Robotic-Assisted Laparoscopic Redo Nissen Fundoplication. Does it Offer Advantages in
Mario Navarrete Arellano*
Hospital Central Militar, Mexico
Submission: June 27, 2019; Published: August 28, 2019
*Corresponding author: Mario Navarrete Arellano, Consultorio 1C, Módulo B, Torre Sur, Calle Sur 136 No. 116, Las Américas, Álvaro Obregón, C.P. 01120. Mexico City, Mexico.
How to cite this article: Mario Navarrete Arellano. Robotic-Assisted Laparoscopic Redo Nissen Fundoplication. Does it Offer Advantages in Children?. Acad J Ped Neonatol. 2019; 7(5): 555781. DOI: 10.19080/AJPN.2019.07.555781
Objective: The experience in RALRNF and its advantages in children is presented.
Materials and Methods: A prospective, observational, and longitudinal study from March 2015 to March 2019, in children treated with RALRNF. Parameters examined: demographic data, diagnoses, surgical technique, recurrence of our PRF, previous surgical approach, time of console surgery, TO surgical findings, bleeding, hemotransfusions, complications, conversions, PO stay, and follow-up. Surgical system used was “da Vinci model, Si versión” (Intuitive Surgical, Inc., Sunnyvale, CA. U.S.A). Measures of central tendency were used. Research Ethics Committee of Hospital approved the study.
Results: In 4 years, 19 RALRNF cases were performed in children; 66.16% were male; averages in age was 10.3 years, stature 135.2cm, and weight was 36.3kg. Previous fundoplications was 10 open, 6 laparoscopic and 3 robotic. Recurrence rate of our PRF cases was 6%. TO findings: HH and wrap dehiscence 52.63% and only wrap dehiscence 47.37%. Average time of console surgery was 280 min. Conversion rate and hemotransfusion was 5.2%. TO complications occurred in 21% and not alter PO evolution, PO complications and mortality 0%. A RALRNF failure occurred (5.2%). Averages PO stay was 2.2 days, and follow-up 24.1 months.
Conclusion: The failed fundoplication is frequent, and RF is complex, difficult and laborious technique. With the RALRNF we achieved low risk of conversion, no complications, few hemotransfusion, short TO stay and low recurrence rate for our patients. The RALRNF if offers advantages to the children. Only expert pediatric surgeons solve them, by conventional laparoscopy. There are few publications of RALRNF in children.
Gastroesophageal reflux is very common in children and can often leads to reflux-esophagitis, peptic esophageal strictures, Barrett’s esophagus. If the conservative treatment fails a patient needs surgical treatment as well as those who suffer from complications and HH [1,2]. Fundoplication is considered a mainstay in the surgical treatment of gastro-esophageal reflux . The most popular operation is laparoscopic primary Nissen fundoplication (LPNF) with the efficiency of more than 80%, and there are authors who refer to this procedure as the gold standard [1, 4].
Pediatric endoscopic surgery in children dates from 1971, the first case of laparoscopy in pediatric surgery was reported by Stephen Gans in this year, in his landmark publication, “Advances in Endoscopy of Infants and Children,” as a peritoneoscopy. The term peritoneoscopy was soon replaced by Pediatric Laparoscopy [5,6]. But the first publications of laparoscopic fundoplication in children date from the early nineties [7-9].
On the other hand, the first minimally invasive robot-assisted surgery in children was the fundoplication technique, were carried out by Meininger et al.  in July 2000 and reported in April 2001 [10,11]. The fundoplication is a leading application of
robotic surgery in children in GI area, since then [12,13].
