All patients are offered a tailored surgical approach based on the preoperative evaluation. Consequently, surgeons who perform redo antireflux procedures should have experience with the complete range of antireflux operations (see Chapters 38-40). We routinely perform intraoperative EGD before making an incision to confirm the preoperative evaluation and assess esophageal length, structural changes, hiatal hernia, active peptic disease, and other concurrent pathologies that would delay, contraindicate, or alter the planned reoperative approach.
We prefer to use the abdominal approach whenever possible. Laparoscopic Nissen fundoplication remains the “gold standard” for reoperation on recurrent GERD; however, approximately 8% to 20% of patients will require a Collis lengthening procedure, with or without hiatal repair, as described in Chapter 42. Rarely, we use other operations, such as Toupet or Dor, with a partial wrap if the patient has dysmotility (see Chapter 40). Regardless of the number of prior surgeries or the technique used (open versus laparoscopic), we approach all reoperations for failed antireflux surgery using minimally invasive technique. Rarely, a frozen abdomen is encountered, rendering the abdominal approach technically prohibitive, and we offer a Belsey–Collis procedure (see Chapter 38). Since procedure length can vary from 1.5 to 8 hours, cases should be scheduled early in the morning. 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. Our reoperative approach is a synthesis of antireflux procedures mentioned in previous chapters.
Approach Through The Left Chest
A left thoracotomy approach can be used for patients with recurrent failure of fundoplication. The esophagus usually is less adhesed and easier to control and dissect from this approach. As in the abdomen, the surgeon must be able to tolerate some bleeding from the liver during the dissection. The same parameters are addressed as in the abdominal approach. The old wrap is taken down, and the cause of the recurrence is identified and fixed. Collis extension is used liberally. The repair can be performed using the Belsey–Mark IV operation or the Nissen operation.
Practices That Differ From Initial Antireflux Repair
Scope Insertion, Trocar Placement, and Adhesiolysis
We place an 11-mm camera port using a modified Hassan technique to minimize inadvertent injury to the abdominal viscera. Placing a periumbilical trocar in a previously operated patient can be technically challenging. If this is not possible because of adhesions, an alternate initial camera port can be placed. After abdominal insufflation with CO2 (the insufflation pressure is 15 mm Hg; when needed, a maximal pressure of 20 mm Hg can be used transiently), a 10-mm laparoscope with a deflectable tip capable of 360-degree angulation is inserted.
To minimize cosmetic scarring, we attempt to use original port scars for trocar placement, but alternate sites can be used if the original ports are improperly placed or densely adhesed. If the abdomen has multiple adhesions, we attempt to place one of the four remaining ports in the least adhesed region of the abdomen in its intended location under direct visualization. Careful dissection of adhesions using scissors, ligature, or hook so that all working ports are inserted is paramount. The remaining ports are inserted sequentially. In our experience, the liberal use of an additional 5-mm port placed in an area free of adhesions can save time, aid in the dissection, and may decrease operative morbidity. Rarely, adhesions are so dense that port relocation is not possible, and the abdominal procedure must be terminated. Care should be taken to avoid inadvertent bowel injury. If this occurs, however, the bowel often can be repaired primarily laparoscopically.
Adhesiolysis is a crucial stage in reoperation; safety depends on retraction, visualization, and identification of the avascular planes. Unfortunately, the time required to perform adhesiolysis cannot be assessed preoperatively. In our experience, it can range from a few minutes to several hours. Care should be taken to avoid known pitfalls of antireflux surgery, such as bleeding, perforation, and vagal injury. Thus we perform surgery in a systematic manner (described below) to minimize these pitfalls. If they occur, most can be managed laparoscopically.
Dissection and Wrap Takedown
The conduct and design of the operation are similar to those described in Chapter 39 on laparoscopic Nissen fundoplication. However, greater care must be taken to avoid traction injuries that lead to bleeding or perforation of visceral organs. Especially relevant are the fibrous bands that attach to the spleen and dissection around the wrap and posterior distal esophagus. If the patient had a previous wrap, it typically will be adhesed to the left side of the liver or herniated into the chest. During this phase of the operation, an understanding of why the previous operation failed must be attained. Thus meticulous attention to detail during dissection is essential.
