Technique of Modified Watson Fundoplication in a Pediatric Patient

Abstract

Background:

Partial fundoplication is an alternative to a complete wrap and is reputed to offer lower long-term risks. Watson et al. described an anterior 120° fundoplication in 1991, which achieved symptomatic improvement in 94% of cases. ¹ A subsequent modification of the original technique was described and involved a 180° anterior wrap. There are limited published reports of this technique in children. A comparison of the Watson fundoplication with the Nissen fundoplication in children by open surgery found they had comparable results. ²

Aim:

To demonstrate the technical steps in a modified Watson fundoplication in children.

Technique:

The video demonstrates five critical steps of the procedure: (1) mobilization of 5 cm of the intra-abdominal esophagus; (2) hiatal narrowing by posterior approximation of the crura; (3) restoration of the angle of his; (4) construction of a 1800 anterior wrap; (5) fixation of the wrap to the esophagus and approximated crura.

Conclusion:

In a series of more than 70 cases, accumulated over 15 years, the authors have not had to reoperate for dysphagia or wrap migration into the chest. Other noted advantages are the ability to belch and the absence of serious gas bloat. In essence, the Watson anterior fundoplication in children offers a durable outcome over long term and is recommended.

Detailed Technical Description of Watson Anterior Fundoplication:

The surgeon stands at the end of the table with the camera operator to his right and video screens to the left and right of the patient's head. Four ports, an umbilical 5 mm with three additional 5-mm working ports and Nathanson Liver retractor are utilized. The operation starts by dividing the gastrohepatic and phrenoesophageal ligament to expose the right side of the esophagus and the contiguous crus. Division of the phrenoesophageal ligament continues superiorly and to the left to expose the anterior hiatal margin and the left crus. At this point, the fundus is freed by taking down attachments to the left hemidiaphragm. The distal esophagus is mobilized circumferentially. A dissector is passed posterior to the esophagus, to the left side emerging in front of the crus. A nylon tape is introduced and passed around the esophagus. This is cut to length and used for traction. Esophageal mobilization proceeds proximally and into the posterior mediastinum until a 5-cm length of intra-abdominal esophagus is available. Hook diathermy is utilized for control of segmental feeder vessels. Once mobilization is complete, reconstruction starts with crural approximation. We utilize 2/0 ethibond sutures on a ski needle taking adequate bites on both sides. A standard slip knot is executed and secured with a further knot. One more stitch is placed to complete crural repair. The anterior wrap starts with restoration of the angle of his. This involves taking a bite of the medial side of the fundus, and with a back-handed stitch, the left side of the hiatus. Slip knots are once again employed. The fundus is rolled over the esophagus and two further sutures are placed to approximate it to the anterior rim of the hiatus. To complete the wrap, the right side of the fundus is approximated to the underlying esophagus and approximated crura behind. Three sutures ∼1 cm apart are applied. These ensure adequate fixation of the mobilized intra-abdominal esophagus. If required, a percutaneous gastrostomy device is placed under vision.

No competing financial interests exist.

Runtime of video: 6 mins 3 secs