12.2.4 S-Gastric Ulcer Repair

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Single-Access-Laparoscopy andForegut-Surgery fromGiovanni Dapri

. Fig. 12.15 A custom-made plastic bag a is used to

remove the specimen through the umbilicus b

closed using absorbable sutures. e nal scar length is approximately 15mm.

12.2.4 S-Gastric Ulcer Repair

(In patients who present with peritonitis, laparoscopy allows the diagnosis and in most cases the treatment. A simple exploration of the abdominal cavity can reveal the presence of a perforated gastric ulcer, and in early diagnosis, SAL is feasible [10]).

e procedure begins with the localization of the perforation aer using a curved suction device to obtain a bacteriological sample of the free liquid that is usually located in the hepatorenal (Morison’s) pouch or in the pelvic (Douglas’) pouch. A percutaneous stitch is passed from the le hypochondrium into the falciform ligament to improve exposure of the gastric antrum, the pylorus, and the rst duodenum. 2/0 silk stitches are inserted in the abdomen through the 11-mm trocar using a straight grasper. e gastric ulcer is repaired using one or two gures of 8 sutures (. Fig.12.16a) and is covered using simple stitches for omentoplasty (. Fig.12.16b) with an ergonomic position that is

. Fig. 12.16 Repair of the gastric ulcer using gures of 8 sutures a, omentoplasty b, and in an ergonomic position

that is similar to multi-trocar laparoscopy c

G. Dapri

. Fig. 12.17 Final lavage of the cavity

similar to multi-trocar laparoscopy (. Fig.12.16c). e procedure is completed with irrigation of the abdominal cavity with saline solution (. Fig.12.17). e nasogastric tube (which was inserted at the beginning of the laparoscopy) is kept in place under smooth suction. e instruments and stitches are removed under view, and both the umbilical fascia and the separate window that was used for the grasper are meticulously closed. e nal scar length is approximately 15 mm.

12.3 Discussion

In the S-Foregut Surgery technique that has been described here, the curved grasping forceps I and III are introduced into the abdomen through a separate opening in the umbilical fascia. is is a specic trick to prevent leakage of the pneumoperitoneum throughout the entire S-procedure. e grasper in the surgeon’s nondominant hand (e.g., the le hand) is not changed throughout the S-procedure, which is in contrast to the other curved instruments in the surgeon’s dominant hand (e.g., the right hand), which are repeatedly changed during the various steps of the procedure. us, placement of a pursestring suture in the umbilical fascia at the beginning of the procedure is essential for maintaining a sucient pneumoperitoneum. is suture is opened only to permit changing the instruments in the surgeon’s dominant hand or to evacuate the smoke that is created during the dissection. A thick sliding stitch such as a 1 PDS stitch is suggested for the umbilical purse-string suture.

e curved grasping forceps I and III and the

curved needle holder II mainly provide two

curves. One curve is at the umbilicus, thus pre-

venting a conict between the surgeon’s hands

and the optical system outside the access area, and

the other curve is between the umbilicus and the

instrument’s tip, thereby establishing the internal

working triangulation. Furthermore, the distal

curve of the grasper III has been drawn to retract

the le liver lobe superiorly, thereby increasing

the exposure of the hiatal region. Other valid

alternatives that can be used to increase the expo-

sure of the hiatus are the placement of a Penrose

drain under the le liver lobe [11, 12], percutane-

ous stitches at the crura junction [13], percutane-

ous stitches through the liver [14], the suspension

of the liver using an EndoCinch [15], or the inser-

tion of a millimetric wire such as Veress needle

[16]. In addition, in the case of a gastric lesion or

perforation in the antrum, pylorus, or rst duode-

num, placing percutaneous stitches from the le

hypochondrium into the falciform ligament can

improve the exposure of the operating eld.

e curved coagulating hook, the curved scissors, the curved bipolar scissors, the curved needle holder I, and the curved suction device have a similar shape and create only one curve, thus preventing a collision between the surgeon’s and the assistant’s hands outside of the umbilicus. Moreover, the open jaws of the curved needle holders I and II are placed at a 45° angle with respect to the main sha; this position permits only a quarter rotation of the surgeon’s wrist to pass or remove the needle in the tissue, thereby preventing potential damage by the curves in the internal viscera.

All of the curved instruments must be inserted into and removed from the abdomen following their curves while maintaining a 45° angle with respect to the abdominal wall.