In children, the current alternatives for fundoplication are the
approaches: open, laparoscopic and robotic for fundoplication,
and the main challenge is to redo fundoplications (RF) in
patients who fail the primary procedure, this occurs in a wide
range between 2.6% to 42%. [1,3,14-16]. On the other hand,
the recurrence of gastroesophageal reflux disease (GERD) after
surgical treatment can be presented independently of the surgical
approach used, as evidenced by Ru W et al.,  in a systematic
review and a meta-analysis of patients undergoing laparoscopic or
open primary Nissen fundoplication, they did not find a significant
difference in the recurrence . Other study by Thomas JF, et al,
they compare recurrence of GERD in children through a study
randomized, laparoscopic (44 patients) VS open primary Nissen
fundoplication (43 patients), with the main outcome measure was
recurrence of GERD. The results where, significantly more patients
that undergoing LPNF (37%) experienced recurrence of GERD,
compared with only 7% to those undergoing open primary Nissen
fundoplication , also with the robotic approach, failures of
primary fundoplication occur between 2% to 4.7 % [19-21]. So,
we can say that the recurrence of GERD after surgical treatment
The most used approaches to perform the Nissen fundoplication
in the world are the open and the laparoscopic. The robot-assisted
has only been slowly adopted for use in children and in particular
with the technique of the primary Nissen fundoplication, there is
special controversy between laparoscopy and robotic approach,
because pediatric surgeons experts in laparoscopy and several
published studies, comparing both approaches, no significant
advantages are observed with the use of the robotic approach, but
yes, a big drawback, that robotic surgery increases costs [3,22,23].
However, robotic surgery offers advantages for the patient and
for the surgeon, which means that procedures for the patient are
It’s important to mention in relation to the experience in the
world of conventional laparo-thoracoscopic surgery in children,
that the application of this, have at least a decade more experience
that the robotic surgery and a significant number of publications
compare conventional laparoscopic results with robotic surgery,
and where in the latter they include the learning curve of surgeons,
what can influence the results and skew the conclusions, as to
time of console surgery, complications, and conversions [22,24].
For example, Rothenberg with his vast experience in
minimally invasive surgery in children, in his report on LPNF
for a 20-years period and procedures realized were 2008, your
results are: average operative time dropped from 109 minutes
for the first 30 cases to 35 minutes for the last 30 cases. In redo
surgery, of the 283 procedures that were RF, the complications
rates were intraoperative 2.2% and PO 4.2%, The overall wrap
failure rate for primary fundoplications was 4.6% and was highest
in the <6-month age group. Based on the results presented, the
author states that LPNF should be considered the gold standard
for antireflux procedures. But, even with the author’s experience,
the failure rate in the group of the laparoscopic redo Nissen
fundoplication (LRNF), was 6.8% .
If conventional laparoscopy is used, the reconstructive and
complex procedures are very challenging, and long periods of time
are necessary to acquire the appropriate skills and confidence, vs.
robotic surgery, the learning curve is shorter [25-28].
There are hospital centers in the world that reoperate the
GERD, through open redo Nissen fundoplication, even having with
minimal invasion, and in other studies they do not mention the
option of laparoscopy [29-32] of what is inferred, the complexity
of the surgical technique and probably the lack of experience in
minimally invasive surgery.
Open redo Nissen Fundoplication or LRNF has a variable
failure rate 6% to 42%, [4,16,33-35], what translates the high
complexity of this pathology.
The robotic surgery enables more refined hand-eye
coordination, superior suturing skills, better dexterity, and
precise dissection. It is achieved by the characteristics of robotic
surgical platforms that include motion scaling, greater optical
magnification, 3D and stereoscopic vision, increased articulated
instrument tip dexterity, tremor filtration, operator-controlled
camera movement, and elimination of the fulcrum effect [36-
39], and all of this translates into greater safety for patients and
advantages for the surgeon.
Robotic surgery is one technology that has gained an enormous
surge in use on adults. The general surgical applications have been
quite varied in adults [40-43].
There have been few reports that have been published
for robotic general pediatric surgery [44-53]. Numerous case
reports, case series, and comparative studies have unequivocally
demonstrated that robotic surgery in children is safe .
Cundy TP et al,  using cumulative summation analysis to
define the learning curve for PRF, time-based surgical process
outcomes were evaluated, as well as clinical outcomes, the authors
identified numerous well-defined learning curve trends to affirm
that experience confers significant temporal improvements, for
the time of console surgery from procedure 34.
RF is generally more difficult because anatomic planes are
obscured by adhesions from the previous surgery, whether it
is open or laparoscopic and the very features that distinguish
minimally invasive surgery can be the cause of concern in
laparoscopic redo surgery because of adhesions. Thus, the
application of laparoscopy to redo surgery, particularly in children,
is controversial because of safety . So complex laparoscopic
surgery should be performed only by an expert pediatric surgeon,
and with a high volume of surgical procedures.
