Laparoscopic Collis-Nissen procedure for failed fundoplication

This video shows a laparoscopic Collis Nissen gastroplasty in a patient with a previous Nissen fundoplication by open approach. Despite the extensive mobilization, it was not possible to achieve an adequate length of intra-abdominal esophagus. A short esophagus was diagnosed and the surgeon performs a Collis gastroplasty. The hiatus is repaired with interrupted non-absorbable sutures. A Nissen fundoplication is performed. This patient had a previous Nissen fundoplication by an open approach. After extensive mobilization, the surgeons diagnose a short esophagus and perform a Collis gastroplasty. They repair the hiatus with interrupted non-absorbable sutures, then perform a Nissen fundoplication. Once they complete the dissection, the authors assess the length of the esophagus. The video shows the authors placing tape around the gastroesophageal junction at the level of the hiatus. The junction between the stomach and the esophagus is at the level of the hiatus, a sign of a short esophagus.

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Virtual University

LAPAROSCOPIC   COLLIS-NISSEN   PROCEDURE   FOR   FAILED   FUNDOPLICATION

Authors
Abstract
This video shows a laparoscopic Collis Nissen gastroplasty in a patient with a previous Nissen fundoplication by open approach.
Despite the extensive mobilization, it was not possible to achieve an adequate length of intra-abdominal esophagus. A short esophagus was diagnosed and the surgeon performs a Collis gastroplasty. The hiatus is repaired with interrupted non-absorbable sutures. A Nissen fundoplication is performed.
This patient had a previous Nissen fundoplication by an open approach. After extensive mobilization, the surgeons diagnose a short esophagus and perform a Collis gastroplasty. They repair the hiatus with interrupted non-absorbable sutures, then perform a Nissen fundoplication. Once they complete the dissection, the authors assess the length of the esophagus. The video shows the authors placing tape around the gastroesophageal junction at the level of the hiatus. The junction between the stomach and the esophagus is at the level of the hiatus, a sign of a short esophagus.
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Media type
Duration
14'37''
Publication
2007-12
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en
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en
E-publication
WeBSurg.com, Dec 2007;7(12).
URL: http://www.websurg.com/doi-vd01en2232.htm

LAPAROSCOPIC   COLLIS-NISSEN   PROCEDURE   FOR   FAILED   FUNDOPLICATION

2. Procedure commencement, identification of cause 01'17''
There is an enlargement of the hiatal orifice with migration of all of the upper part of the stomach with probably the anterior flexus valve which is also within the chest. The first part of the operation is to free all the adhesions around this previous repair to try and re-establish the normal anatomy of the GE junction and the gastric fundus. The dissection is orientated by the position of the right crus which allows to find the cleavage plane between the esophagus or the stomach and the right and left crura. This dissection is performed with the help of the ultrasonic scissors or the normal scissors with electrocautery. The difficulty is to find the exact right plane between the crus and this migrated mechanism. Sometimes the main difficulty is related to the position of the crura and it’s quite frequent to open either the right or the left crura during this part of the dissection. One important step of this operation when we’re dealing with a herniated mechanism is to mobilize as far as possible the esophagus in order to have a good assessment of its length. The left crus is freed; then the right crus is also freed. At this stage of the procedure, we have not yet identified where the vagus trunk is. We can identify the huge herniation of what is probably the fundoplication associated with some fatty tissues. The problem with this stage of the procedure is to identify exactly the cause of the failure: is it related to the closure of the hiatus or is it related to the closure of the esophagus? During this part of the dissection, we can see that there is not that much dissection within the chest so we suspect that at the first operation the intramediastinal dissection of the esophagus was not long enough. This intramediastinal dissection is continued up into the pulmonary vein and sometimes can even be extended up to the carena. At this stage of the procedure, we try to identify the position of the vagus trunk and usually on the left side of this anterior vagus trunk there are some strong adhesions that have to be freed in order to get some more length of the esophagus. Using the ultrasonic system avoids burning injuries to the vagus trunks. In this picture, we can see exactly that the valve has migrated within the chest associated with some fatty tissues and at this stage, we already try to understand the position of the GE junction. Freeing the complete antireflux mechanism is very important; we then try to identify the position of the GE junction and at this stage also we can see that the tape placed around the GE junction migrates quite easily within the chest so again there is a high suspicion of a shortened esophagus. To know exactly the reality of this shortened esophagus, we have to dismantle all the antireflux mechanism. Dismantling this antireflux mechanism is an important step of this operation as we want to re-create the normal anatomy of the GE junction and of the upper part of the gastric fundus, it is only in this position that we will be able to assist properly the position of the GE junction and of course the length of the esophagus. The old suture guides the dissection of this previous antireflux repair. This dissection is carried out with the normal scissors that allows a more precise dissection than the ultrasonic scalpel. The cleavage plane between this right part of the previous fundoplication and the stomach or the esophagus is usually easily found and the dissection can be carried out with the ultrasonic systems. It is also important to look at the posterior attachment of this fundoplication and the lateral attachment which usually quite strongly fixes the antireflux mechanism onto the crura. Once the antireflux mechanism has been dismantled, we look at the upper part of the gastric fundus; we usually mobilize this upper part by dividing some of the first short gastric vessels. That allows a good mobilization of this part of the stomach and this will allow for a good visualization of the GE junction and also prepare for the lengthening procedure.