3
0
CHAPMAN, III, ET AL.
interrupted fashion, 1.5 to 2 cm apart, taking seromus- the use of laparoscopic techniques, robotic surgery is
cular bites of the fundus and a small bite of the anterior more expensive, has a significant learning curve, takes
esophageal wall.
longer to perform, involvesmore manpower, and requires
Once the wrap was completed, it was apparent that a trained surgical team. Certainly, with time, these issues
there was still a fairly wide esophageal hiatus, even with will decrease, and the technology and methods will im-
the bougie in place. We subsequently placed 0 Surgidac prove. As more experience is gained, we will be able to
stitch anterior to the esophagus, approximating the left determine the benefits of robotic surgery for both sur-
5
and right portions of the crura. After completion of this geons and patients.
stitch, the esophageal bougie was removed. The wrap ap-
peared to be nice and floppy and was in good position
(
Fig. 3). One of the posterior crural stitches appeared to
CONCLUSION
be loose; this was subsequently replaced with a new 0
Surgidac stitch. The fan retractor was removed under di-
rect vision. The abdomen was desufflated through the tro-
car ports, and the ports were removed. The fascia and
skin incisions were then closed.
The patient’s postoperative recovery was uneventful.
She required no intravenous narcotics and very little oral
pain medication. She was started immediately on a clear
liquid diet and advanced to a pureed diet. She was dis-
charged home on a pureed diet less than 24 hours after
admission. She will be followed as an outpatient.
We have reported the first robotic Nissen fundoplica-
tion in the United States. As more da Vinci systems are
installed in this country, larger multi-institutional trials
can be performed to help determine the role of robotics
in health care in the 21st century.
ACKNOWLEDGMENTS
The authors would like to express their appreciation to
the entire surgical team: operating room nurses Janet
Hambrook, Gina McCoy, Renee Grainger, and Tom
Gustafson; anesthetist Lucy Glover; and anesthesiologist
Ray Minard, M.D. We also appreciate the support of the
staff of Intuitive Surgical, Inc., and the students, resi-
dents, and staff of the robotic/research laboratory who
helped make this surgery happen.
DISCUSSION
Minimally invasive laparoscopic surgical techniques
have rejuvenated the surgical management of GERD in
the 1990s. The laparoscopic Nissen fundoplication has
become the gold standard for the surgical management
of this disease. The benefits of laparoscopic surgery in-
clude diminished tissue trauma, decreased narcotic use,
earlier oral intake, shorter hospitalization, and a quicker
recovery and return to normal activities. The disadvan-
tages of minimally invasive surgery are loss of tactile
sensation, decreased manual dexterity, and loss of the
REFERENCES
1
2
. DeMeester TR, Peters JH, Bremner CG, Chandrasoma P.
Biology of gastroesophageal reflux disease: Pathophysiol-
ogy relating to medical and surgical treatment. Annu Rev
Med 1999;50:469–506.
. Lonroth H. Efficacy of, and quality of life after antireflux
surgery. Eur J Surg 2000;Suppl 585(1):34–36.
3
third-dimensional view.
With the advent of robotic systems such as the da
Vinci, we have regained the three-dimensional view and 3. Champault GG, Barrat C, Rozon RC, Rizk N, Catheline JM.
have improved surgical dexterity. The robotic camera
system provides a nearly perfect three-dimensional view
with outstanding depth perception. The articulating ro-
botic instruments, with their seven degrees of freedom,
provide a more natural motion, mimicking that of the hu-
man wrist. The surgeon’s hand motions are filtered in
scale through the robotic system so that the articulating
wrists move in a smooth and tremorless fashion. Never-
theless, although we have regained the third-dimensional
view and improved surgical dexterity, there is even less
tactile feedback with the robotic technique than with the
The effect of the learning curve on the outcome of laparo-
scopic treatment for gastroesophagealreflux. Surg Laparosc
Endosc Percutan Techn 1999;9:375–381.
. Satava RM. Emerging technologies for surgery in the 21st
century. Arch Surg 1999;134:1197–1202.
4
5
. Satava RM. Virtual endoscopy: Diagnosis using 3-D visu-
alization and virtual representation. Surg Endosc 1996;10:
1
73–174.
Address reprint requests to:
William H.H. Chapman, III, M.D.
Department of Surgery-TA 245
The Brody School of Medicine
East Carolina University
4
laparoscopic technique.
Clearly, the robotic Nissen fundoplication is an alter-
native in the surgical management of GERD. It would be
premature, though, to state what role robotic surgery will
have in the future treatment of reflux, gallbladder dis-
ease, or other surgical diseases. As was seen initially with
600 Moyle Blvd.
Greenville, NC 27834