Several approaches to a failed fundoplication can be applied through a thoracotomy including a redo Nissen fundoplication and a Belsey Mark IV. Many authors believe that if the original operation was performed transabdominally, a transthoracic approach should be utilized in reoperations. Others believe that only thoracic surgeons should perform thoracic surgery and general surgeons will feel more comfortable, and will have better results, with a laparotomy even in redo operations. Currently, transtho-racic Belsey Mark IV can be useful in patients who have had multiple abdominal procedures, and may be considered as an alternative to transabdominal approaches for surgeons who are well trained in thoracic procedures.13,47,48 Deschamps et al.48 reported their experience with 185 patients who had recurrent reflux after previous fundoplication. They performed a thoracotomy in 133 of these patients and a Belsey Mark IV in 47 (25%). Their median follow-up was 31 months (range, 3-283 months). Complications occurred in (25%) of patients. Mean length of stay was 9 days (range, 5-58 days). Excellent or good results were reported in only 60.2%. Migliore et al.49 found that 12.5% of patients undergoing thoracotomy reported poor results. They advise patients that laparoscopy provides better cosmetic results, has comparable results to open surgery, has less incisional pain, and offers a quicker return to normal life. The authors believe the indications for thoracotomy should be limited to reoperative fundoplication in patients that have concurrent esophageal pathology or extensive intraabdominal adhesions. Many thoracic surgeons have adopted laparoscopic fundoplica-tion into their repertoire with good to excellent results.50

Operative technique. The patient should have cardiac and pulmonary clearance before surgery. Once in the operating room, DVT prophylaxis and perioperative antibiotics are given. A thoracic epidural is placed for postoperative pain management. The patient is intubated with a double lumen tube to allow left lung collapse during the procedure. The patient is then placed in the semilateral position to allow for a thora-coabdominal incision, if needed. A left thoraco-tomy is performed in the 7th or 8th intercostal space and the left lung is excluded. The pulmonary ligament is divided and the esophagus is mobilized to the level of the aortic arch. The esophagus is encircled with a Penrose drain above the level of the inferior pulmonary vein. The middle esophageal artery is divided. The vagus nerves are identified and spared. The hiatal adhesions are lysed and the hernia sac, if present, is excised. Both crura are clearly defined and the previous fundoplication is taken down. The esophagogastric junction is identified and if it cannot be positioned intraab-dominally without tension, a Collis gastroplasty is performed with a GIA stapler. Nonabsorbable crural stitches are placed but are not tied. A 56-to 60-French bougie is placed and either a Nissen (360°) or Belsey Mark IV (270°) wrap is performed based on preoperative manometric studies. The crural stitches are tied after the wrap has been completed. Pledgets or mesh can


be used to buttress the crural closure. Pleural drainage tubes are placed and the thoracotomy is closed.49,51

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    What is thoracotomy fundoplication surgery?
    7 years ago

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