9 Transthoracic Gastroplasty (Collis) and Nissen Fundoplication

Transthoracic Gastroplasty (Collis) 9 and Nissen Fundoplication

INDICATIONS prevent tension from being exerted on the antireflux operation and hernia repair.This newly constructed Short esophagus due to reflux esophagitis esophagus (“neoesophagus”) consists of a tube made from the lesser curvature of the stomach. A 56F Recurrent gastroesophageal reflux with stricture Maloney dilator is passed into the stomach, and the after an antireflux procedure tube is constructed by applying an 80mm linear Previous subtotal gastrectomy generally contrain- cutting stapler precisely at the esophagogastric junc- dicates a Collis-Nissen procedure tion parallel to and snugly alongside the Maloney dilator.When the stapler is fired, the esophageal tube PREOPERATIVE PREPARATION is lengthened by as much as 7cm. If the stapler has been placed snugly against the esophagogastric junc- Dilate the esophageal stricture up to 40F.It can gen- tion,there are no irregularities or outpouchings at this erally be done with Maloney dilators. point. Insert a nasogastric tube down to the stricture. Mobilizing the Esophagus Assessment for colon interposition is prudent in dif- and Stomach ficult cases (see Chapter 5).Bowel preparation allows colon to be used as a conduit if needed. Not only is it important to mobilize the distal esopha- When esophagoscopy reveals severe acute ulcerative gus completely,at least as far up as the inferior pulmo- esophagitis with inflammation and bleeding, a 2- to nary vein, but the proximal stomach must be entirely 3-week period of preoperative intensive medical free of attachments,just as when a Nissen fundoplica- treatment with cimetidine, omeprazole, or both tion is being performed through an abdominal reduces inflammation and lessens the risk of intra- approach. This operation can be accomplished operative perforation of the esophagus. without tension only with full mobilization.It requires dividing the phrenoesophageal and gastrophrenic ligaments,freeing the hiatus throughout its complete PITFALLS AND DANGER POINTS circumference from any attachments to the stomach or lower esophagus, and dividing an accessory left Esophageal perforation hepatic artery, which courses from the left gastric Hemorrhage resulting from traumatizing or avulsing artery across the proximal gastrohepatic ligament to the accessory left hepatic artery, inferior phrenic help supply the left lobe of the liver.After mobiliza- artery, ascending branch of the left gastric artery, tion has been accomplished, the remaining maneu- short gastric vessel, or inferior pulmonary vein vers in the Collis-Nissen operation are not difficult. Laceration of spleen If the esophagus is inadvertently perforated during Inadvertent vagotomy the dissection, exercise careful judgment when deciding whether it is safe to suture the esophageal Inadequate suturing, permitting the fundoplication laceration or a resection and colon or jejunum inter- to slip postoperatively position is necessary. If it is elected to suture the laceration, try to cover the suture line with a flap of OPERATIVE STRATEGY parietal pleura (see Figs. 14–1 to 14–3). Performing an Adequate Gastroplasty Avoiding Hemorrhage The object of performing a gastroplasty is to lengthen Avoiding unnecessary bleeding during any operation a shortened esophagus for an extent sufficient to requires a careful dissection and a knowledge of 115 116 Transthoracic Gastroplasty (Collis) and Nissen Fundoplication vascular anatomy.This is especially important when mobilizing the stomach through a thoracic approach because losing control of the accessory left hepatic, short gastric, or inferior phrenic artery causes the proximal bleeding arterial stump to retract deep into the abdomen. Controlling these retracted vessels is difficult and may require laparotomy or at least a peripheral incision in the diaphragm. Preventing this complication is not difficult if the dissection is orderly and the surgeon is aware of the anatomic location of these vessels. Similarly, careful dissection and avoid- ance of traction along the greater curvature of the stomach helps prevent damaging the spleen.

Avoiding Esophageal Perforation When the distal esophagus is baked into a ﬁbrotic mediastinum, sharp scalpel dissection is safer than blunt dissection if injury to the esophagus and the vagus nerves is to be avoided. Sometimes the ﬁbrosis terminates 8–9cm above the diaphragm. If so, the esophagus and the vagus nerves can easily be encir- cled at this point, which provides a plane for subse- quent dissection of the distal esophagus.

