Collis Nissen for slipped fundoplication with recurrent GERD symptoms

Hiatal hernia recurrence is a dreaded postoperative complication after surgery for gastroesophageal reflux. This video presents a live surgery performed on a patient presenting with recurrent symptoms and dysphagia after previous Nissen fundoplication performed 5 years ago. All the preoperative work-up demonstrates the recurrent reflux, mixed ascites and alkaline reflux associated with an intrathoracic migration of the proximal stomach and probably a slippage of the valve on the upper part of the stomach. This patient has a manometry, which confirmed the weakness of the lower esophageal sphincter (LES) associated with some dysmotility disorders in the lower esophagus.

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Collis Nissen for slipped fundoplication with recurrent GERD symptoms

Authors

B Dallemagne, J Marescaux

Abstract

Hiatal hernia recurrence is a dreaded postoperative complication after surgery for gastroesophageal reflux. This video presents a live surgery performed on a patient presenting with recurrent symptoms and dysphagia after previous Nissen fundoplication performed 5 years ago. All the preoperative work-up demonstrates the recurrent reflux, mixed ascites and alkaline reflux associated with an intrathoracic migration of the proximal stomach and probably a slippage of the valve on the upper part of the stomach. This patient has a manometry, which confirmed the weakness of the lower esophageal sphincter (LES) associated with some dysmotility disorders in the lower esophagus.

Keywords

Laparoscopic management, hiatal hernia recurrence

Media type

Surgical video

Duration

17'00''

Publication

2010-01

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E-publication

WeBSurg.com, Jan 2010;10(01).
URL: http://www.websurg.com/doi-vd01en2810.htm

Collis Nissen for slipped fundoplication with recurrent GERD symptoms

1. Clinical case presentation 00'09''

This video presents a live surgery performed on a patient presenting with recurrent symptoms and dysphagia after previous Nissen fundoplication performed 5 years ago. All the preoperative workup demonstrate the recurrent reflux, mixed ascites and alkaline reflux associated with an intrathoracic migration of the proximal stomach and probably a slippage of the valve on the upper part of the stomach. This patient has a manometry, which confirmed the weakness of the lower esophageal sphincter associated with some dysmotility disorders in the lower esophagus.

2. Peritoneal cavity exploration 01'14''

Going inside the peritoneal cavity, we just found some small adhesions to the left hypochondrium there and you see there were some suture material - gastropexy. But we can’t see anything else, a very clean cavity. So the suspicion is again an intrathoracic migration of the anti-reflux mechanism, or we suspect more a slippage or a herniation through the valve.

3. Start of dissection 01'46''

The first goal is to try and find the diaphragm and the hiatal orifice, so I usually work on this side and try to find a cleavage plane between the liver and the gastro-hepatic ligament. Sometimes I like this approach because I can go quite directly to the right crus, which for me is a very important landmark. Initially, I always start with my surgical sponge, and sometimes when I am in a very difficult situation, I use the suction device in my left hand and my scissors in my right hand to always maintain a very clear surgical field, which is very important in this area because you don’t know where the esophagus is so that’s very dangerous. I will work a little bit on the left side to see if I can localize the position of the diaphragm and the hiatal orifice. There is the stomach there. So on my left I probably have the valve. I think that this is part of the hiatus but I’m not yet very sure. My first impression is that there is some twisting on the valve towards the right side of the patient, I don’t know if I’m right so I’m following the lower part of the liver as there are probably adhesions. That is probably the liver capsule here, so I will try to cut this. We have a very good Italian surgeon specialist in flexible endoscopy and he is working with the team, that is really something important for the future. It is not to fight with the endoscopists, but as surgeons, we have to understand that when we are dealing with this sort of problems, we should be able to cover and get the information that we want. Personally, I am not looking at doing some ERCP or something like that, but I like when I am doing my upper GI surgery to be able to get information that I need instantly, so that is probably why this collaboration is very interesting.

