Laparoscopic Collis Nissen: GERD with short esophagus

This live video demonstrates the Collis-Nissen procedure performed by Dr. Bernard Dallemagne during a surgical course. The patient presented with gastro-esophageal reflux disease and was only discovered intraoperatively to have a short esophagus. The confirmation of this diagnosis and the esophageal lengthening procedure are presented in detail. This video is recommended to surgeons with an interest in upper gastro-intestinal surgery. The author places 5 trocars, directed by plain film findings that raise suspicion of a lipoma of the lower mediastinum. The author eschews the umbilical port for a port slightly above the umbilicus to accommodate the 0-degree scope. The optical port for the left hand is in the direction of hiatus. First, the author must gain traction on the gastroesophageal junction, then examine anatomy. He starts on the lesser omentum to help identify important landmarks, the first of which is the right crus.

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Laparoscopic Collis Nissen: GERD with short esophagus

Authors

Abstract

This live video demonstrates the Collis-Nissen procedure performed by Dr. Bernard Dallemagne during a surgical course. The patient presented with gastro-esophageal reflux disease and was only discovered intraoperatively to have a short esophagus. The confirmation of this diagnosis and the esophageal lengthening procedure are presented in detail. This video is recommended to surgeons with an interest in upper gastro-intestinal surgery.
The author places 5 trocars, directed by plain film findings that raise suspicion of a lipoma of the lower mediastinum. The author eschews the umbilical port for a port slightly above the umbilicus to accommodate the 0-degree scope. The optical port for the left hand is in the direction of hiatus. First, the author must gain traction on the gastroesophageal junction, then examine anatomy. He starts on the lesser omentum to help identify important landmarks, the first of which is the right crus.

Keywords

Collis-Nissen procedure, gastroesophageal reflux disease, GERD, short esophagus, esophageal lengthening procedure, upper GI surgery

Media type

Surgical video

Duration

29'30''

Publication

2007-09

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E-publication

WeBSurg.com, Sept 2007;7(09).
URL: http://www.websurg.com/doi-vd01en2176.htm

Laparoscopic Collis Nissen: GERD with short esophagus

1. Trocar placement 00'15''

Confirmation of a reflux disease with quite a high score of DeMeester regarding PH acid reflux. I think that maybe we will find some sort of lipoma of the lower mediastinum that fixes this hiatal hernia; we will see if this corresponds to the X-rays because this woman is a little bit fat on the outside, inside is fine. We see that on the abdominal wall we have the umbilicus here on my finger; this is the head of the patient, and you see that I am not using the umbilical port. I am using a port, which is placed a little bit above the umbilicus because I am using a 0 degree scope. We have the optical port, this is for my left hand because I am straight in the direction of the hiatus; this is my right hand. So the first thing that we must do is get some traction on the GE junction. So we have this lipoma that we have reduced so maybe we will use it to make the traction on the GE junction.

2. Identification of right crus 01'32''

The first thing to do is to look at the anatomy; for this patient it’s quite easy because there is a large hiatal hernia, then you see I start on the lesser omentum, on the pars flaccida of the lesser omentum. Doing that, I can immediately identify my important landmarks and the first one is the right crus. It is really important to have the landmarks in mind because if you go too far on the right side of the patient, the vena cava is there. I recommend that always when you are starting look for the right crus, if you can’t see it from above, just open the lesser omentum and you can identify exactly this crus. I have seen my right crus, so what I am doing now is opening the phreno-esophageal membrane.

3. Division of phreno-esophageal ligament 02'32''

I am very careful to work just on the anterior layer of the phreno-esophageal membrane because I do not know exactly where the esophagus is by now. We have to deal with this lipoma that is just in front of the junction, I am trying to find a good place to exert traction. Do you use any Trendelenburg tilt? Yes, I would say about 20 degrees, not that much, not the same as in obesity. I am trying to find the opening in the hiatus, taking care of the esophagus because I don’t know yet where it is. I want to clear my right crus.

