(1)
Department of Paediatric Surgery, John Radcliffe Hospital, Oxford University, Oxford, UK
(2)
Department of Paediatric Surgery, Oxford University Hospitals NHS Trust, Oxford Children’s Hospital, John Radcliffe Hospital, Oxford, UK
Abstract
The Thal fundoplication is a 180–270° anterior wrap. The basic dissection is similar to that of any other fundoplication, except that it does not require a posterior window or posterior mobilisation of the oesophagus and requires less dissection of the crus. It achieves the same surgical objectives as other types of fundoplication, i.e., ensuring an intra-abdominal oesophagus, creating an acute angle at the gastro-oesophageal junction, and creating a high-pressure zone around the lower oesophagus [1]. Thal fundoplication has an equivalent success rate in neurologically normal children but has a higher failure rate in neurologically impaired children when compared with the Nissen fundoplication. It also results in less postoperative dysphagia [2].
Keywords
LaparoscopicThalFundoplication18.1 General Information
The Thal fundoplication is a 180–270° anterior wrap. The basic dissection is similar to that of any other fundoplication, except that it does not require a posterior window or posterior mobilisation of the oesophagus and requires less dissection of the crus. It achieves the same surgical objectives as other types of fundoplication, i.e., ensuring an intra-abdominal oesophagus, creating an acute angle at the gastro-oesophageal junction, and creating a high-pressure zone around the lower oesophagus [1]. Thal fundoplication has an equivalent success rate in neurologically normal children but has a higher failure rate in neurologically impaired children when compared with the Nissen fundoplication. It also results in less postoperative dysphagia [2].
18.2 Working Instruments
For children <7 kg:
A 5-mm 30° short scope placed via the umbilicus
One working 3-mm port in the right upper quadrant
One working 5-mm port in the left upper quadrant (with reducer for 3-mm instruments)
Nathanson retractor placed via the epigastrium (Fig. 18.1).
For children >7 kg:
A 5- or 10-mm 30° scope and 5-mm ports should be used
Hook (monopolar) diathermy usually is sufficient for dissection, but an ultrasonic dissector (Thunderbeat [Olympus, Southborough, MA] or Harmonic [Ethicon, Somerville, NJ]) or LigaSure (bipolar; Covidien, Mansfield, MA) may be used, although they usually are not required because division of the short gastric vessels seldom is necessary for a Thal fundoplication.
Fig. 18.1
Port sites
18.3 Positioning, Port Siting, and Ergonomic Considerations
If the child is <7 kg, he/she should be positioned supine with the head up and the legs abducted at the foot of the operating table. If the patient is >7 kg, the Lloyd-Davies position with the hips abducted and minimal flexure of the hip and knees is helpful (Fig. 18.2). The surgeon should stand between the patient’s legs with the monitor over the patient’s head for the best ergonomics.
Fig. 18.2
Patient position
18.4 Surgical Technique
18.4.1 Entry
Empty the bladder with a catheter; use an umbilical or supraumbilical “Hasson” entry. Subsequent ports should be placed under laparoscopic vision in the right upper quadrant and left upper quadrant (for maximum triangulation), and a Nathanson retractor should be inserted at the level of (or just below) the edge of the liver, through the linea alba in the epigastrium.
18.4.2 Retraction
Good liver retraction is crucial; the Nathanson is a very useful retractor because it lifts the liver up and away from the operative field and is one less instrument to get tangled with the surgeon’s instruments (Fig. 18.3).