Because of the curved shape of the instruments, the surgeon can perform the entire procedure in an ergonomic position that is similar to a multi-trocar laparoscopy, as clashing of the instrument tips or crossing of the surgeon’s hands rarely occurs during the SAL procedure [4, 5]. Clearly, however, a learning curve is needed to understand the manner in which the curved instruments should be maneuvered, and in which way the sutures should be placed. Hence, the selection of patients to undergo to S-Foregut Surgery remains an important challenge [6, 7], and the surgeon should exclude

patients whose BMI exceeds 35–40kg/m

or who are taller than 1.80m. In addition, giant hiatal hernia, the dicult localization of benign gastric

Single-Access-Laparoscopy andForegut-Surgery fromGiovanni Dapri

lesions, diuse peritonitis and the dicult localization of a perforated gastric ulcer are all contraindicated for S-Foregut Surgery. Using this procedure in the above cases increases the diculty of the transumbilical approach, increases the duration of the S-procedure, and increases the risk of peri- and postoperative complications.

Finally, because of this technique, the umbilical scar length is similar to the scar that results in multitrocar laparoscopy using a 12-mm trocar, as only one reusable 11-mm trocar is inserted in the umbilicus, and the curved instruments are advanced in the abdomen without trocars. is feature, combined with the fact that all of the materials that are used are reusable, keeps the cost of S-Foregut Surgery similar to the cost of multi- trocar laparoscopy.

I. Ideal cases (i.e., easy to operate, no problems)

II. Not quite ideal cases (some minor diculties

may occur)

III. Problematic cases (dicult to operate, some

operative techniques are considerably more dicult than others)

IV. Very problematic (“horrible”) cases (every

operative step is dicult)

Classication of patients according to intraoperative diculty (I to IV) for single-incision laparoscopy and foregut surgery: I. Female patients, not tall, BMI <25kg/m2, no

giant hernia (if hiatal), no peritonitis (if perforated ulcer), small tumor (if gastric resection), no previous abdominal surgery

II. Male patients, quite tall, BMI >30kg/m2,

previous abdominal surgery

III. Male and tall patients, BMI >40kg/m2, large

hepatomegaly, giant hernia (if hiatal), diuse peritonitis (if perforated ulcer), huge tumor (if resection), previous major abdominal surgery with adhesions

IV. Male patients, high BMI, large hepatomegaly,

intrathoracic giant hernia (if hiatal), late diagnosis and diuse peritonitis (if perforated ulcer), advanced tumor (if resection), previous major abdominal surgery with adhesions

References

1. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl JMed. 2004;350:2050–9.

2. Ve ldkamp R, Kuhry E, Hop WC, etal. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005;6: 477–84.

3. Ahmed I, Paraskeva P.A clinical review of single-incision laparoscopic surgery. Surgeon 2011;9:341–51. doi:10.1016/j.surge.2011.06.003.

4. Romanelli JR, Earle DB.Single-port laparoscopic surgery: an overview. Surg Endosc. 2009;23:1419–27.

5. Froghi F, Sodergren MH, Darzi A, Paraskeva P. Singleincision laparoscopic surgery (SILS) in general surgery. Surg Laparosc Endosc Percutan Tech. 2010;20:191–204.

6. Gill IS, Advincula AP, Aron M, etal. Consensus statement of the consortium for laparoendoscopic singlesite surgery. Surg Endosc. 2010;24:762–8.

7. Ahmed K, Wang TT, Patel WM, et al. The role of singleincision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc. 2011;25:378–96.

8. Hanna GB, Drew T, Clinch P, Hunter B, Cuschieri A. Computer-controlled endoscopic performance assessment system. Surg Endosc. 1998;12:997–1000.

9. Sasaki A, Koeda K, Nakajima J, Obuchi T, Baba S, Wakabayashi G.Single-incision laparoscopic gastric resection for submucosal tumors: report of three cases. Surg Today. 2011;41:133–6.

10 . L ee J , Sung K, Lee D, Lee W, K im W.Single-port laparoscopic

repair of a perforated duodenal ulcer: intracorporeal “cross and twine” knotting. Surg Endosc. 2011;25:229–33.

11. Hamzaoglu I, Karahasanoglu T, Aytac E, Karatas A, Baca B.Transumbilical totally laparoscopic single-port Nissen fundoplication: a new method of liver retraction: the Istanbul Technique. J Gastrointest Surg. 2010;14: 1035–9.

