Laparoscopic Collis-Nissen procedure for failed fundoplication

This video shows a laparoscopic Collis Nissen gastroplasty in a patient with a previous Nissen fundoplication by open approach. Despite the extensive mobilization, it was not possible to achieve an adequate length of intra-abdominal esophagus. A short esophagus was diagnosed and the surgeon performs a Collis gastroplasty. The hiatus is repaired with interrupted non-absorbable sutures. A Nissen fundoplication is performed. This patient had a previous Nissen fundoplication by an open approach. After extensive mobilization, the surgeons diagnose a short esophagus and perform a Collis gastroplasty. They repair the hiatus with interrupted non-absorbable sutures, then perform a Nissen fundoplication. Once they complete the dissection, the authors assess the length of the esophagus. The video shows the authors placing tape around the gastroesophageal junction at the level of the hiatus. The junction between the stomach and the esophagus is at the level of the hiatus, a sign of a short esophagus.

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Laparoscopic Collis-Nissen procedure for failed fundoplication

Authors

B Dallemagne, C Solano

Abstract

This video shows a laparoscopic Collis Nissen gastroplasty in a patient with a previous Nissen fundoplication by open approach.
Despite the extensive mobilization, it was not possible to achieve an adequate length of intra-abdominal esophagus. A short esophagus was diagnosed and the surgeon performs a Collis gastroplasty. The hiatus is repaired with interrupted non-absorbable sutures. A Nissen fundoplication is performed.
This patient had a previous Nissen fundoplication by an open approach. After extensive mobilization, the surgeons diagnose a short esophagus and perform a Collis gastroplasty. They repair the hiatus with interrupted non-absorbable sutures, then perform a Nissen fundoplication. Once they complete the dissection, the authors assess the length of the esophagus. The video shows the authors placing tape around the gastroesophageal junction at the level of the hiatus. The junction between the stomach and the esophagus is at the level of the hiatus, a sign of a short esophagus.

Keywords

laparoscopy, Collis Nissen gastroplasty, Nissen fundoplication, short esophagus

Media type

Surgical video

Duration

14'00''

Publication

2007-12

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E-publication

WeBSurg.com, Dec 2007;7(12).
URL: http://www.websurg.com/doi-vd01en2232.htm

Laparoscopic Collis-Nissen procedure for failed fundoplication

1. Case history 00'07''

This video shows a laparoscopic Collis Nissen fundoplication in a patient with a previous Nissen fundoplication performed with an open approach. This is the case of a 76-year-old female patient who underwent coronary stent placement and abdominoplasty; and in 1998 a Nissen fundoplication by open laparotomy due to long lasting GERD. Six months ago she was referred to the emergency room due to a sudden epigastric pain. The preoperative work-up demonstrated esophagitis associated with a recurrent hiatal hernia. On the barium swallow, we identify herniation of the fundoplication; the position of the GE junction was into the chest so this woman was suspected of having a short esophagus. In this case, our operative strategy is to identify the cause of the failure, then assess the length of the esophagus and if there is a short esophagus we perform a lengthening procedure.

