Laparoscopic Redo Nissen Fundoplication in a 30 kg Child with the 3 mm Percuvance System

The case is a redo fundoplication in a 30 kg child using the 3 mm Percuvance system

The Percuvance instrument is inserted by first inserting a needle tip on the shaft, then inserting through a 5 mm trocar placed in the left mid quadrant, then attaching the grasper

Three Percuvance instruments are used, supplying both liver retraction and stomach manipulation

The stomach retractor needle tip is inserted directly through the abdominal wall and then a grasper is attached to retract on the stomach

The 5 mm effector tips allow for atraumatic manipulation of the stomach in this larger child

The previous wrap appears to be intact but is loosened, and there is a small hiatal hernia

Complete takedown of the wrap and exposure of the left crus is a key maneuver in redo fundoplication

A two-stitch crural repair was performed using 2-0 Ethibond suture

It is extremely important in redo fundoplication to completely take down the previous wrap so that the hiatal defect can be well visualized and repaired appropriately

The stomach is retracted down to further lengthen the esophagus to ensure there is adequate length

The wrap is formed going from stomach to the anterior wall of the esophagus, with the top stitch also including the anterior diaphragmatic rim

Including the anterior diaphragmatic rim in the top stitch helps lock the wrap into the abdomen and hopefully will prevent recurrent herniation

Three sutures are placed, each incorporating a bite of the stomach, a bite of the esophagus, and a bite of the wrap portion of the stomach

Removal of the three Percuvance tips took approximately one minute