spital and does not require a large, tertiary referral medical center.