12. Huang CK, Lo CH, Asim S, Houng JY, Huang SF.A novel technique for liver retraction in laparoscopic bariatric surgery. Obes Surg. 2011;21:676–9.

13. Tacchino RM, Greco F, Matera D, Diumeri G.Singleincision laparoscopic gastric bypass for morbid obesity. Obes Surg. 2010;20:1154–60.

14. Huang CK, Houng JY, Chiang CJ, Chen YS, Lee PH.Single incision transumbilical laparoscopic Roux-en-Y gastric bypass: a rst case report. Obes Surg. 2009;19: 1711–5.

15. Galvani C, Gallo AS, Gorodner MV.Single-incision and dual-incision laparoscopic adjustable gastric band: evaluation of initial experience. Surg Obes Relat Dis. 2012;8:194–200. (Epub ahead of print).

16. Dapri G. Specially designed curved instruments for single- access laparoscopy: 2.5-year experience. Minim Invasive Ther Allied Technol. 2012;21:31–9 (in press).

Gastric Bypass After Failed Fundoplication fromDimitrios Stefanidis

DimitriosStefanidis

13.1 Introduction – 88

13.2 Preoperative Assessment – 88

13.3 Operative Technique – 88

13.4 Special/Unusual Situations – 90

13.5 Postoperative Course – 91

Reference – 91

D. Stefanidis

13.1 Introduction

Gastroesophageal reux disease (GERD) aects 40 % of the American population and has a clear association with obesity. With the incidence of obesity rising at alarming rates in the USA, the prevalence of GERD is also increasing [1, 2]. Some studies have even described a dose– response relationship between obesity and GERD [2]. Even though the mainstay of GERD treatment is pharmacologic, select patients may benet from surgery [3]. Laparoscopic gastric fundoplication is considered the gold standard for the surgical management of GERD, as it is associated with low morbidity, early recovery, and excellent outcomes [3]. Nevertheless, longterm patient follow-up data have cast doubts about the long-term ecacy of the procedure as a considerable percentage of patients have symptom relapse and restart acid-reducing treatment [4]. Importantly, evidence suggests that fundoplications are associated with a higher incidence of failure in the obese compared with the nonobese [5].

Patients who fail their initial fundoplication present a considerable challenge for the surgeon. While redo fundoplication has been shown in a recent review of the literature to be eective in

81.5 % (65–100 %) of patients at a median of 18 months aer surgery, success rates are lower than aer primary fundoplication [6]. Importantly, recent longer-term evidence suggests that treatment failures even for experienced surgeons increase over time with an estimated 50–63 % failure rate at 10 years [7]. Moreover, redo fundoplication is associated with a higher incidence of intraoperative and postoperative complications compared with primary fundoplication [6]. Since obesity is associated with higher failure rates, and laparoscopic Roux-en-Y gastric bypass (LRYGB) induces profound weight loss with comorbidity improvement including GERD resolution [8], when considering a redo operation in the obese population, a LRYGB appears to be a better alternative than redo fundoplication [9, 10]. Moreover, given the high long-term failure rates of redo fundoplication, a LRYGB may be a better alternative for GERD relapse in general. In this chapter, the author will describe his experience with laparoscopic revision of failed fundoplication to Roux-en-Y gastric bypass (RYGB).

13.2 Preoperative Assessment

All patients undergo extensive workup before surgery that includes a detailed history and physical examination, an upper gastrointestinal series (UGI), upper endoscopy, gastric emptying study, and pH testing and/or manometry if the origin of the patient’s symptoms is not evident on endoscopy or UGI.In addition, they undergo preoperative risk assessment and medical clearance in anticipation of a prolonged procedure and a consultation with a nutritionist with experience with gastric bypass surgery.

