Influence of primary surgical access on the expression of the adhesive process and the tactics of redo fundoplication

Background. Despite the widespread adoption of laparoscopic technologies, the problem of recurrent hernias of the diaphragm (HHD) and gastroesophageal reflux disease (GERD) remains relevant. According to data from 2024, 229 repeat interventions were performed due to recurrent HHD and/or GERD, including 178 (74.5%) laparoscopic and 61 (25.5%) open surgeries. One of the key factors determining the complexity of a repeat intervention is the severity of the adhesive process, which may depend on the type of primary surgical access. Objective. The purpose of this study is to evaluate the impact of the surgical approach during primary fundoplication on the presence and prevalence of adhesions, as well as on the tactics of repeated anti-reflux surgery. Material and methods. The retrospective study includes an analysis of data from 64 patients with recurrent hiatal hernias and recurrent gastroesophageal reflux disease who received treatment at the I.V. Davydovsky City Clinical Hospital of the Moscow Health Department between January 2018 and February 2026. Patients were divided into 2 clinical groups depending on the type of surgical access during the primary operation: laparoscopic (n=33) or open (n=31). A comparative analysis was carried out of the severity of the adhesive process, the specifics of surgical tactics, the duration of the operation, the volume of blood loss, and postoperative complications. Results. In the group following primary laparoscopic surgery, an adhesive process requiring adhesiolysis was detected in 11 (33.3%) patients, whereas after open intervention it was detected in 31 (100%) patients. During repeat surgeries after laparoscopic fundoplication, the “direct trocar” technique was used significantly more often (22 cases versus 4 cases), whereas after laparotomy, the optical trocar was predominantly used (25 cases). The average duration of the operation was 101±27.4 and 128±28.2 minutes, respectively; the average blood loss was 91±33 and 134±21 ml. Postoperative complications of grades I–II according to Clavien–Dindo were observed in 6 and 8 patients, respectively; a grade III complication was recorded only after a repeat operation in a patient who had previously undergone laparotomy. Conclusion. Assessment of the frequency and severity of intra-abdominal adhesive processes is directly correlated with the type of surgical approach (laparoscopy or laparotomy) during primary fundoplication: laparoscopic antireflux interventions are associated with a less pronounced adhesive process compared to open approaches. This factor helps to optimize the strategy for performing a repeat intervention, influencing the type of surgical approach, the sequence of operations, and the choice of dissection instruments. This approach is accompanied by a reduction in the duration of the operation, the number of intra- and postoperative complications, as well as intraoperative blood loss, which affects the safety and technical complexity of the operation.