4. Valve identification 05'00''

Here I have what is probably some valve. What is very important to me is to have identified the position of the esophagus, probably here, that is the first important landmark that we need. That is inside the fundoplication right? Yes. Quite a lot of stitches in this patient. Probably the crus is there, this is part of the valve here, I can cut this, and I have the valve below the diaphragm, this is muscle. You see how important it is to play with traction: you can identify the structures. You see it looks more like stomach. And then afterwards, we see what happens with the nerves but that is not my priority at this stage. I try to be as far as possible from the main structures, that is why I am cutting on the edge of the diaphragm, not close to the structures.

5. Slippage identification 07'13''

See this herniation there, hernia sac, that’s right. It corresponds quite well to the swallow that we had. Here you see very well what is a slippage with the valve in this position and the stomach here above the valve, so that’s a nice illustration of a slippage. It’s not easy open like you say, I remember half the times when you did it open you ended up sticking your finger through the stomach at some point. When I’m cutting in one position but it’s because I feel the stitch just under my finger. So you see again a lot of blunt, posterior valve. I don’t know if in the audience people do have the experience with this sort of redo surgery. So finding back the posterior aspect, virgin territory, so the idea is to get there to have the top of the gastric fundus clearer and I am going to the right side of the patient on the posterior aspect. I think that a good instrument in this sort of surgery is the Ligasure®. The aorta, so all this can be divided, so we will probably get some length. You see that again we are reaching the upper limit of the dissection of the first surgeon. So we will open the valve because I will redo it at this point.

6. Collis reconstruction 11'32''

The idea is to recreate the normal anatomy, well not the normal but basic anatomy of the stomach. So endoscopy, now on the main screen you have the endoscopist. There is still a little bit of fundoplication. That was the adhesion that I was struggling with. The tape is a good indicator, I can get more length with a simple mobilization. I will get this last adhesion that we had in the valve and then we will prepare for a Collis. So you’ll do a wedge? Yes.

7. Gastric fundus mobilization 13'00''

We will totally mobilize the gastric fundus to be prepared for the lengthening procedure. What I am going to do is insert a 12mm trocar inside the chest, and I will come from the chest to do the Collis. To perform a Collis gastroplasty from the abdomen, the left 5mm subcostal trocar is replaced by a 12mm trocar that will accommodate the endostapler. A good traction is applied on the GE junction. A bougie is placed in the esophagus and the first application of the endostapler is made in an oblique fashion on the angle of His.

8. Stomach resection 13'46''

It allows to resect or to cut the angle of His leaving a wedge part of the stomach on the left side of the esophagus and a second application of the endostapler will resect this wedge part of the stomach. And you can see that using a 65mm stapler, we probably lengthen the esophagus by 4cm. and usually these 3 applications are sufficient to create this lengthening procedure.

9. Running suture on staple line 14'24''

Then, to cover and secure this staple line mostly in redo operations, we are used to doing a running suture on the staple line using absorbable 3/0 material. This is not necessary usually for primary operations but as soon as we’re dealing with redos, the risk of postoperative leakage is quite high and that is why we are performing this suture in all the patients. Once we have made this lengthening procedure, the next step is to do the crura repair.

10. Crura repair 15'04''

The crura repair is performed in a usual fashion using non-absorbable interrupted sutures. Again the rules to close the hiatus are the normal ones. The bougie is still placed in the esophagus and will help in calibrating this crura repair. And the final step of the operation is to recreate a fundoplication.

11. Floppy fundoplication 15'38''

The fundus has been mobilized so we’re recreating a floppy fundoplication and you can see that this fundoplication is applied on the new segment of the esophagus that has been created by the gastroplasty. And this lengthening procedure will allow the valve to stay below the diaphragm without too much tension back towards the mediastinum. This patient had upper GI series on the first postoperative day, which was excellent and he was allowed to drink and eat. The patient was discharged 2 days after this operation.