Children presenting for initial or RF after feeding gastrostomy
are a subset of patients that may benefit from the robotic approach.This technique is particularly difficult in standard laparoscopy
without dislodgement of the gastrostomy, particularly if there are
abundant adhesions or a replaced left hepatic artery to preserve
There is a scarcity of publications from Latin American
countries to date that describe pediatric patients who have
undergone robotic surgery [13,56,57], and in relation to the
number of RALRNF publications in the world, it is also limited,
including the adult and pediatric population [20,58-62]. Objective
of this study is to present our experience in RALRNF and highlight
its advantages in children.
suspected by the presence of one or more of the following
symptoms and signs: vomiting, regurgitation, heartburn,
epigastric pain, dysphagia, coughing and wheezing, pneumonia,
life-threatening events (apneic spells), among others, and
confirmed with upper GI tract X-Ray (Figure 1 & 2), endoscopy,
and in some cases impedance-pH measurement.
Non-random simples were, all pediatric patients who required
The parameters recorded were gender, age, weight, height,
diagnoses, surgical technique, elapsed time of console surgery,
estimated bleeding, hemotransfusion, complications, conversions,
PO hospital stay, and follow-up. The Clavien-Dindo classification
of surgical complications was used [63,64].
The surgical system used was the da Vinci model, Si version
(Intuitive Surgical, Inc., Sunnyvale, CA. U.S.A). We used 8mm
robotic instruments and trocars, 3 robotic work arms, 8.5mm or
12mm robotic 30° lens for a three-dimensional camera, and a
5mm trocar laparoscopic for one assistant.
The docking charts for robotic surgery that are suggested
for surgical techniques in adults were not applicable in infant
patient, in this case, 4-5cm of separation was possible between
each trocar, due to the limited space in such a small patient.
The surgical tecnique used was Nissen Floppy fundoplication
(RALRNF) (Figures 3-8).
The PO follow-up was at 8, 30, and 90 to 120 days, and then
every 6 months. Between 90 and 120 days, upper GI tract X-Ray
studies were carried out to evaluate the anatomic results of the
We used measures of central tendency. The data was entered
into a spreadsheet in Microsoft Office Excel 2013 version.
In relation to ethical considerations of the study, being of an
observational nature, it was not necessary to consent to enter
the study to the patients. The Research Ethics Committee of the
Hospital evaluated and approved the study. In Mexico, robot
assisted surgery complies with the records and regulations of
the Mexican health authorities. In our institution, robotic surgery
is routinely authorized for execution. In order to perform the
medical-surgical procedures, we obtained the informed consent
in writing from the parents or guardians.
In a 48-months period, we performed 19 RALRNF in pediatric
patients. Of the procedures, 66.16%  were in male, and the
rest were female; the average age was 10.3 years, ranging from 7
months to 17 years. The average height was 135.2cm, and ranged
from 62 to 185cm, with an average weight of 36.3kg, ranging from
5.2 to 102kg; the smallest patient was 7 months old with a height
of 62 cm and weight 5.2kg.
Our 3 most frequent GI procedures in the same period were,
primary fundoplication , redo-fundoplication , and
cholecystectomy  totaled 83 and represented 69.16% in this
área, being the total 120 procedures GI, 13 of the RALRNF, they are
part of the statistics of a previous publication .
Four patients (21%) they have neurological impairment. The
previous fundoplication, in 10 (52.6%) it was open, laparoscopic
in 6 (31.6%) and robotics in 3 (15.8%). One patient previously had
3 fundoplications, one open and two laparoscopic. In our casuistic
the failure rate of the PRF with recurrence of symptoms was 6% (3
patients), and recurrence was presented at 3.5, 11 and 24 months.
The average console surgery time in 4 cases (21%) of RF and
gastrostomy procedures, including gastrostomy dismantlement,
was 280min, varying the times from 235 to 328min, and in 15
cases (79%) of RF only, the average time was 185min, varying the
times from 115 to 360min.
The index transoperative complications was 21% (4 casos),
gastric perforations in 2, a splenic lesion and an esophageal
perforation. This lesion are considered incidental, they do not
alter PO evolution of patients.
The index conversion was 5.2 % and PO complications 0%. A
failure of the RALRNF (5.2%), occurred at 7 months of the PO, in
our patient, there are 3 risk factors for fundoplication failure: PRF
at 3 months of age, neurological impairment present and prompt
recurrence with RRNF at 6.5 months of age and this second
recurrence to the 13.5 months of age.
