Introduction Laparoscopic Nissen fundoplication (LNF) is widely used in the surgical management of gastroesophageal reflux disease (GORD). However, it is a complex operation that requires advanced laparoscopic skills. Very few studies report objective testing postoperatively; those that do show high rates of failure within the first 1–3 years following surgery. Complications and failures of LNF are directly related to surgeon’s experience and the learning curve has been identified as a confounding factor.
The Aim of this is analyse a single surgeon’s first 50 consecutive primary LNFs experience. The data will be used to attempt to define the learning curve (LC) for LNF using success as surrogate marker of competency, and of how this may influence future training.
Methods All the patients who underwent antireflux surgery were entered into a prospectively maintained database. The procedures were performed using a five-trocar technique and with 10-/5- mm ports and instruments. Surgical outcome was recorded using the Viscik symptom evaluation tool and complications graded according to the Dindo-Clavien classification. Captured parameters included patients’ demographics, BMI, ASA grade, pre-operative investigations, operating time, indications for surgery, laparoscopic to open conversion rates, re-operation rates, morbidity, and mortality, follow up, and further investigations and interventions. Systematic case per case retrospective note analysis was performed.
Results The first fifty consecutive cases underwent primary sutured cruroplasty and Nissen’s fundoplication by or under the direct supervision of the operating surgeon. One patient was abandoned due to inability to access the hiatus and one converted to open for bleeding from the omentum upon insertion of the primary port (both were during the first 25 cases). Three patients suffered with complete post-operative dysphagia, 2 resolved during the first 48 hours and one was converted to Toupet’s (they were all during the first 25 cases). On follow up, one patient was re-operated and undone two years following the procedure for continuous epigastric pain with good outcome and one who had belching as a predominant symptom did not derive any symptomatic benefit from the procedure.
Conclusion Laparoscopic antireflux surgery “a reparative procedure” is not a natural extension of laparoscopic cholecystectomy “an extirpative procedure”. Different dissecting skills and mastery of intracorporeal suturing and knot tying are necessary for laparoscopic antireflux surgery. The long and steep learning curve can be modified but not eliminated by systematic training and direct supervision during the first 25 cases. Occasional surgical treatment of GORD must be discouraged in order to achieve best possible surgical outcomes.
Disclosure of Interest None Declared
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