Technical Considerations and Approach to Redo Foregut Surgery

Our research focuses on thoracic surgery with specific regard to re-operative foregut operations. A large portion is surgical outcomes-based research, but we also emphasize quality improvement in surgery, such as with this protocol. In this video, we discuss our approach to re-operative foregut surgery.

In foregut surgery, technological advances continue to be made in the intra-op and pre-op settings. Improvements in diagnostic technology such as with the EndoFLIP system and high resolution manometry provide more accurate information and diagnoses of the foregut. While robotic technology and intra-op monitoring help us provide the best care possible in surgery.

Most literature looking at re-operative foregut surgery emphasizes the outcomes, but not necessarily the approach to performing the operation. We describe a step-by-step approach to the operation while maintaining the general principles broadly, and thus providing a reference for other foregut surgeons. In the future, we will continue to focus on reviewing outcomes of other re-operative foregut surgeries with the goal of developing guidelines and standardizing the management of these cases.

To begin, position the anesthetized patient supine with arms out and a footboard to facilitate steep reverse Trendelenberg positioning. Using the open Hasson technique, enter the peritoneal cavity in the left supra umbilical space to insert the camera port. Next, insert one eight millimeter port in the right-upper quadrant 10 centimeters above the umbilicus, and one port in the left-upper quadrant.

Place the assistant port in the right-lower quadrant. Insert the liver retractor through a five millimeter port, placed in the extreme lateral part of the right-upper quadrant. Then dock the surgical robot.

To reduce hiatal hernia, begin by removing the adhesions of the bowel to the abdominal wall. Then using a robotic bipolar surgical energy device, open the gastro hepatic ligament. Open the lesser sac by removing adhesions and additional short gastric artery branches.

Using a combination of blunt and electrocautery dissection with the robot, dissect the hernia sac circumferentially at the hiatus. Then use laparoscopic scissors to carefully dissect the dense adhesions between the liver and stomach. To note previous fundoplication, perform sharp dissection with laparoscopic scissors and undo the wrap to completely free the stomach.

Next, using the combination of blunt and sharp dissection, mobilize the esophagus transhiatally in the mediastinum. Under endoscopy, identify the gastroesophageal junction, then measure the esophagus from the hiatus to the gastroesophageal junction. Next, perform endoscopy and visualize the mucosa clearly to ensure no injuries, and insufflate the esophagus in stomach to ensure no air leakage.

Begin hiatal repair by performing accrual repair using 0 silk sutures, applying two to three posterior crural stitches. Pass a 56 French bougie into the esophagus, and with the bougie in place, pass a grasper comfortably into the hiatus. Next, for Nissen fundoplication, bring the fundus across the right side posterior to the esophagus and beneath the vagus nerve.

Pass a 58 French bougie into the esophagus and perform a loose fundoplication over the bougie using three 2-0 silk sutures.