The transoperative surgical findings that caused the failure
were, HH and partial or total wrap dehiscence of the fundoplication
10 cases (52.63%) and only partial or total wrap dehiscence in 9
(47.37%). In addition to the above, the common transoperative
findings are multiple adhesions and the liver firmly attached
to the stomach, which makes it difficult to identify anatomical
structures, more bleeding and predisposes to cause injuries to
various anatomical structures.
Only one patient (5.2%) required hemotransfusion and
conversion, his profile: a 9-year-old girl with a weight of 40kg,
a fourth fundoplication, with 200ml of TO bleeding because the
liver was firmly attached to the stomach, with multiple adhesions,
difficult identification of its anatomy, a perforation occurred in the
posterior face of the esophagus and the lack of adequate visibility
of it, forced the conversion of the procedure to open.
The average PO hospital stay was 2.2 days, ranging from 1 to 5
days, and in 14 patients (73.7%) was 1 to 2
The average follow-up was 24.1 months, with ranging from 3
to 49 months.
Successful LRNF in adults was first reported by Frantzides and
Carlson , followed by reports of small series of cases, some
in children. As van der Zee, et al, between December 1993 and
December 1998, for 100 children who underwent a laparoscopic
Thal procedure, 4 of them had to undergo a LRNF. A child was
found with an intrathoracic wrap and a giant HH, underwent a
hernia repair and a redo-Thal, the procedure was more difficult
due to a large HH and the technical limitations of the laparoscopic
procedure. In two other children, the operation was relatively
simple. The last child, the procedure had to be converted to open,
and the authors concluded that, in children, it is feasible to LRNF
after a previous laparoscopic fundoplication and does not increase
Despite the increasing use of laparoscopic fundoplication,
there has been relatively slow acceptance and significant criticism
of its application for LRNF in children. The most major concern
is that at redo surgery, adhesions are usually dense and tissue
planes and gross anatomy can be distorted necessitating advanced
Very high failure rates are reported until of 42% for RF .
Even though, Rothenberg insisted that in experienced hands,
redo by laparoscopic is possible with good results: without
conversions, under complication index, without mortality and
with a low failure rate 6% of RF . In other report of children,
more serious complications have been reported in relation to
LRNF such as esophageal perforation or gastric leak secondary to
difficult dissection, scar tissue, and adhesions from prior surgery
. In another report, of LRNF, there was a 21.8% incidence of
visceral injury in 307 RF. Authors comment on their experience
that reoperative esophageal surgery can be one of the most
challenging procedures that a surgeon will face. Anatomy can
be severely distorted by scarring, fundoplication herniation, and
unexpected findings. Experience and knowledge of normal and
abnormal anatomy is critical to not only a safe operation but also
effective resolution of the patient’s problems .
The diversity of transoperative surgical findings that caused
the failure are: HH, wrap disruption, slipped wrap, crural stenosis,
twisted wrap, and misplaced wrap, being the most frequents: HH,
slipped wrap and misplaced wrap . Our findings in relation
to these, coincide with that reported in other series, HH and/or
partial or total slepped wrap.
In the LRNF, it is recommended: extreme caution during
dissection, because is tedious and anatomic landmarks are
distorted, and successful completion of RF requires familiarity
with this abnormal anatomy. In particular, younger trainees should
be carefully supervised by surgeons with sufficient experience in
revision surgery, for the complex and laborious of these cases,
longer learning curve, in order to prevent serious complications,
reduce conversions and hemotransfusions.
Total thickness perforation of the gastric and esophageal wall
is common during RF and should be detected and resolved. But
also during the surgical dissection can cause partial thickness
visceral injuries or weakening of its walls, which we must also
detect and repair, since potentially they can evolve towards the
perforation in PO period, and obviously it is synonymous with
abdominal catastrophe and its consequences, not detect an
esophageal-gastric perforation during the transoperative period.
After an exhaustive search using the terms: robot-assisted,
laparoscopic, redo, fundoplication and children, it was not possible
to locate publications as or similar to ours., and if there are a good
number of publications on open and laparoscopic approach of the
RF, of which we have already made several considerations.
