The management of gastroesophageal reflux disease (GERD) and hiatal hernia has been an evolving topic in both general and thoracic surgery over the last century. While the introduction of improved medical management in the form of H2-blockers and proton pump inhibitors (PPIs) has reduced the overall volume of patients presenting for surgical management, there remains a definite role for surgery in the circumstances of medical failure or fixed anatomic abnormality. Beginning in the late 1950s with the work of Belsey, Nissen, Hill, and Collis and continuing to the present day, there has been much debate regarding the optimal surgical approach for the correction of reflux disease and repair of hiatal hernia. Most recently, minimally invasive approaches have gained favor. However, the traditional techniques of open hiatal hernia repair and fundoplication still may be preferred in selected patient groups. This chapter concerns the current application of the transthoracic Collis-Belsey repair of hiatal hernia with an eye toward appropriate patient selection and evaluation.
The operation now attributed to Belsey evolved from a series of surgical modifications spanning over a decade of clinical investigation. Belsey's original intent was to create a general approach to the management of reflux disease, and the procedure underwent several iterations before the present Mark IV operation.1 Working in the same era, Collis also sought to answer the question of surgical management of reflux disease. He focused on obtaining an adequate length of intraabdominal esophagus that would permit a tension-free acute angle of esophageal entry into the stomach. Looking for ways to achieve this, he published the first description of tubularization of a section of the lesser curvature of the stomach for use as a distal esophageal equivalent in 1957.2 In 1971, Pearson and colleagues published a series of 24 patients with peptic stricture of the distal esophagus who were treated with a combination Collis gastroplasty and Belsey hiatal hernia repair.3 They reported excellent results, achieving either resolution of stricture or improvement in symptoms of dysphagia in all patients treated in this fashion.
The Collis-Belsey operation, as described by Pearson, gained widespread support as an approach to hiatal hernia repair and a viable antireflux procedure. However, in recent years, minimally invasive approaches to the surgical treatment of GERD have limited application of the Collis-Belsey procedure to a relatively specific subset of patients with foreshortened esophagus. The operation also has a defined role for hiatal hernia repair in the obese patient, when pressure on the abdominal viscera and omentum limits visualization with an intraabdominal approach.
A transthoracic approach to paraesophageal hernia also may be indicated in the reoperative setting in patients who have had a prior abdominal approach. Additionally, patients with impaired esophageal motility benefit from the improved esophageal clearance provided by the partial fundoplication of the Belsey procedure as compared with the “tighter” circumferential wrap described by Nissen. In the setting of incarcerated paraesophageal hernia with gastric volvulus, when an urgent operation ...