OPERATIVE TECHNIQUE Incision With the patient under one-lung anesthesia in the lateral position, left side up, make a skin incision in Fig. 9–2 the sixth intercostal space from the costal margin to the tip of the scapula (Fig. 9–1). Then identify the latissimus dorsi muscle and insert the index ﬁnger underneath it.Transect this muscle with electrocautery; then divide the underlying anterior serratus caudal to the skin incision,as it helps preserve muscle muscle in similar fashion (Fig. 9–2). In both cases function.Then use electrocautery to divide the inter- it is preferable to divide these muscles somewhat costal muscles along the upper border of the seventh rib (Fig. 9–3) and open the pleura. Complete this opening from the costal margin to the region of the lateral spinal muscles. Separate the periosteum and surrounding tissues from a 1cm segment of the posterior portion of the seventh rib lateral to the spinal muscles. Excise a 1cm segment of this rib (Fig. 9–4). Then divide the intercostal neurovascular bundle that runs along the inferior border of this rib (Fig. 9–5). Insert a Finochietto retractor into the incision and gradually increase the distance between the blades of the retractor over a 10-minute period to avoid causing rib fractures. In patients who have under- gone previous surgery of the distal esophagus or proximal stomach, do not hesitate to continue this incision across the costal margin, converting it into Fig. 9–1 a thoracoabdominal incision to facilitate dissection Operative Technique 117

Fig. 9–5

Fig. 9–3

Fig. 9–4 118 Transthoracic Gastroplasty (Collis) and Nissen Fundoplication on the abdominal aspect of the diaphragmatic hiatus Excising the Hernial Sac (see Figs. 3–6, 3–7). Identify the point at which the left branch of the crus Liberating the Esophagus of the diaphragm meets the hernial sac. Any attenu- ated fibers of the phrenoesophageal ligament and Incise the inferior pulmonary ligament with electro- preperitoneal fat are made apparent by applying trac- cautery and then compress the lung and retract it in tion to the diaphragm. Incise these tissues and the anterior and cephalad directions using moist gauze underlying peritoneum (Fig. 9–8).Continue the inci- pads and Harrington retractors.Incise the mediastinal sion in the peritoneum in a circumferential fashion, pleura just medial to the aorta (Figs. 9–6, 9–7).Encir- opening the lateral and anterior aspects of the hernial cle the esophagus with the index finger using the sac; expose the greater curvature of the stomach. indwelling nasogastric tube as a guide. If this cannot Insert the left index finger into the sac and continue be done easily, it may be necessary to initiate sharp the incision along the medial (deep) margin of the dissection at a somewhat higher level,where the fibro- hiatus using the finger as a guide (Fig. 9–9).A branch sis may be less advanced. Encircle the esophagus and of the inferior phrenic artery may be noted postero- the vagus nerves with a latex drain. Continue the dis- laterally near the left vagus nerve; it is divided and section of the esophagus from the inferior pulmonary ligated with 2-0 silk. While attempting to circum- vein down to the diaphragmatic hiatus.After the medi- navigate the proximal stomach, the index finger in astinal pleura has been incised down to the hiatus, the hernial sac encounters an obstruction on the continue the incision anteriorly and divide the pleura lesser curvature side of the esophagogastric junction. of the pericardiophrenic sulcus (Fig. 9–6); otherwise, It represents the proximal margin of the gastro- the medial aspect of the hiatal ring is not visible.If the hepatic ligament, which often contains a 2- to 4-mm right pleural cavity has been inadvertently entered, accessory left hepatic artery coming off the ascend- simply place a moist gauze pad over the rent in the ing left gastric artery. By hugging the lesser curva– pleura to prevent excessive seepage of blood into the ture side of the cardia with the index finger, this right chest and continue the dissection. finger can be passed between the stomach and the

