Laparoscopy with Left Chest Collis Gastroplasty

Introduction

The presence of a shortened esophagus in patients undergoing paraesophageal hernia repair varies significantly in the literature, with high volume centers reporting the need to perform an esophageal lengthening procedure in 5.6% (1) to 63% (2) of cases. The goal of performing an esophageal lengthening procedure is to reduce axial tension on the hernia repair, which may theoretically mitigate recurrence.

Patient Selection and Technique

It is prudent to obtain consent for possible Collis gastroplasty if patients have a history of failed antireflux operation, a long history of GERD, evidence on manometry of short esophagus or dysmotility, moderate to severe esophagitis, a history or presence of a stricture, Barrett’s esophagus, or a large (≥ 5 cm) type I or giant type II hernia (3–5).

In the operating room, the patient is intubated with a single lumen ET tube and then positioned in low lithotomy with the left arm tucked for left chest access. The bed is positioned in reverse Trendelenberg. Standard laparoscopic fundoplication ports and a laparoscopic liver retractor are placed as described previously (6). Standard dissection is performed, reducing the hernia sac. The esophagus is isolated and encircled with a Penrose drain. A type II mediastinal dissection for full esophageal mobilization is completed with care to preserve both vagus nerves (5). The intra-abdominal esophageal length is measured laparoscopically. If the intra-abdominal esophagus is shortened (< 2 cm), the true gastroesophageal junction location is identified endoscopically and intra-abdominal esophageal length is reassessed. If a shortened esophagus is confirmed, the authors proceed with a Collis gastroplasty as described below.

The standard laparoscopic camera is exchanged for an extended length 45-degree camera. Next, a left pleurotomy is created near the diaphragm and the chest is entered with the camera. Holding ventilation may aid this step if visualization is compromised. A 10 mm left 4th-intercostal-space, mid-axillary-line incision is created after local is instilled into the interspace. A 45 mm endoscopic stapler is advanced under direct laparoscopic vision into the abdomen via the pleurotomy and the dissected hiatus.

Once the stapler is intraabdominal, it is articulated fully caudad and a 44 French bougie dilator is advanced into the stomach. Next, the gastric fundus is positioned in the stapler. It is important that the stapler is pushed against the bougie and the short gastric vessel line is retracted laterally towards the three o’clock position before firing. After the gastroplasty is completed, a cruroplasty is completed with interrupted sutures. Finally, the fundoplication is performed over a 54 French bougie (6).

Preference Card

• Standard laparoscopic tower
• Laparoscopic graspers
• Harmonic scalpel
• Laparoscopic liver retractor
• Penrose drain (1/2 inch)
• Extended length 45-degree laparoscopic camera
• 45 mm linear articulating endoscopic stapler
• 44 and 54 French bougie dilators

Tips and Pitfalls

• Patients with a history of prior left thorax surgery may not be candidates for this approach.
• Abdominal insufflation should displace the left lung sufficiently to view the stapler placement. If not, hold ventilation for a short time to facilitate this step.

Results

To date, the authors have performed 12 left thoracoscopic-assisted-laparoscopic Collis gastroplasties. One patient required minimal left thorax adhesiolysis in order to facilitate adequate visualization of the stapler entering the chest and subsequently the abdomen; therefore a chest tube was left in place to control a potential air leak No patients had a leak from the single staple line and no recurrences have been observed to date.

References

1. Oelschlager BK, Pellegrini CA, Hunter JG, Brunt ML, Soper NJ, Sheppard BC, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg. 2011;213(4):461–8.
2. Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ, et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg. 2010;139(2):395–404.
3. Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery. Ann Surg. 2000;232(5):630–40.
4. Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic Collis gastroplasty is the treatment of choice for the shortened esophagus. Am J Surg. 1996;171(5):477–81.
5. O’Rourke RW, Khajanchee YS, Urbach DR, Lee NN, Lockhart B, Hansen PD, et al. Extended transmediastinal dissection: an alternative to gastroplasty for short esophagus. Arch Surg Chic Ill 1960. 2003;138(7):735–40.
6. Jutric Z, Louie BE. Laparoscopic paraesophageal hernia repair. Surg Laparosc Endosc Percutan Tech. 2013;23(5):436–41.