A variety of minimally invasive surgical techniques have been described to treat the acquired short esophagus. These include the use of circular and linear staplers, passed through the left chest, through the right chest, and through a small epigastric incision. For the most part, these techniques have been discarded in favor of the laparoscopic wedge gastroplasty, also known as wedge fundectomy, or wedge Collis gastroplasty.
The indication for wedge gastroplasty for esophageal lengthening is the need to establish sufficient intraabdominal esophageal length to perform a fundoplication. Predictors of esophageal shortening include large hiatal hernia, Barrett esophagus, esophageal stricture, severe GERD or failed hiatal hernia repair with transdiaphragmatic migration of the stomach. It is not clear that any one of these conditions is more predictive of shortening than another, but certainly a combination of factors (Barrett and stricture and large hernia) increases the likelihood that the esophagus will be short. Accurate diagnosis of the short esophagus can only occur intraoperatively, after thorough esophageal mobilization has been carried high in the mediastinum, to the level of left inferior pulmonary vein.
Following maximal transhiatal mediastinal dissection of the esophagus, the left and right crura are brought together with graspers and all inferior tension on the gastroesophageal (GE) junction is released. If the GE junction, as marked by the superior border of the epiphrenic fat pad, retracts to within 2.5 cm of the closed hiatus, esophageal shortening can be diagnosed.
Collis gastroplasty is most often performed within setting of a laparoscopic Nissen fundoplication. This is generally performed in the supine position with the legs extended and abducted 30 to 60 degrees so the surgeon may stand between the legs to perform the operation (Figure 1). Trocars are set up identically to the laparoscopic fundoplication (Figure 2).
After complete mobilization of the esophagus, the decision to perform a Collis gastroplasty is usually made before the hiatal defect is closed. There are two reasons for this. First, the open hiatus will best accommodate the tip of the endoscopic stapling device, whereas the closed hiatus may make it more difficult to complete the high end of the staple line. Second, there is minimal contamination of the upper abdomen with this technique; exposing the staple line to pledgets or mesh risks contamination of these foreign bodies. On the other hand, it is sometimes difficult to assess the true length of the intraabdominal esophagus until the crura are completely closed. For this reason it is occasionally necessary to perform Collis gastroplasty after crural closure.
The first step in performance of a laparoscopic wedge Collis ...