Fig. 9–6 Operative Technique 119

Fig. 9–7

Fig. 9–8 120 Transthoracic Gastroplasty (Collis) and Nissen Fundoplication

Fig. 9–9 gastrohepatic ligament, delivering the ligament into Dilating an Esophageal Stricture the chest, deep to the stomach. Identify the artery and ligate it proximally and distally with 2-0 silk. Ascertain that the esophagus is lying in a straight line Divide it between the two ligatures (Fig. 9–10).After in the mediastinum.Ask the anesthesiologist or a sur- this step, it should be possible to pass the index gical assistant to pass Maloney dilators into the esoph- ﬁnger around the entire circumference of the proxi- agus through the mouth after removing the indwelling mal stomach and encounter no attachments between nasogastric tube. As the dilator is passed down the the stomach and the hiatus.Throughout these maneu- esophagus, guide it manually into the lumen of the vers, repeatedly check on the location of the vagus stricture.Successively larger bougies are passed,up to nerves and preserve them. Excise the peritoneum size 50–60F,which can be successfully accomplished that constituted the hernial sac. in probably 95% of cases.Occasionally,forceful dilata-

Fig. 9–10 Operative Technique 121 tion of this type causes the lower esophagus to burst gastric vessels have been divided and about 12–15cm in the presence of unyielding transmural fibrosis. In of greater curvature has been mobilized. this case,resect the damaged esophagus and perform a colonic or jejunal interposition between the healthy esophagus and the stomach (see Chapter 5). Gastroplasty Verify that the esophagogastric junction has indeed Dividing the Short Gastric Vessels been completely mobilized. Identify the point at which the greater curvature of the stomach meets Continue the dissection along the greater curvature the esophagus. Overlying this area is a thin fat pad of the stomach in an inferior direction until the first perhaps 3cm in diameter. Carefully dissect this fat short gastric vessel is encountered. Use a long right- pad away from the serosa of the stomach and the angled Mixter clamp to encircle this vessel with two longitudinal muscle of the esophagus (Fig. 9–11). 2-0 silk ligatures. Tie each ligature, leaving at least Avoid damaging the anterior vagus nerve. 1cm between them. Divide between ligatures. Con- Pass a 56–60F Maloney dilator into the stomach tinue this process until about five proximal short and position it along the lesser curvature.Then apply

Fig. 9–11 122 Transthoracic Gastroplasty (Collis) and Nissen Fundoplication an 80mm linear cutting stapler parallel and closely Performing a Modified adjacent to the Maloney dilator; a Babcock clamp Nissen Fundoplication retracts the greater curvature of the stomach in a lateral direction (Fig. 9–12). Fire the stapler and Because the neoesophagus has utilized a portion of remove it. Verify that the staples have been shaped the gastric fundus,there may not be sufficient remain- into an adequate B and that there are no leaks.Lightly ing stomach to perform the Nissen fundoplication in electrocoagulate the everted mucosa.This maneuver the classic manner. Instead, as seen in Figure 9–14, will have lengthened the esophagus by approxi- the apex of the gastric fundus is wrapped around the mately 6–7cm (Fig. 9–13). In most cases no addi- neoesophagus in a counter-clockwise fashion. tional length of neoesophagus is necessary because Before inserting any sutures, remove the indwell- of the greater lengths now available in these stapling ing large Maloney dilator and replace it with one of devices. Although this step is not shown here, it is 50F. Place a large hemostatic clip at the site of the wise as a precautionary measure to oversew the new esophagogastric junction (i.e., the junction of staple lines with two continuous Lembert sutures of the neoesophagus with the stomach) as a radio- 4-0 Prolene or PDS: one continuous suture to invert graphic marker. The fundoplication should encircle the staple line along the neoesophagus and a second the neoesophagus in a loose wrap for a distance of continuous suture to invert the staple line along the 3cm (Fig. 9–15). gastric fundus. A continuous suture of the Lembert Figure 9–15 illustrates insertion of the first Nissen type is suitable, taking care not to turn in an exces- fundoplication stitch including a 5- to 6-mm bite of sive amount of tissue, as it would narrow the neo- gastric wall, then a bite of the neoesophagus, and esophagus unnecessarily. finally a bite of the opposite wall of the gastric fundus.