13.3 Operative Technique

All patients receive preoperative antibiotics (cefazolin 2g IV and metronidazole 500mg IV) and deep venous thrombosis prophylaxis (5,000 U subcutaneous Heparin or 30mg of Lovenox and sequential compression devices). A Foley catheter is placed and, depending on the age and comorbidities of the patient, invasive monitoring may be instituted. e patient is positioned supine with both arms out. A footboard is placed, and the patient is attached securely to the bed to allow steep reverse Trendelenburg position. Two monitors are placed at either side of the patient’s head at the eye level of the surgeon and assistant. e surgeon stands on the right side of the table and the assistant on the le; a camera operator is also required to drive a 30° 10-mm scope. A ve- trocar technique (three 12-mm and two 5-mm disposable trocars) is used, and a Nathanson liver retractor is placed in the subxiphoid position to retract the le lobe of the liver up to expose the hiatus (oen this retractor is not needed, as the le lobe of the liver is adherent to the diaphragm and is self retracted) (. Fig.13.1).

e peritoneal cavity is accessed using the Optiview technique (5-mm noncutting trocar) in a lateral location of the le or right upper quadrants away from previous scars to avoid intraabdominal injuries. Pneumoperitoneum to 15mmHg is established, and the remaining trocars are introduced under direct visualization. If needed, the Nathanson retractor is placed later during the case. e initial step of the procedure is to divide any adhesions between the omentum and/or bowel and the abdominal wall to gain access to the upper abdomen and the hiatus and to be able to introduce all trocars. Such adhesions are

Arbeitskanal des

Gastric Bypass After Failed Fundoplication fromDimitrios Stefanidis

and the greater curve. Any remaining short gas-

Nathanson-

Leberretraktor

Zirkulärstapler

tric vessels are taken safely with the harmonic scalpel, and the dissection continues cephalad until the le crus is encountered. e two planes of dissection are connected, and the stomach and esophagus are separated carefully from the crura. Scar tissue can be dense in this area due to previ-

Arbeitskanal des

Operateurs

Assistenten

ous crural stitches. Given that anatomic planes can be very obscure, dissecting near any identied stitches can minimize the risk for gastric or

Optiktrokar

esophageal injuries. A Penrose drain should be passed behind and wrapped around the esophagus to act as a handle for the assistant to retract the esophagus and stomach outside the mediastinum and facilitate esophageal dissection high into the mediastinum. is dissection can be challenging due to scarring from the previous operation(s) and the presence of a herniated wrap which is not uncommon. e posterior vagus should be identied and preserved during this step if possible.

Once an adequate length of esophagus

. Fig. 13.1 Trocar positioning

(>2–3cm) is restored intra-abdominally, the most

tedious part of this procedure begins which is takcommon aer previous open fundoplication. My preference is then to dissect the le lobe of the liver o the stomach (usually densely adherent) until the caudate lobe and the right crus are seen. I nd that there usually is an unscarred plane between the caudate lobe and the right crus, which when entered allows the surgeon to more easily dene the anatomy in an otherwise scarred and anatomically obscure hiatus. An accessory le hepatic artery can oen be found in this plane and should be anticipated; if small, I usually take it but otherwise preserve it. e surgeon needs to be very careful not to injure the vena cava, which is close to the right crus. During this dissection, the surgeon uses his le hand to retract the liver away from the stomach and harmonic scalpel or cold scissors in the right for safe dissection, while the assistant uses his right hand to retract the stomach toward the spleen and the le hand to provide counter traction to the surgeon. A suction device in the le hand of the assistant may be very useful to remove blood from the operating eld.

e dissection then continues between the right crus and the stomach/ esophagus and is carried anteriorly toward the le crus. e anterior vagus should be identied during this step, but it is oen impossible due to dense scar tissue. Once the limits of this dissection are reached, the dissection is shied to the le side of the stomach

ing down the previous fundoplication. e surgeon’s patience is tested during this step and slow, very careful dissection is key to avoid enterotomies, as planes are usually obscured. In general, it is easier to start the dissection at the lowest aspect of the fundoplication and develop the plane between the stomach and the fundoplication. is plane is oen less scared and, once developed, allows liing the wrap up from the esophagus making its separation easier and safer. e sutures of the previous fundoplication are very helpful in orienting the surgeon to the area where he/she needs to divide the fundoplication but are not always visible immediately. Some surgeons divide the fundoplication with a stapler but this is not my preference. In the case of a posterior partial fundoplication, each side needs to be separated from the stomach and esophagus carefully. Once the wrap is undone, the stomach should be returned back to its anatomic position by dissecting the wrap o its posterior attachments to the stomach. Occasionally, a previously undissected hiatal hernia sac may be encountered during this dissection making recognition of anatomic planes even more challenging. Complete takedown of the fundoplication should be guided and conrmed by intraoperative endoscopy.