2. Procedure commencement, identification of cause 01'17''

There is an enlargement of the hiatal orifice with migration of all of the upper part of the stomach with probably the anterior flexus valve which is also within the chest. The first part of the operation is to free all the adhesions around this previous repair to try and re-establish the normal anatomy of the GE junction and the gastric fundus. The dissection is orientated by the position of the right crus which allows to find the cleavage plane between the esophagus or the stomach and the right and left crura. This dissection is performed with the help of the ultrasonic scissors or the normal scissors with electrocautery. The difficulty is to find the exact right plane between the crus and this migrated mechanism. Sometimes the main difficulty is related to the position of the crura and it’s quite frequent to open either the right or the left crura during this part of the dissection. One important step of this operation when we’re dealing with a herniated mechanism is to mobilize as far as possible the esophagus in order to have a good assessment of its length. The left crus is freed; then the right crus is also freed. At this stage of the procedure, we have not yet identified where the vagus trunk is. We can identify the huge herniation of what is probably the fundoplication associated with some fatty tissues. The problem with this stage of the procedure is to identify exactly the cause of the failure: is it related to the closure of the hiatus or is it related to the closure of the esophagus? During this part of the dissection, we can see that there is not that much dissection within the chest so we suspect that at the first operation the intramediastinal dissection of the esophagus was not long enough. This intramediastinal dissection is continued up into the pulmonary vein and sometimes can even be extended up to the carena. At this stage of the procedure, we try to identify the position of the vagus trunk and usually on the left side of this anterior vagus trunk there are some strong adhesions that have to be freed in order to get some more length of the esophagus. Using the ultrasonic system avoids burning injuries to the vagus trunks. In this picture, we can see exactly that the valve has migrated within the chest associated with some fatty tissues and at this stage, we already try to understand the position of the GE junction. Freeing the complete antireflux mechanism is very important; we then try to identify the position of the GE junction and at this stage also we can see that the tape placed around the GE junction migrates quite easily within the chest so again there is a high suspicion of a shortened esophagus. To know exactly the reality of this shortened esophagus, we have to dismantle all the antireflux mechanism. Dismantling this antireflux mechanism is an important step of this operation as we want to re-create the normal anatomy of the GE junction and of the upper part of the gastric fundus, it is only in this position that we will be able to assist properly the position of the GE junction and of course the length of the esophagus. The old suture guides the dissection of this previous antireflux repair. This dissection is carried out with the normal scissors that allows a more precise dissection than the ultrasonic scalpel. The cleavage plane between this right part of the previous fundoplication and the stomach or the esophagus is usually easily found and the dissection can be carried out with the ultrasonic systems. It is also important to look at the posterior attachment of this fundoplication and the lateral attachment which usually quite strongly fixes the antireflux mechanism onto the crura. Once the antireflux mechanism has been dismantled, we look at the upper part of the gastric fundus; we usually mobilize this upper part by dividing some of the first short gastric vessels. That allows a good mobilization of this part of the stomach and this will allow for a good visualization of the GE junction and also prepare for the lengthening procedure.

3. Assessing the length of the esophagus 09'29''

Once the whole dissection has been made, we assess once again the length of the esophagus. Here you can see that the tape is being placed around the GE junction at the level of the hiatus. We can also see that the junction between the stomach and the esophagus is lying down at the level of the hiatus, a sure sign of a short esophagus because the Z line is probably 1cm above the anatomical GE junction.

4. Collis gastroplasty 09'58''

In these conditions we need to do the lengthening procedure. We place the bougie into the esophagus. A linear stapler is introduced into the abdomen and will be fired twice to create this lengthening procedure of the esophagus at the level of the angle of His. In fact, the first stapler is introduced in an oblique fashion and will make contact with the bougie. Then a second stapler is positioned parallel to the bougie in order to avoid stenosis. The residual segment of the angle of His is resected and placed in a bag. This technique allows us to have a total abdominal approach without the need for a thoracic access. The esophageal length is usually increased by 2 to 3cm. This neo-esophagus allows the correct positioning of the fundoplication without tension. Usually crura repair is performed with non-absorbable interrupted sutures. Calibration of this crura repair can be assessed with the help of the intra-esophageal bougie. The final step of this operation is to recreate an antireflux mechanism. In this patient, we decide to perform a Nissen fundoplication.

5. Redo Nissen\'s fundoplication 12'20''

The mobilization of the gastric fundus has been performed in the initial part of the operation when we were dismantling all the previous antireflux mechanism. A classic Nissen fundoplication will be created around this new segment of the lower esophagus. A short, floppy and 2cm long valve will be created. This valve is secured by separate stitches of non-absorbable material; one or two stitches usually fixes the fundoplication onto the anterior wall of this esophagus. Calibration of the fundoplication is also performed using the bougie which is still in the esophagus. At the end of the operation, trocars are withdrawn under direct vision. Usually, a contrast swallow study is done on postoperative day 1. In this case, the X-ray demonstrated the good position of the fundoplication around the neo-esophagus. A normal diet was resumed on the same day.