Fig. 9–12 Operative Technique 123

Fig. 9–13

Fig. 9–14 Fig. 9–15 124 Transthoracic Gastroplasty (Collis) and Nissen Fundoplication

Fig. 9–16

These bites should be deep to the submucosa but not into the lumen of the stomach. We prefer 2-0 Fig. 9–17 Tevdek for these sutures.A total of three or four fundoplication sutures are used at 1cm intervals (Figs. 9–16, 9–17). Now remove the Maloney dilator from the esophagus and replace it with a nasogastric tube. and tie them to approximate the ribs. Close the over- Figure 9–18 illustrates that the fundoplication wrap lying serratus and latissimus muscles in two layers around the neoesophagus is loose enough to admit with 2-0 PG continuous sutures. Close the skin with the ﬁngertip. Optionally, invert the layer of fundopli- continuous or interrupted ﬁne nylon sutures. cation sutures by oversewing it with a continuous Lembert seromuscular suture of 4-0 Prolene (not illustrated).

Closing the Hiatal Defect Close the defect in the posterior portion of the hiatus by inserting 0 Tevdek interrupted sutures through the right and left margins of the hiatus. Take a bite 1.5–2.0cm in width and include overlying parietal pleura.After checking for hemostasis, reduce the fundoplication into the abdomen. It should slide down with ease. Then tie each of the sutures, leaving space for the surgeon’s ﬁngertip alongside the esophagus or neoesophagus with a nasogastric tube in place (Figs. 9–19, 9–20). Place a hemostatic clip at the edge of the hiatus as a marker. It is not necessary to resuture the incision in the mediastinal pleura. Irrigate the mediastinum and thoracic cavity with warm saline and check for complete hemostasis. Insert a 36F chest tube through a puncture wound below the level of the incision and bring the tube up the posterior gutter above the hilus of the lung.Insert three to ﬁve interrupted no. 2 PDS pericostal sutures Fig. 9–18 Operative Technique 125

Fig. 9–19

Fig. 9–20 126 Transthoracic Gastroplasty (Collis) and Nissen Fundoplication

POSTOPERATIVE CARE by oversewing the fundoplication suture line with a continuous Lembert seromuscular suture. Continue nasogastric suction for 1–3 days. Necrosis of the gastroplasty tube.This complication Continue perioperative antibiotics for 24 hours. was reported by Orringer and Orringer during an operation for recurrent hiatus hernia. They warned Obtain an esophagram (ﬁrst water-soluble then thin that traumatizing the lesser curve of the stomach may barium) on postoperative day 7. doom a gastroplasty tube. Remove the chest drainage tube on day 3 unless drainage is excessive. REFERENCES

COMPLICATIONS Gastal OL, Hagan JA, Peters JH, et al. Short esophagus: anal- ysis of predictors and clinical implications. Arch Surg Obstruction. Occasionally there is a partial obstruc- 1999;134:633. tion at the area of the fundoplication due to edema Jobe BA,Horvath KD,Swanstrom LL.Postoperative function during the first 2 weeks following surgery.If the wrap following laparoscopic Collis gastroplasty for shortened is too tight, this obstruction may persist. esophagus.Arch Surg 1998;133:867. Recurrent gastroesophageal reflux. This is uncom- Orringer MB,Orringer JS.The combined Collis-Nissen operation: early assessment of reflux control. Ann Thorac mon after the Collis-Nissen procedure unless the fun- Surg 1982;33:534. doplication suture line disrupts. Stirling MC, Orringer MB. Continued assessment of the Leakage from the gastroplasty or fundoplication combined Collis-Nissen operation. Ann Thorac Surg sutures.This complication is rare. If the fundoplica- 1989;47:224. tion sutures are inserted into the lumen of the stomach Urschel HC, Razzuk MA,Wood RE, et al.An improved surgi- and the suture is tied with strangulating force, a leak cal technique for the complicated hiatal hernia with is possible.The risk of this occurring may be reduced gastroesophageal reflux.Ann Thorac Surg 1973;15:443.