A roadmap for the establishment of pediatric laparoscopic fundoplication

The way to introduce laparoscopic fundoplication (LF) to a pediatric surgical unit has not been well described. We have taken a measured approach to introducing LF and report our experience in this paper.

All patients undergoing LF from the first case in April 2003 to December 2007 were reviewed retrospectively. Cases were identified from theater and discharge databases, and data were captured by using a structured proforma.

Eighty-five LFs were performed on 51 males and 34 females, with a median age of 46.5 months (range, 2-218). Fifty-one cases (60%) were neurologically impaired; a further 26 (31%) had significant comorbidity. Seventy-eight (92%) cases were performed by, or under the supervision of, the two senior authors. The first 10 cases were performed under the mentorship of a visiting surgeon from an established pediatric laparoscopic center. Thereafter, LF was conducted as a two- then a one-consultant operation and was finally performed primarily by trainees under consultant supervision. The total number of LFs increased from 4 in 2003 to 29 in 2007. Nine major complications occurred in 8 patients (5 gastric perforations, 1 colonic gastrostomy tube insertion, 1 nasogastric tube sutured into a wrap, 1 midgut, and 1 gastric volvulus). Seven cases required a conversion to an open fundoplication. There was no 30-day mortality. Six patients have died since surgery; in none of the patients was the LF implicated.

We recommend a measured approach to the introduction of LF with the transition from mentorship to local consultant practice and, finally, to a trainee procedure under consultant supervision. This approach yielded satisfactory results while minimising the disruption to trainee experience.