Chapter 38: Belsey–Mark IV Fundoplication/Collis Gastroplasty

INTRODUCTION

The management of gastroesophageal reflux disease (GERD) and hiatal hernia has evolved in both general and thoracic surgery over the course of the past century. The advent of H₂ blockers and proton pump inhibitors (PPIs) markedly improved options for medical management and reduced the number of patients presenting to the surgeon. However, a well-defined role for surgical treatment remains in the circumstances of medical failure or medication intolerance, as well as for a fixed anatomic abnormality such as a larger hiatal hernia. Beginning in the late 1950s with the work of Belsey, Nissen, Hill, and Collis and extending through the present day, the optimal surgical approach to reflux disease and repair of paraesophageal hernia has been a topic of debate among surgeons. In the modern era, minimally invasive approaches (predominantly laparoscopy) have become the mainstay of surgical treatment for both GERD and hiatal hernia. However, the traditional techniques of open hiatal hernia repair and fundoplication are required in select patient groups. This chapter discusses the current application of the transthoracic Collis–Belsey approach to hiatal hernia repair with a focus on appropriate patient selection and evaluation.

GENERAL PRINCIPLES

The operation now attributed to Dr. Belsey is the culmination of several rounds of clinical experimentation spanning over a decade’s worth of experience. Dr. Belsey’s original intent was to create a general approach to the management of reflux disease, and several iterations were needed to arrive at the Mark IV, the version most commonly used today.¹ In parallel to Belsey’s work, Collis also sought to develop a surgical solution for gastroesophageal reflux. Collis focused on the importance of obtaining an adequate length of intraabdominal esophagus to allow for a tension-free, acute angle of esophageal entry into the stomach. Looking for ways to achieve this, he published the first description of the tubularization of a section of the lesser curvature of the stomach for use as a distal esophageal equivalent in 1957.² In 1971, Pearson et al.³ published a series of 24 patients with peptic stricture of the distal esophagus treated with a combination of the Collis gastroplasty and Belsey hiatal hernia repair. They reported excellent results, with either resolution or improvement in the symptoms of dysphagia in all patients.

The “Collis–Belsey” operation, as described by Pearson, was historically felt to be the standard of care both as an approach to hiatal hernia repair and a viable antireflux procedure. In recent years, however, the efficacy of minimally invasive approaches to the surgical treatment of GERD has limited application of the Collis–Belsey procedure to a relatively specific subset of patients. The operation is now most frequently utilized in the reoperative setting following a failed prior abdominal approach (either laparoscopically or open). This is particularly true in the setting of a large hiatal hernia, which may be difficult to reduce laparoscopically because of the formation of intrathoracic or mediastinal adhesions, or when ...