 Benefits of laparoscopic approaches to GERD and paraesophageal hernias Why consider the laparoscopic approach to anti-reflux surgery? There are several clinical differences between open surgical approaches and laparoscopic repairs. Whereas standard open procedures usually involve an incision of 8 to 9 inches in length, the laparoscopic approach requires four to five individual half-inch incisions used for endoscopic surgical instruments and the laparoscopic camera system (Figure 3). Thus the primary advantage of the laparoscopic approach is the potential for reduced operative morbidity, resulting in an earlier hospital recovery and return to normal activities. Although the average hospitalization following "open" surgical repair is commonly seven to 10 days, the hospital stay has averaged less than two days among the more than 200 patients on whom we have performed laparoscopic anti-reflux surgery. Furthermore, return to full activity usually takes four to six weeks following open surgery, but such recovery usually requires only one to two weeks following most laparoscopic anti-reflux repairs. The overall cost related to chronic medical management or open anti-reflux surgical procedures may also be considerably reduced with the use of these laparoscopic approaches to anti-reflux surgery. This is primarily related to the reduced time of hospitalization and the avoidance of chronic medicinal therapies characteristic of non-surgical management of GERD. The laparoscopic procedure performed for GERD by surgeon members of the Allegheny Center for Lung and Thoracic Disease is an anti-reflux repair that is essentially identical to that performed in open surgical techniques. Nissen fundoplication and the modified fundoplication variants tailored toward patients with weakened esophageal body peristalsis provide the most effective relief of reflux while avoiding repair-related dysphagia or difficulties with eructation. Utilizing these management concepts, we have been able to achieve a 95 percent control of GERD symptoms among our laparoscopic anti-reflux surgery patients at a mean follow-up of over 14 months. An equal percentage of these patients state that their lifestyle has significantly improved following their laparoscopic anti-reflux surgery. Fundoplication remains the most reliable and expedient means of treating patients with persistent GERD. It appears that laparoscopic fundoplication may be the method of choice for most non-complex cases of GERD. Nevertheless, attention should be paid to the performance of the key aspects of open standard anti-reflux surgery in order to avoid potential peri-operative complications. Mature surgical experience with open and laparoscopic esophageal surgical techniques can prevent some of the more serious complications, such as vagal nerve injury, tissue ulceration or ischemia, and splenopancreatic injury. Our experience at Allegheny University Hospitals, Allegheny General has demonstrated that outcomes can also be optimized by using a careful pre-surgical analysis of the patient's candidacy for the procedure. The Allegheny Center for Lung and Thoracic Disease surgical team continues an ongoing assessment of the validity of the laparoscopic approach to surgical treatment of GERD. This effort includes both basic laboratory and clinical investigational studies focusing on the treatment efficacy of these minimally invasive surgical approaches and potential technical modifications directed toward the specific pathologic features of each patient's gastroesophageal reflux disease pattern.
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