e last part of the procedure is the creation of

the gastric bypass, which tends to be the easiest

D. Stefanidis

and most straightforward part of the operation. A

gastric pouch is created using a linear stapling

device and thicker than usual staple loads (green),

oen with staple line reinforcement. Unlike a reg-

ular RYGB where pouch creation is started at the

lesser curvature, these cases oen require that the

division of the stomach starts at the greater curva-

ture and progresses toward the lesser. is

approach is aided by the previous division of the

short gastric vessels, minimizes bleeding at the

usually scarred lesser curvature, and avoids dis-

rupting blood supply to the pouch. When this

horizontal transection is completed, the fundus

that was wrapped around the esophagus is divided

vertically and removed leaving a small lesser

curve-based pouch for anastomosis with the jeju-

num. e removed fundus is oen the area where

enterotomies occur and oen appears ischemic at

the end of the dissection. e size of the pouch is

tailored to the patient’s BMI.In obese patients, a

small 30-cc pouch is created, whereas in normal

weight patients, a slightly larger pouch is created.

A very large pouch should be avoided as it may

predispose patients to future anastomotic ulcer-

ations as a result of acid secretion. If patients have

preoperative evidence of gastroparesis, however,

the pouch is created small independent of the

BMI to avoid bezoar formation in the future. Gas-

troparesis is not uncommon in this patient popu-

lation and should be looked for preoperatively.

e anvil of a 25-mm circular stapler is then intro-

duced via the mouth at the end of an orogastric

tube DST Series™ EEA™ OrVil™ Device, Medtronic,

MInneapolis, MN and exteriorized and le in

place at the most dependent and mobile portion

of the pouch. e jejunum is then divided approx-

imately 50cm from the ligament of Treitz or at an

area that allows the bowel to easily reach the hia-

tus. A 100-cm Roux limb is measured. A jejunoje-

junostomy is then created between that point of

the Roux and the cut end of the biliopancreatic

limb using 60-mm linear staple loads (white) red

in opposite directions to minimize narrowing of

this anastomosis during closure of the enteroto-

mies. e enterotomies are closed with another

ring of the same stapler. e 25-mm EEA stapler

is then introduced via the right upper quadrant

trocar site inside the cut end of the Roux; its spike

exteriorized through the antimesenteric border of

the Roux and connected to the anvil in the pouch.

An antecolic antegastric circular-stapled gastroje-

junostomy is then performed. e anastomosis is

checked by endoscopy for leaks or bleeding, which is addressed if present. e quality of the resected “tissue donuts” is also examined. Finally, both mesenteric defects (jejunojejunostomy and Peterson’s) are closed with a running permanent suture to avoid postoperative internal hernias.

Before leaving the operating room, a decision is made about whether to place a gastrostomy tube in the gastric remnant. While leaving a gastrostomy tube can prove invaluable in the postoperative course of some patients, it can also lead to signicant complaints by patients that do not need it. e tube is placed laparoscopically using either a Stamm technique, if the remnant can easily reach the abdominal wall, or a Witzel technique, if remnant mobility is limited. In general, I prefer to leave a gastrostomy tube in patients aer a very dicult procedure, in patients who are normal weight or had signicant weight loss before the surgery to support their nutrition and minimize weight loss aer surgery, or in any high- risk patient. A drain is not routinely le under the anastomosis unless specic concerns about the anastomosis exist.

13.4 Special/Unusual Situations

As previously mentioned, patients with previous open procedures usually have incisional hernias at their upper midline incision. ese hernias need to be repaired, ideally with a biologic mesh, during the procedure. If the hernia is not repaired or individual defects are closed primarily with suture (the surgeon may be tempted to do this at the end of a very long and dicult laparoscopic case), the risk of postoperative bowel obstructions may be signicant. e author has encountered most postoperative problems in this patient subgroup, and therefore an open procedure may be advisable.

Most enterotomies occur at the gastric fundus that was wrapped around the esophagus. Oen, that part of the stomach also appears to have compromised blood supply. By removing it, the chance for postoperative leaks from a recognized and repaired or a missed enterotomy is likely decreased.

Holes in the esophagus represent a more difcult challenge for the surgeon. In one case, the author encountered a hole in the anterior esophagus aer dissection of the esophagus and stomach from the le lobe of the liver in a patient with a history of multiple prior antireux procedures including a prior Angelchik procedure and later

Gastric Bypass After Failed Fundoplication fromDimitrios Stefanidis

removal of the device. To address this issue, the author created a longer pouch in the horizontal axis, folded the extra fundus over and sutured it to the anterior esophagus to cover the esophageal hole similar to a Dor fundoplication. is patient did not have to be converted to an open procedure but took considerably longer to complete. e patient did very well.

