How I do a trans-thoracic fundoplication

(Brendan Ellis, Medical Illustrator, Royal Victoria Hospital, for the excellent
drawings)
Anaesthesia: Patient left lateral, general anaesthesia with muscle
relaxation, double lumen ETT preferable though not essential.
Incision: Postero-lateral thoracotomy, over 7th rib.
Retraction: Standard De Bakey retractor,
preferably protecting intercostal nerve.
Mobilisation: Start by dividing the
inferior pulmonary ligament. This exposes
the oesophagus and the hernial sac (if
there is not a sizeable hernia sac the
abdominal approach should usually be
used). Medially dissect the bloodless plain
between the oesophagus and the
pericardium. This will bring you to
the pleura on the right side and will
expose the crura anteriorly. At the
diaphragmatic extent the pericardial fat
will be divided . Superiorly the dissection
should be continued osterior to the
inferior pulmonary vein and well up to
normal oesophagus.
Posterior dissection: Lift the sac medially and dissect from the aortic adventitia
(Ethicon Powerstar scissors reduce bleeding here). It is important to continue the
dissection well down to the diaphragm to expose the crurae posteriorly. Superiorly
continue the dissection to normal oesophagus. Later it will be necessary to
mobilise almost as far as the aortic arch to allow reduction of the hernia. As the
dissection proceeds into the mediastinum the right pleura will be reached and it
will be possible to tape the oesophagus outside the vagi.
Lifting the oesophagus forward and teasing the tissues from the back of the sac
will reveal the right crus. Continue to tease it off the sac revealing peritoneum only
between you and the caudate lobe of the liver. Break through the peritoneum with
blunt dissection.

Anteriorly, enter the sac. Divide it anteriorly in line with the left crus and continue
this dissection forward and around till you reach the hole previously made in the
peritoneum posteriorly. It is usually necessary to divide the hepatic branches of the
vagi and accompanying vessels, and the pericardial fat to complete this
mobilisation.
Posteriorly, divide the sac carefully avoiding the short gastric vessels. It may later
be necessary to divide a number of these after ligation in continuity, in order to free
enough fundus for a tension-free wrap. As one reaches the short gastrics it will be
necessary to divide the peritoneal reflection between the sac and the stomach to
allow encirclement of the oesophagus at the OGJ. The sac now forms a fan anterior
to the oesophagus. Redundant sac can now be excised (Fig 1).
I generally do not need to perform any special manoeuvres to reduce the hernia or
lengthen the oesophagus. I have not found it necessary to perform an oesophageal
lengthening procedure in the PPI era.

Excising the fat pad: The gastro-oesophageal fat

pad now needs to be excised to allow the wrap to
lie against the oesophagus(Fig. 2).Leaving the fat
pad allows a conduit for para-oesophageal
recurrence. It can be difficut to protect the vagal
nerves at this stage. Thickenings in the residual
sac can mimic these nerves.

Placement of Crural Sutures: As it is

difficult to place the crural sutures after
the fundoplication has been performed it
is best to place the sutures at this stage
and tie them later. I frequently place more
sutures medially than necessary at this
stage and remove them later without tying
if they look too tight. Usually Iplace three
interupted silk sutures (Fig. 3) though
more recently I have used two horizontal
mattress Ethibond sutures over a Teflon
buttress.
Fundoplication: Unlike the posterior abdominal fundoplication I perform an
anterior fundoplication through the chest. Some short gastrics may need to be
divided at this stage. A 50 Fr Maloney bougie is then passed by the anaesthetist
and guided by the surgeon into the stomach (make sure to relax on the oesophageal
tape to allow the bougie into the stomach). The fundus is brought round the OGJ as
for an abdominal Nissen but also inkwells as for a Belsey. The position is adjusted
so that the wrap is not unduly tight. Ensure that the fundus is used and not the body
of the stomach or an hourglass deformity
will result.
The fundoplication is sutured in place
using 2 strips of Teflon, 2cm x 0.5cm as
buttresses on the outside of the wrap. (De
Meester describes using additional Teflon
between the stomach and the oesophagus
within the wrap.) I use a 0 Ethibond on a
double ended 40mm needle (PLL 6375
Ethicon Ltd, Edinburgh) to pass three
horizontal mattress sutures. The sutures
pass through the Teflon, fundus, anterior
oesophageal wall, fundus and Teflon
(Figure 4). I try to pick up serosal wall of
the cardia with the distal suture. Thus the
wrap straddles the OGJ. It is easier to

place the sutures with the bougie withdrawn into the oesophagus. The sutures are
tied, however, with the bougie in place to prevent postoperative dysphagia.

Securing the wrap below the diaphragm: Withdraw the bougie to the midoesophagus. Three "Belsey-type" sutures are used to inkwell the wrap below the
diaphragm, just like the second layer of the Belsey Mark IV procedure. I frequently
use a Teflon buttress on the diaphragmatic and oesophageal ends of these sutures
though it may not be completely necessary. Try to get the first (against the
pericardium anteriorly) well around onto the right crus, at "2 o'clock". The second
lies laterally at "9 o'clock". The third (at "7 o'clock") may overlap some of the as
yet untied crural sutures. As these sutures are gradually tightened in turn the repair
is reduced.
Closing the crurae: Replace the bougie
and tighten the crural sutures from
posterior to anterior. The last sutures may
be redundant if the hiatus is snug against
the bougie. For a large hiatus, particularly
with a para-oesophageal hernia, additional
sutures can be placed anterior to the
oesophagus. It is important to close all
defects in the crural limbs posteriorly as I
have seen para-oesophageal recurrences
between crural sutures even though the
commonest place seems to be between
crural repair and oesophagus. Withdraw
the bougie. After ensuring haemostasis,
place a good underwater seal drain basally
with the tip lying behind the oesophagus
in the mediastinum.

Postoperative care: No nasogastric tube

is placed (unless complications are
expected). Attention is paid to good
analgesia (epidural if possible, injecting
the phrenic nerve with Marcaine or
Chirocaine reduces the shoulder tip pain)
and respiratory physiotherapy .
Mobilisation commences the day
following surgery. Liquids can be
commenced the following day though
patients frequently do not feel like any
oral intake. A semisolid diet is allowed
after the second PO day. Patients are
warned that postoperative dysphagia,
bloating and flatulence are to be expected
in the first few weeks and that they will probably only tolerate a soft diet for those
weeks. They are advised not to undertake heavy physical labour for 3-6 months
after surgery till the findoplication is well fibrosed in place.

Other points
Only operate on those who have clear indications of reflux on Barium,
OGD, histology or pH studies, or have a para-oesophageal hernia on barium.
Beware of operating on people who have other vague symptoms, gastritis,
bile gastritis, irritable bowel disease
These symptoms will be more apparent once the reflux is gone and your
operation will be blamed for them.
Be cautious about operating on someone whose reflux has not been altered
significantly by PPI's
I tend to perform a tighter wrap than previously as we are now competing
with good drugs - the PPI's

 I tend to get a baseline contrast swallow in the first few days after surgery
mainly for medico-legal purposes. If there is too much hold-up it is possible
to revise the wrap easily within the first week.