4. Hiatal dissection 03'32''

You’ll notice that he uses a lot of blunt dissection up in that area. That is right, this is the pleura and I am doing a lot of blunt dissection because it’s important initially just to get the position of the esophagus. We can now identify a little better the exact position of the esophagus and you see that just changing a little bit the traction on the GE junction helps in reducing this hernia. You see I am following the hiatal orifice from the right crus up to the left crus. I know that in this area I have to identify first the left crus before cutting anything because I know that sometimes the anterior vagus trunk can be alongside the left crus. What I will do is clean this before cutting everything. I am trying to stay in the right plane and progressively identify the left crus. I am looking for the anterior vagus at this point, I know that it is somewhere there so I am trying to find the left border of the esophagus. You see that I am cleaning this part; I have a stricture there and I don’t know if it is the vagus trunk, there is still some stomach. You see that the idea of having blunt dissection first is to identify these attachments and the vagus trunk is inside, so I clean and I divide afterwards. This is the vagus trunk. So I am safe in the upper part and as I know that I have to mobilize the esophagus because of the large hiatal hernia, I want to get it back into the abdomen. I want to have this low esophagus without tension into the abdomen so I am cleaning it quite high. We can go very far within the mediastinum. Now we can see more clearly the esophagus, I think that the vagus trunk is there, it’s coming down here. We have well mobilized the upper part of the esophagus and we will go down to this area where we have to mobilize the whole GE junction, there is probably some residual stomach fixed at the level of the hiatus. I am trying with blunt movements, slow movements to put traction on the structures.

5. Division of accessory left hepatic artery 06'45''

I have problems getting access to this, so I am going to divide, it’s quite rare but I am going to do this for safety because I want to have a clear view of the back here. Because it’s a difficult case I think that confusion with anatomy is possible. Here we have the cardiac lobe, left crus, right crus, I am still working on the right crus and I am safe there because I know exactly where I am. We can get access to this posterior lipoma. When I have identified the different planes I can divide it. The surgeon is behind the esophagus, behind the stomach.

6. Posterior and left dissection 08'00''

I am trying to work alongside the left crus, which is here, dividing this plane between the esophageal part of the lipoma and now that I have done my dissection plane here I can work on the other side of the esophagus in order to clean it from the left side. We are fighting a little bit with the fat to find a good way in. The spleen is nearer than usual, it’s all been pulled across. I am introducing a gas into the abdomen; I will try to use this gas to retract the fatty tissues. My aim now is to work on these attachments down there and to do so I will clear the space for my posterior window. I am still following the left crus, this is it here. What do you think about the length of the esophagus? It is worrisome, it’s quite short. I think you have some work in the mediastinum. I know that I have cleared my left crus, I am coming back on the right side of the esophagus and if I am right I will find my way very easily. Now I have a good view, I know that I can divide this. You are going to put a sling around this now? Yes, it is very helpful to maintain everything, as Lee said there is probably a lot of work on the esophagus. I will also put a tape around there. We have captured the esophagus well, now we can work on it. I agree that if I release my traction, I will have problems with the length of the esophagus. Now we are going back on the chest. We have the vagus trunk within the drain, so I will detach that. I am not working too close to the vagus trunk and I know that I have the adhesions to take down there. I always keep my eyes on the vagus trunk. You see there are quite strong adhesions there and the pleura is thick, this is part of the inflammatory process. That is why we are a little bit worried about the length of the esophagus. I am using traction to try and identify the anterior vagus trunk, I think that it is probably somewhere here. In the giant hernias, it can be quite difficult to find the vagal trunk sometimes. When you are using this traction, you see that the cord appears. By chance we have lost the drain, it is going backwards, that’s an indirect sign that there is a problem with the length of the esophagus. I think we will probably have to do some work in this patient on the length of the esophagus. We have a nice view of the pulmonary vein, just to show how high you are. I am at the back of the esophagus with these adhesions, there is a big artery there. Sometimes that’s what helps the most when there is a large artery there. First I want to identify exactly the positions of the main structures, I am working from below. There is some smoke and I am sorry but if we open those ports, the pressure goes immediately and it’s really difficult in this patient. At this stage, we are good for the mediastinal mobilization. This is the crura and the junction is on the drain. Initially we don’t have this length, this band would go back immediately into the mediastinum. Just to show that this extensive trans-hiatal mobilization helps in reducing the junction. Lee is still a little worried: I think the band is around the stomach, I am afraid that the ligament is somewhere around here. Here is the angle of His, we can now see the anatomy a little better but are still having problems with the drain going back into the mediastinum. We will now try to identify a little more the back of the cardia and as I am always mobilizing the short gastric to do a Nissen.

