We are indebted to Pearson's excellent description of the Collis–Belsey procedure in the chapter on open gastroplasty in his textbook of Esophageal Surgery.7
A thoracic epidural catheter and arterial line are placed in the preoperative holding area. After induction of general anesthesia, a double lumen endotracheal tube is placed to provide optimal lung isolation and maximal exposure. The anesthesiologist will also assist with placement of the esophageal Bougie to aid proper sizing of the gastroplasty.
An upper endoscopy may be performed at the outset of the procedure to assess for the presence of stricture or other pathology before commencing the fundoplication and gastroplasty. This would not be obligatory in the setting of an elective repair, when all the obligatory data have been obtained. However, when gastric volvulus and the threat of gastric necrosis necessitate an urgent trip to the operating room, it is prudent to inspect endoscopically before making an incision. Upper endoscopy is performed most easily when the patient is still in the supine position.
When the operative procedure begins, the patient should be in the left thoracotomy position, with pressure points padded appropriately. After properly securing the patient, the operating table should be flexed to open the left interspaces for maximal exposure. A generous sixth or seventh interspace posterolateral thoracotomy is created, dividing the muscle of the latissimus dorsi but sparing the serratus anterior. Occasionally, a rib will need to be “shingled” posteriorly to achieve better exposure, but this is not common if the interspace is opened slowly and widely to allow gentle rib spreading.
Dissection of the Esophagus and Stomach
The inferior pulmonary ligament is divided with electrocautery to permit the lung to retract into the upper hemithorax and expose the esophagus, which lies anterior to the descending aorta and posterior to the pericardium. There may be a large hernia sac above the hiatus. Whether this is present or not, the initial circumferential dissection of the esophagus should be at the level of the inferior pulmonary vein to permit identification of both vagus nerves. Beginning the dissection at this level allows one to mobilize a sufficient length of esophagus to facilitate the gastroplasty and a tension-free return to the abdomen. A Penrose drain is passed around the esophagus and used for gentle retraction.
Attention is then turned to the hiatus. The hiatal hernia sac (which consists of parietal pleura), phrenoesophageal membrane, and peritoneum should be dissected from the hiatus circumferentially. By dividing the hernia sac, the serosa of the stomach is exposed, and the abdomen may be entered safely (Fig. 38-3). The crura should be dissected free during this stage. To freely deliver the stomach into the chest, the gastrohepatic omentum, which tethers the cardia below the diaphragm, is divided at this point. To more fully mobilize the fundus, the highest 2 to 3 short gastric vessels may be ligated and divided (Fig. 38-4). These maneuvers are especially helpful in situations of intrathoracic gastric volvulus to ensure that proper orientation of the stomach is maintained once it is reduced to the abdomen. Three to five crural closure sutures (0 braided polyester) are placed but left untied.
View of the incarcerated stomach from left thoracotomy after dissection of hiatal hernia sac.
The fundus is shown retracted by a Babcock clamp.
The gastroesophageal junction (GEJ) is identified with its overlying fat pad. Dissection of the fat pad, elevating it off the GEJ, commences at its posterolateral aspect, just to the left of the posterior (right) vagus nerve. As the fat pad is dissected anteriorly, the anterior (left) vagus nerve is mobilized along with the fat pad and retracted to the right and away from the EGJ. Small vessels coursing between the fat pad and the gastric wall may need to be controlled individually with electrocautery, vascular clips, or direct ligation.
Creation of the Gastric Tube (Esophageal Lengthening)
A gastric tube is created from the cardia of the stomach (Fig. 38-5A). A 48 to 50F Bougie is passed into the stomach along the lesser curvature by the anesthesiologist and guided by the surgeon to avoid malpositioning or perforation during placement. The fundus is retracted and a thick tissue stapler is placed alongside the Bougie and fired to add 4 to 5 cm of extra length to the esophagus (Fig. 38-5B). This permits the neo-GEJ to lie without tension below the diaphragm. However, since this neoesophagus (gastric tube) will not retain normal esophageal motility, segments longer than 4 to 5 cm are not advised. We oversew the gastroplasty staple line with 3-0 polypropylene suture, taking care not to narrow the gastric tube.
Collis gastroplasty for esophageal lengthening. A. The fundus is retracted with a Babcock clamp. B. A thick tissue stapler is placed at the angle of His alongside a 48 to 50F esophageal bougie. A 4- to 5-cm staple line is created (Inset). The staple line is subsequently oversewn with 3-0 polypropylene suture (not shown).
Fundoplication and Return to the Abdomen
The fundoplication is a partial wrap of 270 degrees created with three rows of horizontal mattressed, double-armed 2-0 or 3-0 braided polyester or silk sutures. The sutures should be placed partial thickness (seromuscular), but must be deep enough to permit apposition of the fundus to the esophagus without tearing out. The middle suture of each row should straddle the staple line used to create the gastric tube (Fig. 38-6A). The other sutures of each row are therefore 135 degrees left and right of the middle suture. The next row is spaced 1.5 cm from the fold created by tying down the sutures in the previous row (Fig. 38-6B). The last row of sutures is not tied down after placement; rather, the needles are passed into the abdomen via the hiatus and then back up through the diaphragm to anchor the reconstruction (Fig. 38-6C). A malleable retractor or sterile spoon can be used to protect the abdominal viscera during this maneuver. The transdiaphragmatic sutures should continue the 270-degree spacing of the fundoplication. The GEJ, with its fundoplication in place, is then returned to the abdomen and the transdiaphragmatic sutures are tied down to anchor the wrap to the underside of the diaphragm anteriorly (Figs. 38-7 and 38-8). The crural sutures are then tied down, establishing an adequate length of the posterior aspect of the hiatus. When tied, the reconstructed hiatus should remain lax enough to admit a finger alongside the esophagus. A completion flexible endoscopy may be of assistance in ensuring both the fundoplication and crural repair are appropriate.
Fundoplication. A. Initial middle suture is placed in mattress fashion on either side of oversewn gastroplasty staple line to begin fundoplication. Left and right mattress sutures then are placed 135 degrees to either side of this initial middle suture for this row. B. The first-row sutures have been tied down, the middle row of the next suture is placed and the next row's middle suture is placed, again straddling the staple line. Note that the sutures are placed 1.5 cm away from the fold created by the first row of sutures. Again, sutures will be placed to the left and right of this middle suture to continue to create the 270-degree fundoplication. C. Finally, the last row is placed in similar fashion but not tied down until the needles are passed through the diaphragm, and the gastroesophageal junction and fundoplication are returned to the abdomen.
Appearance of the fundoplication just before placement of the third and final row of sutures. Note the presence of the untied crural sutures.
The GEJ and fundoplication have been returned to the abdomen, and the transdiaphragmatic sutures have been tied. Note also that the crural sutures also have been tied at this stage.
A nasogastric tube is placed with guidance by the surgeon at the field. The chest is irrigated, and a flexible or standard chest drain is placed. The chest is closed in standard fashion after ensuring good lung reexpansion. Every effort is made to extubate the patient in the operating room at the completion of the case.