Laparoscopic Collis gastroplasty and partial fundoplication for valve slippage

Re-operative antireflux surgery represents a challenging and complex clinical undertaking requiring careful patient selection as well as a high level of technical expertise. The procedures themselves are associated with a high rate of morbidity. This video shows a laparoscopic Collis gastroplasty and partial fundoplication for the treatment of valve slippage.

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Laparoscopic Collis gastroplasty and partial fundoplication for valve slippage

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

Re-operative antireflux surgery represents a challenging and complex clinical undertaking requiring careful patient selection as well as a high level of technical expertise. The procedures themselves are associated with a high rate of morbidity.
This video shows a laparoscopic Collis gastroplasty and partial fundoplication for the treatment of valve slippage.

Classification

clinical cases

Keywords

Laparoscopic Collis gastroplasty, partial fundoplication, valve slippage

Media type

Surgical video

Duration

25'00''

Publication

2009-07

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Subtitles

E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2649.htm

Laparoscopic Collis gastroplasty and partial fundoplication for valve slippage

1. Introduction 00'20''

You can see the CT-scan that has been performed yesterday evening. You see the stomach area and the problem that appears just behind the heart. Naturally this is easily seen in 3D. See the patient, we remove bones. You can turn around, see behind, or put things in transparency if you prefer, and we can remove the heart to have a good view of the pathology. You can see it clearly here. Here is the functional examination performed by Dr. Perretta. This showed that the peristalsis of the esophagus is normal. The wrap and the high pressure zone are clearly identified but there is a suspicion of migration as well. This patient has no clear sign of acid reflux. The DeMeester score is normal. There is no known acid reflux. It was found on tracing that there were many short reflux episodes and now we are going to perform the operation.

2. Intraoperative overview 01'49''

This is the laparoscopic view of this patient. See the liver. When we start, we must try to identify the problem and understand why this patient is refluxing, because sometimes even if they have some kind of intrathoracic migration, they can still have some control of reflux, which is not the case here, so probably there is an association with a disruption of the fundoplication. So wrong fundoplication to start and probably some migration of the stomach through the fundoplication. So we check: see this is probably the remnant of the first fundoplication and a big surgical mistake with this huge part of the stomach, which is above. That’s a typical mistake of Nissen fundoplications: the surgeon is using the body of the stomach instead of the gastric fundus to create the fundoplication. So that’s part of the problem. See here the stitches are placed on the wrong part. And probably we can imagine that it’s a Nissen that was performed without gastric mobilization or at least the short gastrics because I can find clips here. You’ll see that when I’m doing a redo, I’m using mostly scissors because I feel I’m much more precise when trying to find the different cleavage planes.

3. Freeing of adhesions 03'28''

Here there is no big deal because the anatomy is well respected because you have segment I of the liver, the vena cava, the right crus I guess, and everything is inside the chest so I want to just free this adhesion. And then you’re trying to find the original planes. That’s probably the limits. So I’m using sponge inside the cavity. It’s probably the best way to clean the different structures and be able to identify them more clearly. These are muscles so I’m in the right direction. As soon as you find a cleavage plane, you’ll follow this plane. Maybe I’m a little bit too much on the muscle.

4. Left crus identification 04'26''

So this is my left crus there; and I have some adhesions there. I have to cross this area. I have to see where my left crus is. It’s probably there. We know that when we’re doing an anti-reflux procedure, we do this way. The risk of peroperative complication such as pneumothorax is very high. Sometimes it’s quite difficult to get across the patient, what’s involved in some of this reflux surgery. You don’t have to fix yourself on one side; you have to change all the time and try to find a passage. My goal at this point is to identify the main structures and I wonder if I don’t have some vagus trunk somewhere there. Again see how important is the traction that we place. Because as soon as the assistant is relaxing a little bit, we can see and feel the difference. So probably I’ll cut this with the ultrasonic system because otherwise it’s going to bleed. Just cut with the ultra-shears because it’s not the perfect plane so I’m afraid that it can bleed.

5. Identification of esophagogastric junction 06'10''

So now I’ll try to get my junction and pass around it so that I can catch everything and get it back to the abdomen. That’s the goal. So I’ll look again for my different landmarks from behind the esophagus. This important landmark is the left crus. I have to work on the other side. I’ll try to find my passage maybe from this side. It looks like the hiatus is totally broken down as well. Yes, indeed. I have clips there. Probably I have to work a little bit on the side there. I don’t know where my left pleura is. It looks like it’s pleura there. By manipulation and traction, you’re recreating the cleavage plane.