7. Gastric fundus mobilization 14'38''

I will now mobilize and have a clearer view on the GE junction from the back. I am trying not to divide the stomach. The assistant on the left side of the patient is holding the splenogastric ligament, this is my right hand coming from the xiphoid process. One of the rules for Nissen surgery is to divide the short gastrics, there is no question any more, everyone with experience says we should do so. It’s so important to avoid the usual complication, but it’s true that back in the early experience in 1992-3 when we had very large fundus we would say that in 85 or 90% of the patients it can be divided. We can see this lipoma from the back, this was something that was in the mediastinum there, I want to clear it because if I keep it within the valve, I could have some problems of compression of the lower esophagus; I need to put it outside the valve. As you illustrated, it is important to stay right on the stomach so you don’t get the splenic artery. Very important lipoma there. Of course, I don’t have to dissect all the posterior aspect of the stomach, that’s why I have changed my orientation a little. I will clear this part where we can see part of the gastrophrenic ligament. I am following the axis of the esophagus because it is important to keep some landmarks, otherwise as Lee said we are going on the left side of the stomach and dividing the gastric artery so there is always a need to re-orientate. The landmark I use is for that posterior dissection is I dissect until I can see the posterior vagus to be sure to have a good posterior window. I think I’m ok on the left side, now we will go check the junction again.

8. Confirmation of short esophagus 17'28''

The junction should be 1,5cm above the anatomical junction. My drain is in a good position, we release the traction. It goes back in the chest, but the problem is that it is just at the crura, you’ll probably gain a little bit by elevating it anterior. For the audience, he is going beyond the pulmonary vein, so he’s coming up into the carina In fact, the lymph nodes that you see on the left of your screen are probably the subcarinal lymph nodes. You see there are still some little fixations there. That little vein there that looks like serosa, I think that is probably stomach. I don’t think so. I think I will do a Collis, do you agree Lee? As you are pulling right now with traction you have maybe 1 or 1,5cm. With experience, I can tell that according to the profile and anatomy of this woman, I’m sure that if I am not lengthening the esophagus, I have a recurrent hernia within the next 12 to 18 months.

9. Stapled-wedge Collis gastroplasty 19'35''

I have changed my left hypochondrium trocar from a 5 to a 12mm, it is this one. We have introduced a 45 French bougie into the esophagus, it is rigid, see the difference. This is the fundus, I have the bougie there, I can feel it and now from the left side of the patient I have the fundus, anterior surface, posterior surface. I am holding the bougie with my left hand and I will go here, I am safe because I am on my bougie. I am making sure I am inside now, I will fire. There will be some gastric remnant on the esophagus. I still have to do another one, afterwards I will divide the remnant there. If I come in now with my stapler I will remove this little part, you see I have the length of my esophagus there. That is the final cut with the 45. I can do my wrap here, I have to clear the fatty tissues there and my valve will be here. Initially, we are there, and now I can do my valve here; I am quite pleased because I know that I won’t have this migration problem. Now you are going to take away this lipoma material? Yes, I am struggling with the fatty tissues again but I want to see the vagus trunk. My valve wont be here but a little lower, that’s why I have to clear that. That is the right part of this lipoma that we have divided from the back of the cardia. What is the percentage of Collis that you perform in a year in your practice? We do between 3 and 4 percent. Have you ever had any trouble with the Collises that you have done? Interesting that you ask that because I had the first leak that I have ever had just before I came here. If I put the valve there, everything would be up into the chest, but now I can place my valve on the drain. I will do it a bit below on the stomach and you see that my fundus is already prepared.

10. Crural repair 23'58''

Only thing is that I have a very short fundus in this patient so maybe I will do a partial fundoplication. The mobilization of the lipoma is done and then we have closed the crura, I will show you that. This is my crura repair with two stitches, good size of the hiatus so we can do a good valve.

11. Short floppy Nissen fundoplication 26'09''

The fundus is there. What about the use of the partial fundoplication versus a Nissen in this particular situation? That’s right but we checked it beforehand and it was good for Nissen so I think that we can do something like that, but initially I agree that I was a little bit concerned about the size of the fundus and I thought I would do a partial fundoplication, I think I would do it also as it would look like this. Problem is that you have to find the valve visually. What I am doing here is trying to invert the line of the stapler within my valve. We are finishing the fundoplication and I am fixing the valve but just to show you that we make it a bit loose. I have put two stitches there, without any fixation on the cardia, and I am fixing on both sides again to avoid too much pressure on the gastric wall because I know that this segment there hasn’t got a very good motility, so I am trying to make it as loose as possible. I think that we have a good anti-reflux mechanism that will mostly prevent the liquid regurgitation which is usually the major problem for this sort of patient because it is not controlled by the PPI’s.