Belsey Mark IV Procedure

Preparation

Thorough preoperative preparation is crucial for optimizing patient outcomes. This typically involves:

• Comprehensive Patient Assessment:
  • Detailed Medical History: Focusing on reflux symptoms (heartburn, regurgitation, dysphagia), previous surgeries, and comorbidities.
  • Physical Examination.
• Diagnostic Studies:
  • Esophagogastroduodenoscopy (EGD): To visualize the esophagus, stomach, and duodenum, assess the degree of esophagitis, identify any strictures or Barrett’s esophagus, and evaluate the anatomy of the hernia. Biopsies may be taken.
  • Barium Swallow (Esophagogram): To delineate the anatomy of the hiatal hernia, assess esophageal motility, and evaluate the length of the esophagus.
  • Esophageal Manometry: To assess esophageal motor function and lower esophageal sphincter (LES) characteristics. This is particularly important to rule out achalasia or other motility disorders that might contraindicate or alter the surgical plan.
  • 24-hour pH Monitoring: To objectively quantify esophageal acid exposure and correlate symptoms with reflux episodes.
• Medication Management:
  • Proton pump inhibitors (PPIs) are often continued until the day of surgery.
  • Anticoagulants or antiplatelet agents may need to be discontinued for a specific period before surgery, in consultation with the prescribing physician, to minimize bleeding risk.
• Pulmonary Function Tests: May be indicated, especially in patients with pre-existing lung disease, as the procedure involves a thoracotomy.
• Nutritional Assessment: To ensure the patient is in an optimal nutritional state for healing.
• Anesthesia Consultation: To assess anesthetic risks and plan for intraoperative and postoperative management, including pain control (e.g., epidural catheter).
• Patient Counseling: Detailed discussion of the procedure, its risks, benefits, alternatives, and expected postoperative course.
• Fasting: Patients are typically instructed to have nothing to eat or drink (NPO) for at least 6-8 hours before surgery.
• Prophylactic Antibiotics: Administered shortly before the surgical incision to prevent infection.
• Deep Vein Thrombosis (DVT) Prophylaxis: Including pneumatic compression stockings and/or anticoagulant medication.

Patient Positioning

For the Belsey Mark IV procedure, the patient is positioned in the right lateral decubitus position. This means the patient lies on their right side, with the left side of the chest exposed.

Key aspects of positioning include:

• Securing the Patient: The patient is securely strapped to the operating table to prevent movement during the surgery.
• Padding: Pressure points, such as the axilla, hips, knees, and ankles, are carefully padded to prevent nerve injury or pressure sores. A “shoulder roll” may be placed an arm’s length below the axilla to protect the brachial plexus.
• Table Flexion: The operating table may be flexed to open up the intercostal spaces on the left side, providing better exposure for the surgeon.
• Arm Position: The patient’s arms are typically positioned to allow optimal surgical access; the lower arm may be placed on an arm board, and the upper arm supported, often flexed at the elbow and resting on a padded support.
• Reverse Trendelenburg: The table may be tilted into a reverse Trendelenburg position (head up) until the axis of the upper spine is parallel to the floor, which can aid in exposure.

This positioning provides optimal access to the left thoracic cavity, the distal esophagus, and the diaphragm.

Surgical Approach

The Belsey Mark IV procedure involves a left posterolateral thoracotomy with these key steps:

• Initial Access: A curved incision is made in the sixth or seventh intercostal space on the left chest, from posterior to anterior axillary line.
• Muscle Management: The latissimus dorsi is divided while preserving the serratus anterior when possible.
• Chest Entry: Intercostal muscles are carefully incised above the rib, avoiding the neurovascular bundle. Rib spreaders provide exposure.
• Lung Access: With single-lung ventilation, the left lung is retracted to expose the posterior mediastinum, diaphragm, and distal esophagus.
• Final Exposure: The mediastinal pleura is incised vertically from the hiatus to the pulmonary vein level, with possible division of the inferior pulmonary ligament.

This technique ensures clear access to the surgical area for the fundoplication and hiatal repair.

Intraoperative Steps

The key intraoperative steps of the Belsey Mark IV procedure are:

1. Esophageal Mobilization:
   • Carefully free the distal esophagus from surrounding tissues
   • Preserve vagus nerves
   • Place Penrose drain for traction
   • Extend mobilization as needed for tension-free repair
   • Cut phrenoesophageal membrane at hiatus
2. Hernia Management:
   • Free hernia sac if present
   • Return stomach to abdomen
   • Remove hernia sac
3. Fundus Preparation:
   • Mobilize gastric fundus
   • Remove fat pad at gastroesophageal junction
4. Hiatal Repair:
   • Identify diaphragmatic crura
   • Place 3-4 posterior sutures
   • Leave sutures untied until after fundoplication
5. Two-Layer Fundoplication:
   • First Layer:
     • Place 3-4 horizontal mattress sutures
     • Create 240-270° anterior wrap
   • Second Layer:
     • Add proximal row of sutures
     • Anchor wrap to diaphragm
6. Final Steps:
   • Position fundoplication below diaphragm
   • Tie all sutures
   • Place chest tube
   • Close incision in layers

A bougie (40-50 French) may be used during fundoplication to prevent narrowing.

