Step 1
Surgical Anatomy
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A comprehensive understanding of the anatomy of the esophagus and stomach is essential before performing surgical fundoplication or other operations of the foregut.
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Figures 33-1 and 33-2 demonstrate the key surgical anatomy required to perform a transabdominal laparoscopic Collis gastroplasty and fundoplication successfully (see Fig. 33-1 ).
Figure 33-1
Figure 33-2
Step 2
Preoperative Considerations
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Gastroesophageal reflux disease (GERD) is one of the most common disorders of the gastrointestinal tract, affecting up to 40% percent of the population. Whereas most patients with GERD suffer from mild symptoms of heartburn and regurgitation, a small percentage of these patients will develop complications of reflux, including esophagitis, esophageal strictures, Barrett esophagus, hiatal hernias, and shortened esophagus. Intrinsic shortening of the esophagus is the result of the chronic inflammation associated with GERD.
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Preoperative evaluation of patients with GERD includes endoscopy, 24-hour esophageal pH monitoring, esophageal manometry, and fluoroscopic barium studies. The presence of a shortened esophagus may be suggested by a hiatal hernia greater than 5 cm in diameter, type III hiatal hernias, Barrett esophagus, a history of caustic ingestion, sarcoidosis, scleroderma, or Crohn disease.
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Indications for the surgical treatment of reflux disease include (1) patients with complications of reflux, such as esophageal stricture, Barrett esophagus, Cameron ulcers, and anemia; (2) patients with symptoms that are refractory to medical treatment; and (3) patients who are well controlled with medical therapy who wish to avoid the need to take long-term medications. The presence of a hiatal hernia alone is not generally considered an indication for repair. Hiatal hernias associated with symptoms of GERD or obstruction should undergo operative repair. However, the benefits of repairing an asymptomatic paraesophageal hernia remain an area of significant controversy.
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A Collis gastroplasty is a necessary adjunct to fundoplication in patients with a shortened esophagus. In most patients, the esophagus can be adequately mobilized to allow for a fundoplication without an esophageal lengthening procedure. Predicting which patients will require a Collis gastroplasty preoperatively is extremely difficult. The presence of the gastroesophageal (GE) junction at the level of the diaphragm or below on an endoscopy or other imaging study effectively excludes esophageal shortening. However, the presence of a fixed hiatal hernia does not reliably predict a shortened esophagus. In fact, most patients with large fixed hiatal hernias may undergo fundoplication without esophageal lengthening, but failure to recognize a shortened esophagus is likely to result in an early hiatal hernia recurrence.
Step 3
Operative Steps
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The patient is positioned on a split-leg table or in the low lithotomy position to allow the surgeon to stand between the legs. Placing the patient’s arms at his or her sides allows for greater flexibility for placement of the liver retractor as well as for assistants standing at the bedside.
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Skin cleansing with a chlorhexidine-based preparation, as recommended by the Centers for Disease Control and Prevention, is used and extends from the nipples to the inguinal ligaments craniocaudally and should extend to the posterior axillary line on either side.
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Access to the peritoneal cavity is obtained by using either the Veress needle or a Hasson technique. The initial trocar should be positioned in the midline approximately 15 cm below the xyphoid process. Placement of this port at the umbilicus may limit the surgeon’s ability later to dissect into the mediastinum to obtain adequate esophageal mobilization. Additional ports are placed for retraction and exposure and include 5-mm ports in the right midclavicular line, the subxyphoid position, and the left anterior axillary line. A 12-mm port is placed in the left midclavicular line, which is used for introducing the stapling device (see Fig. 33-2 ).
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A liver retractor is placed through the subxyphoid port site to retract the left lobe of the liver anteriorly and expose the esophageal hiatus.
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Gentle retraction is used to reduce the contents of the hiatal defect into the peritoneal cavity. The left lateral port site is used to maintain retraction on the stomach.
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Initial dissection is performed along the greater curvature of the stomach, approximately 1 cm lateral to the stomach, dividing the short gastric vessels. Dissection is performed along the cephalad third of the stomach and extending up to the level of the left diaphragmatic crus. Attachments between the posterior wall of the stomach and the retroperitoneum are also released.
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The hernia sac is incised along the medial border of the left crus of the diaphragm. Using blunt dissection, a plane is dissected above the hernia sac, reducing the hernia sac into the abdomen. The esophagus is identified in the mediastinum above the hernia sac. The use of an esophageal bougie may facilitate identification of the esophagus in some patients.
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The gastrohepatic ligament is incised through its avascular portion and extended up to the phrenoesophageal ligament. Care must be taken to identify an accessory left hepatic artery within the gastrohepatic ligament. The peritoneum and hernia sac over the anterior aspect of the esophagus are incised carefully to avoid injury to the underlying anterior vagus nerve. The hernia sac and preesophageal fat pad are fully reduced from the mediastinum into the abdomen.
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The esophagus is encircled with a Penrose drain to facilitate anterior retraction of the esophagus. Posterior hernia sac attachments between the esophagus and the diaphragm are carefully incised while identifying the posterior vagus nerve, which is left adherent to the esophagus to avoid injury.
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The esophagus is then circumferentially mobilized into the mediastinum to ensure a minimum of 2.5 to 3 cm of intra-abdominal esophageal length. If the GE junction does not remain below the diaphragm with an adequate tension-free intra-abdominal length, then a Collis gastroplasty is required to prevent the postoperative migration of the stomach into the mediastinum.
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A stapled wedge Collis gastroplasty is performed using a reticulating endoscopic linear stapler. A 48 to 52 French bougie is placed transorally and introduced into the stomach. The fundus is marked adjacent to the bougie in the desired location of the newly created GE junction. This is typically 3 to 5 cm below the Angle of His. The reticulating stapler is introduced through the left midclavicular port and maximally angled toward the bougie. The stapler is placed along the greater curvature of the stomach with the anvil directed toward the marked location on the fundus. Two to three applications of the stapler are generally required. The stapler is then reticulated such that the anvil of the stapler is parallel to the bougie and fired in a vertical fashion to excise a wedge of fundus, thus creating a 3- to 5-cm neoesophagus ( Fig. 33-3 ).
