What are the formal contraindications to the laparoscopic approach?
G. Champault (Paris)
Although it is generally accepted that the indications for the treatment of gastroesophageal reflux disease (GERD) by laparoscopy are the same as those of "conventional" surgery, the contraindications are different.
They can be classified into four categories.
"Feasibility" covers the basic conditions required for surgery, both in terms of equipment (monitor, trocars) and in terms of the surgical, anesthetic or nursing team. The experience of the surgeon, his training and knowledge of the techniques, if deficient, are among the main causes of failure and, in particular, play a determinant role in the onset of complications, especially dangerous perforations of the esophagus and stomach . These problems could be overcome by an accreditation system based on criteria of training, practice, experience and recruitment.
The contraindications of laparoscopy itself apply to the treatment of GERD. They are now generally recognized and consist of failure or deficiencies of the main physiological functions: global heart failure, valve disease, coronary artery disease, obstructive lung disease, chronic respiratory failure, advanced hepatocellular insufficiency, closed angle glaucoma... Others are more relative and depend on how well disorders are tolerated: disorders of hemostasis, asthma, renal failure, physiological age, marked obesity. All these factors must be evaluated by a detailed preoperative assessment designed to balance the risks run by the patient against the expected advantages of surgical treatment by laparoscopy. These considerations must allow for the possible need to convert to laparotomy as a result of an unforeseen intraoperative complication such as uncontrollable bleeding.
Conditions affecting the hiatal region constitute the third factor. Rather than the morphology and the weight of the patient, the contraindication is more usually due to previous surgery affecting the epigastrium or left hypochondrium, generalized peritonitis, gastrectomy, splenectomy, colectomy (transverse or of the splenic flexure) etc. In practice, the local conditions are often only accurately assessed on visual and instrumental exploration, pneumoperitoneum having been created by "open laparoscopy". Here too the experience of the surgeon is a determinant factor. The hiatal approach is sometimes possible as the price of careful and patient adhesiolysis, but in other cases the local conditions are such as to rule out laparoscopy, especially if it is not possible to recognize the anatomic structures.
Finally, factors concerning the esophagogastric junction may rule out the possibility of a laparoscopic approach.
In cases where there is voluminous engagement of the stomach in the thorax, repositioning and fixing is often difficult, but nevertheless their laparoscopic treatment is frequently reported nowadays . One of the problems they present is the closure of the gaping hiatal orifice for which the simple bringing together of the diaphragmatic crura is insufficient and which may require a prosthesis.
Re-operations after failure of previous treatments  whether conventional or laparoscopic, can often also be carried out by laparoscopy. As a rule they confirm the weakly adhesiogenic character of earlier laparoscopic approaches. Thus, depending on the circumstances, it is possible to perform reconstruction of a partly or wholly defective valve, or to reposition and fix a failed Nissen type procedure, to repair an excessively tight valve with Endo GIA forceps or to release the crura of the diaphragm in cases of persistent severe dysphagia that do not respond to dietary measures and dilation. However, here too, it may prove impossible or dangerous to return to a previously operated hiatus.
The "non-lowerable" cardia or acquired short esophagus is clearly a condition for which the laparoscopic approach faces the maximum of difficulties . It is difficult to predict on the basis of preoperative data, except perhaps by manometry and endoscopy. In these situations, it is important to know when to abandon laparoscopy, before or during the operation, in order to avoid the risk of complications (pneumothorax, hemorrhage, perforation and failure due to the fact that the valve formed is perigastric rather than esophageal). Although this is not clear from the surgical data, the same is true when the laparoscopic surgeon discovers large lesions of peri-esophagitis extending into the mediastinum .
Finally, it is worth considering the justification for laparoscopic treatment of GERD under circumstances in which "lesions associated with Barrett's esophagus with moderate to severe dysplasia have been identified", but this is quite another problem...
Despite the above considerations with which we are all familiar, the formal contra-indications for the laparoscopic treatment of GERD are few (3 to 5%) and well founded [2, 3, 6]; they mainly concern the condition of the patient rather than the disease itself.