From our results the aspects that we consider transcendent
are: the robotic procedures, fundoplication is surgical technique
the most frecuente of robotic GI área , and the failure rate
of the PRF (6%) and the RRNF (5.2%) are at the lower limits of
what was reported in previous publications, without difference
in relation to the antecedent of the primary fundoplication, with
respect to those previously published, being in order of greater or
lesser frequency in our casuistry, open, laparoscopic and robotic
The transoperative findings found do not differ from those
published in these cases of revision antireflux surgery, generally with dense and firm adhesions, anatomy altered and difficult to
identify, risk of significant bleeding when the liver was firmly
attached to the stomach. We caused gastric and esophageal
perforations, and splenic lesion, only the esophageal perforation
was of significance, since it forced to the only conversion to open
surgery, the others did not alter the PO evolution, and no PO
complications or mortality occurred, and the PO stay was brief in
the majority of the patients.
Independently that we do not find similar publications in
children, to have a reference in relation to our times of console
surgery, we consider that they are satisfactory taking into account
the complexity of the cases.
The patient who required hemotransfusion and conversion
was his fourth fundoplication and found the liver firmly attached
to the stomach, firm adhesions, it was difficult to identify its
anatomy, it favored an incidental perforation of the esophagus,
and it was not possible to visualize its exact site, which forced the
conversion to open surgery.
The failures of the fundoplication are more related to patients
of younger age, with ongoing retching in the PO period, extensive
dissection of the hiatus in primary surgery, patients with
neurological impairment and a shorter time to re-operation [30,
69]. Our patient who evolved with recurrence after the robotic
fundoplication redo, meets 3 of the 5 factors mentioned above.
It is very important to perform a fundoplication with any of
the 3 approaches, to reduce the risk of failure to take into account
the following recommendations: minimal dissection of the
hiatus, only enough mobilization of the esophagus for adequate
creation of intraabdominal esophagus, creation of a tension-free
and appropriate orientation, and positioning of the wrap and
omission of esophagocrural sutures [4,70,71]. As well as, the use
of biosynthetic mesh enhance hiatal repair, can reduce the risk of
The need for a revision surgery after a fundoplication is a very
variable event and, fundamentally, it is considered that it depends
on the experience of the surgeon and the volume of surgeries
depending on the center where he works, and the volume of cases
(experience) per surgeon . The results of published series
of patients with redo, open or laparoscopic fundoplication show
that the index of failure of this, is greater than in primary surgery
Robotic surgery has special applications in complex and
reconstructive surgery. In the GI area in children, RRNF with HH
or not and the correction of bilio-digestive anomalies, the robotic
surgery is very profitable. In these procedures, from the open
technique, we jump to robotic surgery. Due to the characteristics
and advantages of this technology, it overcomes the limitations of
conventional laparoscopy, we achieve a lower risk of conversions,
fewer complications, less hemotransfusions, short stay PO,
increase patient safety and the probability of failures and other
reinterventions can be reduced, as our results show with mediumterm
Due to the limitations of conventional laparoscopic surgery,
complex cases or reconstructive surgery in children can only be
performed by a limited number of highly qualified surgeons, with
advanced skills and sufficient experience .
Long-term follow-up outcomes from large prospective
comparative (randomized) studies are necessary to prove these
preliminary data in support of the use of robotic systems in
pediatric patients with failed anti-reflux surgery.
The failed fundoplication is frequent, and RF is complex,
difficult and laborious technique. In the redo, open or laparoscopic
fundoplication, the failure rate is higher than in primary surgery
and increases with other re-operations.
With the RALRNF, we achieved low risk of conversion, no
complications, few hemotransfusions, short PO stay and low
recurrence rate for our patients, for which we affirm that RALRNF
is safe and effective and if offers advantages to the pediatric
There are few publications of RALRNF in children. Advantages
of robotic surgery are application in complex surgeries, in small
operating field, difficult access, delicate dissection, need control
of hemostasis and intracorporeal sutures. Only expert pediatric
surgeons solve them, by conventional laparoscopy.
Long-term follow-up outcomes from large prospective
comparative (randomized) studies are necessary to prove these
data’s in support of the use of robotic systems in pediatric patients
with failed anti-reflux surgery.
The author declares to be Proctor of the da Vinci Surgical
System and sometimes receives salary for advice to Surgeons in
their first robotic procedures, from the marketing company in
my country, as part of the support in the training of Surgeons by
this company. But, in relation to the treatment of patients and the
execution of this manuscript, no economic financing was received
from commercial companies.