Collis Nissen procedure: a technique to be learned

Antireflux operations are commonly performed. Nissen fundoplication is the “gold standard” antireflux procedure. Some problems could be encountered when a short esophagus is found. This is the case of patient with reflux disease in which a short esophagus is found during the surgical procedure. A Collis Nissen operation is performed.

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Collis   Nissen   procedure:   a   technique   to   be   learned

Authors
B Dallemagne, S Perretta, J Marescaux
Abstract
Antireflux operations are commonly performed. Nissen fundoplication is the “gold standard” antireflux procedure. Some problems could be encountered when a short esophagus is found. This is the case of patient with reflux disease in which a short esophagus is found during the surgical procedure. A Collis Nissen operation is performed.
Keywords
Collis Nissen procedure, fundoplication, crura repair
Media type
Duration
34'00''
Publication
2011-12
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3553.htm

Collis   Nissen   procedure:   a   technique   to   be   learned

2. Trocars position 01'23''
You can see that for the optical system, we’re not using the umbilicus but we’re working a little bit above the umbilicus—it’s a question of distance between this port and the GE junction, which should be somewhere here. So you have to go a little bit high on the abdominal wall and as a start, we have two lateral ports, right and left. And this right one will be used for the liver retractor and the left one will be used for the retraction during the procedure to expose different structures. This is the laparoscopic view so the second trocar, I’ll check from inside, for my right hand, see the costal margin is here so I’ll put it a little bit probably on the right of the mid-clavicular line. It’ll used for my right hand. See I’m always checking from the inside the position of my trocars, not from the outside. With regards to the lower pole of the left liver lobe, probably I’ll insert my second port there and this port will be used by my left hand. So this is a typical port positioning that we’re using for all the surgery of the GE junction. So this is the view that we get, that we’re discovering with you. See the obliquity of the crus, and that may lead to some positioning of the lower esophageal sphincter within the chest so probably a sphincter that is migrating sometimes inside the chest, and it has a very low intrathoracic pressure when it goes back in the chest and because of the negative pressure that will laed to incompetency of the sphincter so that’s probably a good indication for surgery. At this point, I think that there is a nasogastric tube inside so we’re starting with a nasogastric tube and now that I’m sure that the stomach is flat, I’ll ask for removal of the nasogastric tube because I don’t want to have any tube inside during the dissection so you know the anatomy: segment I, pars flaccida, pars condensa, and here you have the branches of the vagus trunk, see the nasogastric tube is getting out, see the crus through this here. And I’ll try to preserve the small branches that are crossing in the lesser omentum because these branches are going to the gallbladder and to the pylorus, so I try to preserve it if I can.
8. Esophageal dissection 09'54''
So therefore I’ll need to mobilize the esophagus within the mediastinum. You see the pleura. So I try to free a little bit the esophagus. You see I’m using a lot of blunt dissection and when I’ve identified the structures, I’m cutting. Regarding the pleura, you see that we can see quite well the pleura there so if you have some perforation of the pleura, that’s not a big issue because usually the only thing to do is talk to the anesthesiologist and say that you have a perforation and you’ll increase a little bit the PEEP and maybe the ventilation rate, and it’s not a big issue so no room for thoracic drainage or anything because that’s a pneumo with CO2 so it will resolve within a few hours after the operation. So you see the heart and the pulmonary vein there—so it’s usually my upper limit and you see that there are quite strong adhesions in this chest so that’s why I’m very careful and I’ll move to the left side of the esophagus so you see I’m spending some time to do this because you’ll see afterwards that probably I’ll get my free segment of the esophagus inside the peritoneal cavity. And this is the vagus trunk here but here usually you have strong afixation of the esophagus so I try to clear that again in order to get my length so you see I feel this quite strong so I want to release it. But to release it, I have to be sure that my vagus trunk is not in the field. Now it’s more free so we’re going back. I’m checking my vagus trunk—you can see it. See it’s a very important operative step because I’m working on that for now 15 minutes, and very interestingly when we look at different operators, the vast majority of them are spending this amount of time just to get a good mobilization of the lower esophagus. So we check again. And you see now, at the beginning we had this drain getting rapidly at the level of the crura muscles, and now we get a little bit more length.
9. Gastric mobilization 14'05''
To start my gastric mobilization, it’s really the upper part of the gastrosplenic ligament, see the stomach is there, this is the fundus, you see it’s really the upper part of the fundus that we’re mobilizing, not the stomach, and that’s very important, and this is really when you want to find it, you’ve just to go through the splenogastric ligament and really you see you go on the top of the splenogastric ligament, and then when you find the fat pad and you’re entering the lesser sac. You see just opening laterally the back of the stomach so we can expose quite well. See the posterior attachment of the gastric fundus and this is very important because this part of the fundus will come on the right side of the esophagus when we’re creating the valve so that’s why we need to mobilize this. So I’ll have a more floppy fundus and I’ll go on the top there gently because we can see that the gastrophrenic ligament is going behind the spleen so I have to take this down, and very gentle traction because otherwise you’ll have the spleen with you. I want this posterior fundic vessel. That’s the last thing that fixes the fundus and afterwards I’ll get access to my left crus. See the left crus is there and the last part of the gastrophrenic ligament. And when I’m doing that, I’m also enlarging the posterior esophageal window so my valve will have quite a large space to go behind the esophagus. Of course, be careful not to take the vagus