6. Vagus nerve identification 07'58''

See the vagus trunk is there, the anterior one. I saw the posterior one there. It’s always a little bit like detective work, isn’t it? We can discover what went wrong and we can correct that. Here I think that we have already taken down part of the sutures that were placed for the valve you see. See this twist of the stomach there. Very typical from the laparoscopic experience. Probably there is some herniation through the valve. You see how it herniates. That’s the problem right there. See the stomach is still there. So it’s probably fixed somewhere here. The risk when we’re doing that is to do a small perforation or injury to the gastric wall, which is not very important as soon as you recognize it and as long as you can suture it.

7. Gastric fundus mobilization 09'48''

Going up, you see the way we are mobilizing the gastric fundus and then I’ll probably find the last adhesions on the superior part of the fundus because if I want to redo something anyhow, I have to control the short gastrics so I’ll start with that. As a rule in these patients having this sort of recurrence, they are usually not very slim patients. At this point, the risk is to get the right gastric artery. It is a little bit blind but I can feel it. One of the other things about redo surgery is that nearly every surgeon does it slightly differently. Some people put stitches here and there and others will not. This left diaphragmatic artery is quite common; it is a little artery that crosses towards the left crus. I remember that initially you could injure this artery when doing your posterior window. After having restored the anatomy, I will probably do a per-operative endoscopy and check the junction below the diaphragm. Of course if I have a little doubt about that, I will do a Collis. We have to exactly identify the position of the stomach, so I think I’m right there. If you have an intra-thoracic migration, you don’t have a sac because you don’t have the phrenoesophageal ligament anymore. See the vagus trunk there, it will be much more easier if we need to do a Collis or something like that. It looks much more normal now. Personally, I would place it there.

8. Intraoperative endoscopic assistance 12'30''

We have the endoscopic view, a bit of Barrett’s esophagus. Yes there is some metaplasia of the lower esophagus that we can see quite well. Now from outside, I am checking the Z-line, which is there. A little bit lower. Now the endoscopist will pass into the stomach and check the fundus from inside just to make sure that we have dismantled all the mechanism, it is in a retroflex position. Looks pretty reversed. Yes I think so, we can see the fundus that is well freed, see I’m pushing on the fundus there. We have a quite normal usual anatomy. We have restored everything and now we will see what we are going to do. There is still a problem, we know where the GE junction is, but look at where it is, it is going back into the chest even if we’ve got all the stomach. The first step will be to extend the intra-thoracic mobilization to see if we can get it back. I want to show you the extension of the mobilization. Within the mediastinum, we went up to the pulmonary vein. We are just continuing the mobilization of the fundus and the freeing of the angle of His. See where the angle is, so it’s quite short in fact.

9. Collis reconstruction 15'45''

If we can, we will probably put a stapler there to do a short Collis. We are just fighting with the fatness around the cardia to prepare for a Collis, and you see we have cleaned all this part around the esophagus and the cardia because we will staple and do a Collis in this patient. See the axis of the esophagus, this is the angle of His. I will staple and probably lengthen by probably 3cm. The idea is to get this length without removing too much of the gastric fundus. So this one is a 45. What would be the harm if you removed too much of the fundus or made it too long than the lower esophagus? It wouldn’t be a problem, but for the fundoplication maybe it is more difficult if you have removed part of the gastric fundus. Looks like there is still some fat connected to the back of the GE junction or? I probably have to clean a little bit more. But we can see the vagus there which you have preserved very nicely. We are doing the crura repair, so I will show you in a few seconds what we have done. We have cleaned the GE junction, so everything is ready for the final repair. We have a very good musculature on the diaphragm, so I don’t need to put any reinforcements. Usually when I do a Collis or something like that, I don’t like to put too much mesh just next to that. We still have the bougie inside because for a Collis I like to have this bougie when doing the fundoplication. We have cleaned, this is the staple line and of course I won’t place my valve here but I will place it here and we have cleaned the back of the esophagus so the valve will be in this position, on the neo-esophagus, not the GE junction, which is here. Do you always aim at doing a 360 degree wrap in this situation? Not that sure, because this guy has a very short fundus, so I will probably do a partial. I am not very comfortable with full because I don’t have a very ample fundus there, it has thickened and that is always a problem in redos. This part is very thick so not very mobile, that’s a problem. So I will do a partial there, just crossing on my staple line. When we think back to what it was like when we first looked in there, what you have achieved is a great tribute to you and your team.