++
On complete evaluation of the patient, a tailored approach is offered to treat short esophagus. Surgeons who perform redo antireflux procedures should be familiar with the full scope of fundoplication procedures (see Chapters 38-40 and 42), because the patient's unique circumstances will warrant a tailored approach.17
++
We prefer the abdominal approach, when possible. Laparoscopic Nissen fundoplication is the “gold standard” for GERD or paraesophageal hernia. However, up to 14% of patients will require a Collis lengthening procedure, with or without hiatal repair. Rarely, we use other operations, such as Toupet or Dor (see Chapter 40), with a partial wrap for coexisting dysmotility. Regardless of the number of prior surgeries or techniques used (open vs. laparoscopic), we approach all antireflux operations using minimally invasive technique. Rarely, a frozen abdomen is encountered, rendering the abdominal approach technically prohibitive, and we offer a Belsey–Collis procedure instead (see Chapter 38). In our experience, over 95% of these surgeries can be completed minimally invasively without resort to open technique.
++
The patient is induced using combined anesthesia (i.e., general anesthesia with endotracheal intubation and epidural analgesia). Endoscopy is performed. The patient is placed supine in the lithotomy position. Both arms are tucked in at the sides, and the bed is placed in a shallow anti-Trendelenburg position. A nasogastric tube is inserted for drainage and decompression of the stomach. The stages of the operation are identical to those described in Chapter 39 (Nissen fundoplication). Briefly, these include placement of the camera port using Hassan technique, followed by placement of four additional ports, division of the short gastric vessels with the anterior and posterior gastrosplenic ligaments, opening of the left gastrophrenic ligament with exposure of the left crus, opening of the gastrohepatic ligament, division of the peritoneum over the right crus, and opening of the overlying peritoneum to expose its edge. We do not attempt to directly identify the esophagus before opening the crura because of the risk of perforation. The esophagus is revealed by its orientation, longitudinal muscle fibers, and the vagus nerves, which lie medial to the crura. We avoid dividing any structure that could be confused with the vagus nerves until both nerves have been identified. The right crus is dissected from its confluence to the median arcuate ligament, where it joins the left crus. Great care to prevent perforation of the esophagus or stomach should be taken during mobilization of the GEJ. The esophagus is retracted upward, and a window is opened and widened bluntly to reveal the left side of the abdomen. Finally, we open the superior esophagophrenic ligament.
+++
Esophageal Mobilization
++
The esophagus in our opinion should be mobilized high in the mediastinum to obtain adequate esophageal length. An understanding of thoracic esophageal anatomy is essential when performing mediastinal mobilization (Fig. 42-2). Care should be taken not to injure the left and right vagus nerves (12–3 o'clock and 6–9 o'clock), the aorta and aortic esophageal branches (6 o'clock), the posterior membranous wall or the left mainstem bronchus (deep 2 o'clock), the azygos vein (deep 10 o'clock), the pleura (bilateral), and the pericardium (12–3 o'clock). In general, caution should be taken when performing this dissection because serious injury may result if the surgeon loses anatomic orientation.
++
++
Practically speaking, once the esophagus has been dissected free of the crural elements, we grasp the fat pad and pull it caudally to the patient's left. Through another port, we retract the right crus away from the esophagus using a Kittner to allow blunt and sharp dissection of the esophagus high into the mediastinum. The dissection proceeds in a clockwise fashion by appropriate retraction. In this way, the esophagus can be freed at least 5 to 7 cm proximal to the hiatus, which usually provides sufficient length for a “no-tension” wrap. This maneuver requires experience, and care must be taken to avoid injury to the vagii or aorta and to avoid entering the pleurae. On occasion, one should expect the patient to have subcutaneous emphysema or neck discomfort postoperatively due to dissection of CO2 in the mediastinum.
+++
Assessing Esophageal Length
++
After esophageal mobilization is complete, the fat pad is medialized (taking care not to injure the anterior vagus nerve). This facilitates an accurate tension-free assessment of the level of the GEJ. In making this assessment, one considers the esophageal length measured during intraoperative endoscopy, findings on barium swallow, and the visualized location of the GEJ when no traction is placed on the stomach. A Collis lengthening procedure is performed at this juncture, if the esophagus appears to be short despite lengthening. The nasogastric tube is removed, and a bougie (size 52–58 based on the patient's height and weight) is inserted to 50 cm (Fig. 42-3A). The 5-mm left midclavicular port is replaced by a 12-mm port. The stomach is then aligned and stabilized using a grasper on the left side of the GEJ and an additional grasper on the short gastric line near the region of the first short gastric artery. A reticulating Endo-GIA stapler (with a 30-mm blue staple cartridge) is applied for three sequential firings, forming a gastric wedge of cardia that is fashioned and removed (Fig. 42-3B and Table 42-1).
++
++
+++
Hiatal Closure and Wrap Formation
++
After the gastroplasty is complete, the bougie is withdrawn to 25 cm. We routinely close the crura using an Endostitch device (Auto Suture, Norwalk, CT) and a Ti-rite knot (Ti-rite Knot Device, Wilson-Cook Medical, Winston-Salem, NC). With access from the left midclavicular port, the esophagus is elevated, exposing the crura, which are visually assessed for strength. If they appear weak or the patient has a large paraesophageal hernia, we request rehydration of a biodegradable collagen mesh (SurgAssist System, Power Medical Interventions, New Hope, PA) by the scrub nurse on the back table. Typically, at least three stitches are needed for crural closure. The first is placed beyond the crural confluence (V, similar to a vascular anastomosis). Before tying the last stitch, the bougie is reintroduced to 50 cm and the hiatal closure is assessed. Optimally, there should be a few millimeters between the esophagus and the diaphragm. If a mesh reinforcement of the crura is indicated, the mesh is cut to size and sutured anteriorly to itself and to the diaphragm and then posteriorly to itself and the hiatus. Securing the mesh in this manner prevents migration and provides a biologic scaffold, thereby reducing the incidence of recurrence owing to hiatal hernia.
++
The choice of fundoplication depends on the results of preoperative manometry testing. We perform a laparoscopic Nissen–Collis fundoplication for most patients with short esophagus. This procedure is similar to the laparoscopic Nissen fundoplication described in Chapter 39. The apical point of the staple line is brought under the esophagus and “shoeshined” with the greater curvature (Fig. 42-4A). This operation is similar to the laparoscopic Nissen fundoplication with one important exception: the target point of the stitch (wrap-“esophagus”-wrap) used to secure the wrap in the Nissen– Collis procedure is the Collis gastroplasty or neoesophagus (Fig. 42-4B). The bougie then is removed. A nasogastric tube is placed, and the ports are closed laparoscopically. After gaining consciousness, the patient is extubated and taken to recovery.
++