trunk so you see now I have probably a good window for my esophagus so it’s enough. And you see the difference when I’m pulling on it, I have a very good length but you have to evaluate without traction so the idea of the fundoplication is to place the valve around the GE junction, and probably the endoscopic GE junction is here. So my valve should be here without traction. So I will just check if I can get a bit more length, but you see when you’re pulling, you have good length. I’m fighting with the pleura a bit there. It’s really millimetre by millimetre that you get this length, the aorta is there, and this is the access that we use for transhiatal esophagectomy, because there are still some indications for this surgery. At this point, they probably have some shortened esophagus, see the traction and the umbilical tape getting back to the chest. There’s the short esophagus – I know that if I’m doing this, doing the valve around the GE junction, then the traction back inside the chest will do this, and my valve will probably go back into the chest. Imagine the valve is here – the esophagus will go through the valve and I will have a slippage so I need to do a Collis. I even do not need endoscopy because I know that my anatomical junction is there, and the endoscopic junction is 1cm above, so the GE junction is probably there. I have a short esophagus so I’ll do a Collis.
11. Stapling 21'23''
So probably my upper limit will be somewhere here, so I’m on the bougie, and I will push and articulate my stapler to do the wedge resection of the angle of His. The problem is to find the good placement of the stapler. I’m doing this wedge. You see I’m just next to the bougie there, and this is the angle of His so I’m crossing the angle of His like this. So it’s just a question of good placement of the first. So probably I will cut this and we’ll check afterwards. You see the wedge, the esophageal border is there. I will probably apply a second stapler like this. Again my bougie is inside, so I will apply my stapler on my bougie. We’re doing a short lengthening, we don’t need a lot of centimetres. I will check – this is the first GE junction that we had, and this is the second GE junction that we had, I’ve increased probably 3cm. It’s enough because the valve will be placed here and not here. Imagine my valve being here, normally, the risk of going up is very high, if I place my valve on this part, the probability – you see I have no tension anymore on this valve as compared to the one there. That’s the advantage of the Collis lengthening. I will continue the mobilization of this fat, because my valve will be there. This is the area where I want to place my fundoplication, so the anatomical junction is here, GE junction, endoscopic junction is probably here, and my new valve will be here, so I will have a segment of stomach, creating a gastroesophageal tube. I can have some acid in that – some patients complain of heartburn, they can use a bit of PPIs, but on the other hand these patients usually complain a lot about regurgitation. This mechanism prevents regurgitation. That’s why they are very pleased even if in some patients there is some heartburn. I’m separating, clearing the lesser curve, and my valve will be in this channel. It’s a very interesting case because it shows that reflux surgery is not just a valve, we have to take into account a lot of different parameters and that’s the way to get good results, the problem with this surgery is that people think it’s just a valve, but it’s not. Now I will check from the side. This is still the crura. This patient has a flat position or a head up position? A little bit of head up, not too much, because he’s not very adipose so I don’t need that much – I’m checking the position of my posterior vagus trunk, it’s there, it’s within the umbilical tape, so I can open this. Now I will go above and now my vagus trunk is somewhere; that’s why I have to be very careful. Here’s the one, you see it. People who want to dissect with a tube inside can have a lot of difficulties because of the rigidity that bougies provoke. I will now externalize the posterior vagus trunk and I will get my umbilical tape in the new GE junction. And the valve will pass in this window. Initially it was there, and now it will be here. I will go for the crural repair. The left crus is there.
13. Fundoplication 30'25''
Now we’re doing the valve. You see the line of the stapler will be incorporated within the valve so it will be a protection. I try to go this way and find it. I grab it, I will check what I’ve got. You see the posterior attachment there, I check that there is no twist, that I’m using the same gastric fold – you see the line here, the line on the other side will be covered by the fundoplication. Silvana will show us the stomach, you see we’re using really the fundus, I’m not using the body of the stomach like this. I’m using really the fundus, and that’s important because if you’re using this, you will do that, and you see there is a pouch there, and this pouch may create problems afterwards. Patients complain from left hypochondrium pain. Do you prefer a complete wrap or a partial wrap? I’m really pleased with my total valve. Years ago, we made a ten-year review of my first hundred patients, and I had more recurrences in the partial group than in the total. When you look at all the randomized trials that have been made, usually the results are quite similar, like in South Africa, etc. There was a guy who was doing a lot of partials, thousands, I heard that now he is doing Nissen, so there are probably some reasons for that. Today with this intra-abdominal I have no problem, it takes a bit longer I agree, but it’s not a big surgery. That’s why I use it more and more. This is our new GE junction there, it’s nice, you see, and I will fix the valve to this new GE junction. We just check, you see the staple line is there, covered by the fundoplication. When you have a shorter esophagus and a staple line going high in the chest, it’s better to do a reinforcement of the staple line because we have got a leak from the staple line at the upper part. So if part of it is within the chest, I would do a reinforcement of the staple line with a running suture. Just to remind you that the old one was probably somewhere here, now we have a good valve, placed well below the diaphragm, the crura repair is good, we can remove the nasogastric tube, it’s very floppy, it’s fixed here and here to anchor it, we have removed the nasogastric tube, and we have a quite floppy fundoplication. This is the final result, with the vagus trunk anterior and posterior outside of the valve. The valve is well stabilized, this is the final result.