Dissection of the Gastrosplenic Ligament
Typically, dissection is begun by dividing the gastrosplenic ligament. This is carried out sequentially, anteriorly first and then posteriorly, using a 5-mm LigaSure (Valleylab, Boulder, CO) device. The highest two or three short gastric arteries are divided, if not already divided during the initial operation. After reaching the left GEJ, the left gastrophrenic ligament is opened, exposing the left crus. If a hiatal hernia is identified, its contents are reduced into the abdomen, and the peritoneal sac is amputated and removed.
Mobilization of the Distal Esophagus and Proximal Stomach on the Right
Prior fundoplication typically causes dense adhesion between the wrap and the left lobe of the liver. Dissection in this region can be technically challenging. Perforation of the stomach or esophagus and injury to the vagus nerve must be avoided at all costs. The gastrohepatic ligament is opened above the caudate lobe in an avascular region (near the liver), avoiding the left gastric artery, the possibility of a replaced hepatic artery, and vagal branches. The anatomy may be difficult to navigate because of the prior surgery and presence of adhesions. When separating the wrap from the liver, we find it is safer to err on the side of the liver as opposed to causing visceral injury to the stomach. Any bleeding is usually short-lived and easily controlled with retraction. The right crus is identified, and the overlying peritoneum is opened exposing its edge. We do not attempt to directly identify the esophagus before opening the crura because of the risk of perforation. In addition, the vagi are always found medial to the crura. The right crus is dissected from its confluence to the median arcuate ligament, where it joins the left crus. Dissection is done meticulously, taking only a thin layer of peritoneum.
The esophagus is revealed by its orientation, longitudinal muscle fibers, and the vagus. We routinely divide the esophagophrenic attachments and peritoneum over the crura in a semicircular fashion down to the median arcuate ligament, taking care to avoid injuring the anterior and posterior branches of the vagus. Finally, the wrap is opened along the plane where it was sewn in the previous operation. This is a difficult step because defining the plane may be technically challenging and remaining within that plane while not causing a perforation may be difficult. Occasionally, the general location of the suture line can be stapled to separate the wrap. 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. We avoid dividing any structure that could be the vagus until the two nerves are identified.
Assessing Esophageal Length
The fat pad is medialized (taking care not to injure the anterior vagus nerve) to accurately assess the level of the GEJ. This determination is made in the context of the esophageal length measurements that were made during intraoperative endoscopy, barium swallow, and the visualized location of the GEJ when no traction is placed on the stomach. If the patient is found to have a short esophagus, the Collis lengthening procedure is performed at this juncture (see Chapter 42).
A crucial step in the operation is the moment when the operating surgeon integrates all the preoperative and operative findings and determines the cause of the failed antireflux procedure. In this regard, it is important to dissect the old wrap completely because this usually will verify the cause of the failure. An excellent summary of this decision-making process was published by Swanstrom et al.24 A standard redo wrap then is fashioned, taking into account any lessons learned from the patient's preoperative workup or the intraoperative findings. For example, if the wrap is too loose, a small bougie can be used to calibrate the opening. If there is a short esophagus, a Collis extension is performed. If the wrap was “shoeshined” inadequately at the first operation, an attempt should be made to fashion a more accurate configuration. If the surgeon fails to determine the cause of the previous failure, chances are that the redo procedure also will fail to deliver good long-term palliation.
In addition, when performing a redo procedure, we tend to take a maximal approach when doubt exists. For example, if the esophagus is of equivocal length, we lengthen it. If the crura are of questionable strength, we reinforce them with bioabsorbable mesh, and if gastric emptying is delayed or vagal injury is suspected, we place a percutaneous gastrostomy tube (PEG).
For all redo procedures, we place a Jackson-Pratt no. 10 drain to the left of the wrap because in our experience the postoperative risk of leak is greater with redo surgery.
The hiatus is often fused and does not need to be closed. When it does require closure, we use the method described in previous chapters for simple closure or crural reinforcement (see Chapters 39 and 42). Choice of fundoplication depends on information gathered during the preoperative evaluation and intraoperative findings. The techniques for the various wraps also have been described in previous chapters.
Some patients who present with reflux after multiple surgeries are found to have a nearly frozen GEJ. In these patients we are often unable to completely dissect off the wrap but instead are able to tighten it anteriorly over a bougie by taking additional stitches to bunch it up. We find that the incidence of gastric leaks in these patients is higher. Rather than risk having to come back emergently, we leave Jackson-Pratt drains around the GEJ and insert a PEG to control the gastric output.