Collis Nissen fundoplication in a patient with Barrett's esophagus

This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15 years' history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.

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Collis Nissen fundoplication in a patient with Barrett's esophagus

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15 years' history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.

Keywords

laparoscopy, Barrett's esophagus, short esophagus, Collis Nissen fundoplication

Media type

Surgical video

Duration

17'00''

Publication

2011-01

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E-publication

WeBSurg.com, Jan 2011;11(01).
URL: http://www.websurg.com/doi-vd01en3154.htm

Collis Nissen fundoplication in a patient with Barrett's esophagus

1. Clinical case presentation 00'17''

A 65-year-old man with a 15 years’ history of typical GERD symptoms. The preoperative workup included endoscopy, esophageal manometry confirming the diagnosis of GERD, which was associated with Barrett’s esophagus and ineffective esophageal motility. An upper GI series showed a moderate size hiatal hernia.

2. Surgical steps 00'38''

The trocar placement is the same as for the Nissen fundoplication technique. A 5-trocar technique is used with the patient placed in reverse Trendelenburg.

3. Identification of anatomical landmarks 00'49''

Surgery starts with the identification of the anatomical landmarks at the hiatus and dissection of the gastroesophageal junction (GEJ). This dissection allows the identification of the essential anatomical landmarks that will guide the following steps of the procedure.

4. Dissection of the gastroesophageal junction 01'12''

We usually start the dissection on the right side. The pars condensa of the lesser omentum is opened making sure to preserve the left hepatic artery and the hepatic branch of the vagus nerve. This maneuver shows the way to the right crura, which needs to be identified before the dissection of the esophagus. Blunt dissection of the cleavage plane internal to the crus allows to identify the position of the esophagus. Once the position of the esophagus is identified, the phrenoesophageal membrane is opened anteriorly along the anterior border of the hiatal orifice towards the left crus. At this point, a retroesophageal window is created with careful identification of the posterior vagus nerve, which is kept along with the esophagus.

5. Mediastinal dissection 02'37''

In this patient, due to the presence of a considerable lipoma at the gastroesophageal junction, the hepatic branches of the vagus are taken to improve visualization and decrease the risk of injury related to blind maneuvers. An umbilical tape is then placed around the gastroesophageal junction, which should be able to rest without traction for at least 2cm below the diaphragmatic hiatus. Now to the mediastinal dissection. The aim of the subsequent dissection is to bring at least 2cm of the distal esophagus below the hiatus. We routinely carry out an extensive mediastinal dissection in order to mobilize completely the distal esophagus. This dissection is carefully performed in a blunt fashion, posteriorly, laterally and anteriorly, while manipulating the esophagus with the umbilical tape. The endoscope is advanced to the diaphragmatic hiatus to provide good visualization. A 30-degree lens is advantageous here. The anterolateral aspect of the esophagus is dissected free from areolar tissue with longitudinal blunt dissection, avoiding injury to the esophagus itself and the vagus nerve. As shown here, in patients with a long history of GERD, it is usual to encounter dense adhesions laterally, which make the dissection more difficult and may result in opening of the pleura, which are generally easily managed with an increase in PEEP pressures. The anterior and posterior vagus nerves are dissected along with the esophagus for as high as possible and it is important to avoid inadvertent injury by excessive traction or electrocautery. The dissection is carried out up to the level of the inferior pulmonary vein, and higher if needed, in order to gain maximal length.

6. Short gastric vessel division 05'53''

In order to build a floppy valve, the fundus must be completely mobilized by dividing the short gastric vessels, up to the posterior fundic artery and all the gastrophrenic attachments. The dissection begins low along the greater curvature at the level of the fundus, between the inferior short gastric and first left gastroepiploic vessel. An avascular plane is followed, and the lesser sac is readily entered along the greater curve. The short gastrics are divided, progressing cephalad, skeletonizing the greater curve of the stomach up to the last fundic artery. A greater dissection is not necessary. In this patient, the great amount of supramesocolic fat makes this step more challenging. Adjusting the position of the assistant’s instrument in order to open the lesser sac, the dissection trajectory is better visualized and the assistance of a sponge retraction is sometimes useful. The gastroesophageal junction is now checked again. After a thorough mediastinal dissection, it does not descend more than 2cm below the diaphragmatic hiatus, therefore we are facing a short esophagus and an esophageal lengthening procedure is necessary.

7. Assessing esophageal length 07'15''

At this point, the mediastinal dissection is continued to gain as much esophageal length as possible. In fact, the next step is to determine how much esophageal lengthening is necessary. If only 2 to 3cm are required, then it is possible to proceed with a trans-abdominal Collis gastroplasty such as in this case. If a longer length is needed, then it is preferable to perform a trans-thoracic Collis gastroplasty.

8. Collis gastroplasty 07'46''

The cardia and the fundus of the stomach must first be prepared in the following manner. The fat pad at the cardia is excised completely for good visualization of the gastroesophageal junction. The fundus must be completely mobilized by dividing the first upper short gastric vessels, then the posterior fundic artery, and finally the gastrophrenic attachments. The main 5mm left subcostal working trocar is changed to a 12mm one to facilitate the passage of the stapling device. A bougie is passed into the esophagus. The fundus of the stomach is retracted inferiorly and anteriorly and a 45mm endoscopic stapler is placed through the left subcostal port, directed towards the esophagus. The upper part of the fundus is stapled obliquely, with the tip of the stapler directed towards the bougie. Sometimes, repeated firings are necessary in order to create a small gastric wedge at the fundus, terminating when the tip of the stapler encounters the esophageal bougie. The stapler is then re-orientated parallel to the bougie, with the tip of the stapler directed cephalad. This time the stomach is retracted inferiorly and to the left. The stapler is then fired in this fashion excising the gastric wedge that was initially created. This maneuver is useful to lengthen the esophagus by 2 to 3cm. The crura are re-approximated with 2 non-absorbable sutures, taking care not to overtighten the hiatus.

9. Nissen fundoplication 13'00''

Finally, a short floppy Nissen fundoplication is built. The fundus of the stomach is passed behind the neo-esophagus, taking care to cover the staple line with the fundal wrap. One suture is placed anteriorly to secure the edge of the wrap to the esophagus.

10. Positioning of a Vicryl mesh 15'11''

In this rather obese patient, a Vicryl mesh is placed around the hiatus onto the diaphragm to temporarily reinforce the closure and help prevent early postoperative migration due to abrupt increase of intra-abdominal pressure, such as in case of coughing at extubation or vomiting effort in the postoperative period.

11. Postoperative follow-up 15'43''

Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus such as in this case must be considered at high risk for having a short esophagus. In our opinion, liberal if not routine intraoperative endoscopy and liberal addition of a Collis gastroplasty is a key factor to prevent recurrences. A gastrograffin swallow was performed on the first postoperative day to confirm both the integrity and patency of the Collis gastroplasty and Nissen fundoplication. The patient was then allowed soft diet and discharged on the third postoperative day.