Another very important aspect is the use of appropriate size staplers. Tissues are scarred and staple formations are more likely to fail if the increased thickness of the tissues is not accounted for by the surgeon. In addition, while the author usually creates his gastrojejunostomy in an antecolic antegastric fashion with a transoral circular stapler, he uses a hand-sewn anastomosis and/or a retrocolic Roux limb if tissue mobility, thickness, and the presence of anastomotic tension dictate. Moreover, in exceptionally dicult cases if the dissection in the hiatus is unsafe due to very dense scar tissue, it may be prudent to create a longer transverse gastric pouch without taking the fundoplication down and the anastomosis in an area of the pouch where the tissue quality is better. is approach is suboptimal but may need to be adopted for patient safety. e author has had to adopt this approach in a patient aer a previous Collis–Nissen procedure complicated by a postoperative leak. e tissues at the time of surgery were extremely scarred and dissection unsafe in the hiatus. On the other hand, the author also had to revise a patient 5 years aer she had this approach at another facility. While the patient’s reux symptoms had initially resolved for 3–4 years, they became severe again necessitating taking down the fundoplication and making the pouch small by the author.

13.5 Postoperative Course

All patients are monitored closely postoperatively using continuous pulse oximetry and heart rate monitoring in the appropriate hospital setting. Older and sicker patients may be kept intubated overnight in the intensive care unit. A swallow study is obtained selectively the day aer surgery, and the patients are started on a liquid diet. ey are discharged home 2–4 days later when they can tolerate their diet, are comfortable moving, and have no other concerning issues. e author has performed over 70 of these procedures in the last

7 years with good results. All procedures have been completed laparoscopically without conversions; however, three patients required a laparotomy and two a laparoscopy in the early postoperative period due to bowel obstruction. No mortalities have been encountered, and one leak at the gastrojejunal anastomosis occurred. All patients have had resolution of their preoperative symptoms and excellent reux control immediately aer surgery. Adjustment to the eating limitations of RYGB has been challenging for a small proportion of patients early aer surgery, but overall patient satisfaction has been excellent. It should be noted that these patients should be investigated aggressively aer surgery if any concerning symptoms/signs occur to allow for early reintervention if needed.

References

1. Anand G, Katz PO.Gastroesophageal reux disease and obesity. Gastroenterol Clin North Am. 2010;39(1):39–46.

2. Hampel H, Abraham NS, El-Serag HB.Meta-analysis: obesity and the risk for gastroesophageal reux disease and its complications. Ann Intern Med. 2005;143(3):199–211.

3. Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD.Guidelines for surgical treatment of gastroesophageal reux disease. Surg Endosc. 2010;24(11):2647–69.

4. Spechler SJ, Lee E, Ahnen D, Goyal RK, Hirano I, Ramirez F, Raufman JP, Sampliner R, Schnell T, Sontag S, Vlahcevic ZR, Young R, Williford W.Long-term outcome of medical and surgical therapies for gastroesophageal reux disease: follow-up of a randomized controlled trial. JAMA. 2001;285(18):2331–8.

5. Perez AR, Moncure AC, Rattner DW.Obesity adversely aects the outcome of antireux operations. Surg Endosc. 2001;15:986–9.

6. van Beek DB, Auyang ED, Soper NJ.A comprehensive review of laparoscopic redo fundoplication. Surg Endosc. 2011;25(3):706–12.

7. Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, Jehaes C.Long-term results after laparoscopic reoperation for failed antireux procedures. Br JSurg. 2011;98:1581–7. Epub: 2011 Jun 28.

8. Frezza EE, Ikramuddin S, Gourash W, etal. Symptomatic improvement in gastroesophageal reux disease (GERD) following laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2002;16:1027–31.

9. Houghton SG, Nelson LG, Swain JM, etal. Is Roux-en-Y gastric bypass safe after previous antireux surgery? Technical feasibility and postoperative symptom assessment. Surg Obes Relat Dis. 2005;1:475–80.

10. Raftopoulos I, Awais O, Courcoulas AP, Luketich JD. Laparoscopic gastric bypass after antireux surgery for the treatment of gastroesophageal reux in morbidly obese patients: initial experience. Obes Surg. 2004;14:1373–80.