Laparoscopic surgery in Europe-Development and education

Techniques and results of laparoscopic antireflux surgery in Germany

BACKGROUND

This study aimed to evaluate the development and outcomes of laparoscopic antireflux surgery in Germany using a nationwide representative survey.

METHODS

A written questionnaire including 34 detailed questions and 288 structured items about diagnostic and therapeutic approaches, number of procedures, complications, and mortality was sent to 546 randomly selected German surgeons (33% of the registered general surgeons) at the end of 2000.

RESULTS

The response rate was 72%, and a total of 2,540 antireflux procedures were reported. According to the survey, 81% of all procedures were performed laparoscopically, and 0.1% were performed thoracoscopically. As reported, 65% were total fundoplications, 31% were partial fundoplications, and 4% were other procedures. Of the surgeons who had experience with laparoscopic antireflux techniques (29%), 71% preferred a 5-trocar technique, and 91% used the Harmonic Scalpel for dissection. There were significant technical variations among the surgical procedures (e.g., use and size of the bougie, length of the wrap, additional gastropexy, fixation of the wrap). The overall complication rate for laparoscopic fundoplication was 7.7% (5.7% surgical and 2% nonsurgical complications), including rates of 0.6% for esophageal perforations and 0.6% for splenic lesions. The conversion rate was 2.9%; the reoperation rate was 1.6%; and the overall hospital mortality rate was 0.13%. The authors observed a striking learning curve difference in complication rates between hospitals performing fewer than 10 laparoscopic antireflux techniques annually and those performing more than 10 fundoplications per year (14% vs 5.1%, p < 0.001). Long-term dysphagia and interventions occasioned by dysphagia occurred significantly more often after total fundoplications than after partial fundoplications (6.6% vs 2.4%; p < 0.001). Similar findings were reported for Nissen versus floppy Nissen procedures. The overall failure rate, however, was similar for both groups (Nissen 8.7%; partial 9%, difference not significant).

CONCLUSIONS

Until now, no unique laparoscopic antireflux technique has been accepted, and a number of different antireflux procedures with numerous modifications have been reported. The morbidity and mortality rates reported in this article compare very well with those in the literature, and 1-year-follow-up results are promising.

Laparoscopic management of a small bowel perforation caused by a toothpick

A 58-year-old man underwent an emergency laparoscopic procedure for small bowel perforation with peritonitis after the ingestion of a wooden toothpick. Treatment consisted of laparoscopic removal of the foreign body, followed by lavage of the abdominal cavity and laparoscopic closure of the perforation, including omentoplasty. The patient recovered from peritonitis and was discharged from the hospital on day 14 after the operation.