The management of gastroesophageal reflux disease and hiatus hernia has continually evolved in both general and thoracic surgery over the last century. Although the introduction of improved medical management in the form of H₂ blockers and proton pump inhibitors (PPIs) has reduced the number of patients presenting to the surgeon for management of this disease, a well-defined role for surgical treatment remains in the circumstances of medical failure or medication intolerance as well as for a fixed anatomical abnormality. Beginning in the late 1950s with the work of Belsey, Nissen, Hill, and Collis and extending through the present day, there has been great debate as to the optimal surgical approach to reflux disease and repair of paraesophageal hernia. Most recently, minimally invasive approaches have gained favor. However, the traditional techniques of open hiatal hernia repair and fundoplication are required in select patient groups. This chapter will discuss the current application of the transthoracic Collis–Belsey approach to hiatal hernia repair with a focus on appropriate patient selection and evaluation.

The operation now attributed to Belsey is the culmination of several rounds of clinical experimentation spanning over a decade’s worth of experience. Dr. Belsey’s original intent was to create a general approach to the management of reflux disease, and several iterations were needed to arrive at the Mark IV version, which is most commonly used today.¹ In parallel to Belsey’s work, Collis also sought to develop a surgical solution for gastroesophageal reflux, focusing on the importance of obtaining an adequate length of intra-abdominal esophagus to allow for a tension-free acute angle of esophageal entry into the stomach. Looking for ways to achieve this, he published the first description of the tubularization of a section of the lesser curvature of the stomach for use as a distal esophageal equivalent in 1957.² In 1971, Pearson et al.³ published a series of 24 patients with peptic stricture of the distal esophagus treated with a combination gastroplasty and Belsey hiatal hernia repair. They reported excellent results with either resolution or improvement in the symptoms of dysphagia in all patients.

The “Collis–Belsey” operation, as described by Pearson, gained a great amount of support as an approach to hiatal hernia repair and a viable antireflux procedure. In recent years, however, the advent of efficacious minimally invasive approaches to the surgical treatment of GERD has limited application of the Collis–Belsey procedure to a relatively specific subset of patients with esophageal stricture and foreshortened esophagus. The operation also has a defined role as an option in the repair of hiatal hernia in the obese patient in whom the bulk and pressure from the abdominal viscera and omentum limit visualization with an abdominal or laparoscopic approach.

A transthoracic approach to paraesophageal hernia may also be preferred in the reoperative setting in patients who have had a prior abdominal repair. In addition, patients with impaired esophageal motility identified preoperatively may benefit from the improved esophageal clearance provided by the partial fundoplication of the Belsey procedure as compared with the “tighter” circumferential wrap described by Nissen. In the setting of incarcerated paraesophageal hernia with gastric volvulus, when an urgent operation is indicated to prevent gastric necrosis or bleeding, it may not be known whether the patient has normal motility or a foreshortened esophagus. A Collis–Belsey approach will address both concerns in this setting.

A thorough assessment of the patient is of paramount importance in determining the appropriate surgical approach. A detailed history of symptoms and prior interventions can give an accurate impression of the severity of the disease process. All patients should undergo esophagogastroduodenoscopy (EGD) both to assess the anatomic relationship of the esophagogastric junction (EGJ) to the diaphragm as well as the degree of esophagitis and the presence of stricture. EGD also can define the size and degree of organoaxial volvulus of a paraesophageal hernia. A barium esophagram may be helpful to further assess esophageal length and the anatomy of the paraesophageal hernia. A foreshortened esophagus will produce tension on the hiatal repair or fundoplication and these patients benefit greatly from an esophageal lengthening procedure. Peptic stricture of the distal esophagus is indicative of a transmural inflammatory process which, as it heals, causes a cicatricial scar which binds the esophageal mucosa and submucosa to the muscularis. Fibrosis involving the inner circular muscle layer produces luminal stricture, whereas involvement extending to the outer longitudinal muscle layer leads to esophageal shortening.

An assessment of esophageal motility with a manometric pressure catheter is essential. This instrument affords appropriate characterization of the intrinsic esophageal function, which, if abnormal, may mandate partial fundoplication to avoid significant dysphagia postoperatively. A complete evaluation will include quantification of the extent of reflux with 24-hour pH monitoring and correlation of symptoms with periods of decreased distal esophageal pH.

The recent introduction of accurate high-resolution manometric (HRM) studies has paved the way for even more accurate characterization of both motility within the esophageal body and function of the lower esophageal sphincter. The technique uses a manometry catheter with multiple, closely spaced sensors to gather accurate manometric data throughout the entire length of the esophagus rather than from a limited number of isolated positions. These data may be independently evaluated as a pressure tracing. More recently, a technique known as esophageal pressure topography (EPT) plotting⁴ has provided even more detailed analysis of HRM studies. This process uses an interpolated average of data between sensors to create a seamless isobaric color plot, which permits the function of the entire esophagus to be presented in a single visual display. The improved data have rendered this approach the new gold standard for the diagnosis of esophageal motility disorders.⁵ Distinct HRM patterns are identifiable for each pathologic condition,⁶ allowing the surgeon to make accurate preoperative assessments of the extent of dysmotility and to develop the appropriate operative plan. This is especially important with respect to the choice of fundoplication.

Occasionally, a hiatal hernia may be detected incidentally on plain chest radiographs (Fig. 38-1). It may manifest as a retrocardiac air-fluid level. If a paraesophageal hernia is causing symptoms of postprandial pain, retching, or early satiety, an abdominal CT scan may reveal the abnormally positioned intrathoracic stomach (Fig. 38-2).

Once the patient is deemed an appropriate surgical candidate, a careful evaluation of their pulmonary function and cardiac health should be undertaken both by the surgeon and the anesthesiologist. We routinely recommend preoperative anesthesia consultation both to achieve this goal and to discuss thoracic epidural placement and other strategies for postoperative pain control.

We are indebted to Pearson’s excellent description of the Collis–Belsey procedure in the chapter on open gastroplasty in his textbook of Esophageal Surgery.⁷

Anesthesia

A thoracic epidural catheter and arterial line are placed in the preoperative holding area. After induction of general anesthesia, a double lumen endotracheal tube is placed to provide optimal lung isolation and maximal exposure. The anesthesiologist will also assist with placement of the esophageal Bougie to aid proper sizing of the gastroplasty.

Positioning and Incision

An upper endoscopy may be performed at the outset of the procedure to assess for the presence of stricture or other pathology before commencing the fundoplication and gastroplasty. This would not be obligatory in the setting of an elective repair, when all the obligatory data have been obtained. However, when gastric volvulus and the threat of gastric necrosis necessitate an urgent trip to the operating room, it is prudent to inspect endoscopically before making an incision. Upper endoscopy is performed most easily when the patient is still in the supine position.

When the operative procedure begins, the patient should be in the left thoracotomy position, with pressure points padded appropriately. After properly securing the patient, the operating table should be flexed to open the left interspaces for maximal exposure. A generous sixth or seventh interspace posterolateral thoracotomy is created, dividing the muscle of the latissimus dorsi but sparing the serratus anterior. Occasionally, a rib will need to be “shingled” posteriorly to achieve better exposure, but this is not common if the interspace is opened slowly and widely to allow gentle rib spreading.