Reconstruction

The reconstructive aspect of the Belsey Mark IV procedure creates a new antireflux barrier at the gastroesophageal junction (GEJ) and ensures its stable position within the abdomen through partial fundoplication and fixation.

The key elements of the reconstruction are:

1. Partial Anterior Fundoplication:
   • The procedure creates a partial wrap of the gastric fundus around the anterior and lateral aspects of the distal esophagus. This wrap covers 240 to 270 degrees of the esophageal circumference, unlike the Nissen fundoplication’s complete 360-degree wrap.
   • This partial wrap reduces the risk of postoperative dysphagia (difficulty swallowing) and gas bloat syndrome compared to total fundoplications.
2. Two-Layer Suture Technique:
   • First Layer (Esophagofundal Approximation): Three or four horizontal mattress sutures join the anterior wall of the gastric fundus to the anterolateral aspects of the distal esophagus. Placed 1.5-2 cm below the esophagogastric junction, these sutures form the fundic wrap.
   • Second Layer (Gastrodiaphragmatic Fixation): A second row of horizontal mattress sutures incorporates:
     • The anterior rim of the diaphragmatic hiatus
     • The wrapped gastric fundus
     • The esophageal wall, anchoring the fundoplication to the diaphragm’s undersurface
3. Restoration of an Intra-abdominal Segment of Esophagus:
   • The reconstruction maintains at least 2-3 cm of distal esophagus within the abdomen’s positive-pressure environment. The second layer’s gastrodiaphragmatic sutures prevent the GEJ from moving back into the chest.
4. Crural Repair (Hiatoplasty):
   • Sutures bring together the diaphragmatic crura behind the esophagus, narrowing the hiatus enough to prevent re-herniation while avoiding constriction.

The Belsey Mark IV reconstruction achieves four key goals:

• Augment the Lower Esophageal Sphincter (LES): Using the wrapped gastric fundus as reinforcement
• Lengthen the Intra-abdominal Esophagus: Exposing more esophagus to abdominal pressure to prevent reflux
• Secure the GEJ Below the Diaphragm: Preventing hiatal hernia recurrence
• Maintain the Angle of His: Preserving the acute angle between esophagus and gastric fundus that helps prevent reflux

For patients with a short esophagus where tension-free intra-abdominal fundoplication isn’t possible despite thorough mobilization, surgeons may add a Collis gastroplasty. This procedure creates a neo-esophagus from the gastric cardia with a stapling device, effectively lengthening the esophagus before constructing the Belsey fundoplication.

Possible Complications and Management

Like any surgical procedure, the Belsey Mark IV operation carries potential risks and complications. These can be broadly categorized into general surgical complications and those specific to the procedure or thoracic approach.

General Surgical Complications:

• Bleeding:
  • Intraoperative or postoperative.
  • Management: May require blood transfusion or, rarely, reoperation to control hemorrhage.
• Infection:
  • Wound infection, empyema (pus in the pleural space), or pneumonia.
  • Management: Antibiotics, drainage if necessary (e.g., for empyema), and supportive care.
• Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE):
  • Blood clots in the legs that can travel to the lungs.
  • Management: Prophylaxis (stockings, anticoagulants), and therapeutic anticoagulation if DVT/PE occurs.
• Anesthetic Complications: Reactions to anesthesia, respiratory issues.

Complications Specific to Thoracotomy and Belsey Mark IV Procedure:

• Post-Thoracotomy Pain Syndrome:
  • Chronic pain in the thoracotomy incision site, which can be neuropathic.
  • Management: Multimodal pain management, including nerve blocks, analgesics (NSAIDs, opioids, neuropathic agents).
• Pulmonary Complications:
  • Atelectasis (lung collapse), pneumonia, respiratory insufficiency, prolonged air leak from chest tube.
  • Management: Chest physiotherapy, incentive spirometry, antibiotics for pneumonia, prolonged chest tube drainage if needed.
• Atrial Fibrillation or Other Arrhythmias:
  • Common after thoracic surgery.
  • Management: Rate control, rhythm control with medications, or cardioversion if hemodynamically unstable.
• Esophageal Injury/Perforation/Leak:
  • Rare but serious complication during dissection or suturing. Contained leaks may also occur.
  • Management: Immediate repair if recognized intraoperatively. Postoperative leaks may require reoperation, stenting, or conservative management with drainage and antibiotics, depending on severity.
• Gastric Injury: Perforation or injury to the stomach during mobilization or wrap creation.
  • Management: Intraoperative repair.
• Splenic Injury: Can occur during mobilization of the gastric fundus.
  • Management: Repair or, rarely, splenectomy.
• Vagal Nerve Injury:
  • Can lead to delayed gastric emptying or other gastrointestinal motility issues.
  • Management: Usually conservative; prokinetic agents may be tried.
• Dysphagia (Difficulty Swallowing):
  • Can be transient due to postoperative edema or persistent if the wrap is too tight or the hiatal repair is too constrictive.
  • Management: Usually resolves with time. Persistent dysphagia may require dietary modifications, esophageal dilation, or rarely, revisional surgery.
• Gas Bloat Syndrome: Difficulty belching or vomiting, leading to abdominal discomfort and bloating. Less common with partial fundoplications like the Belsey.
  • Management: Dietary modifications, medications.
• Recurrent Hernia or Reflux Symptoms:
  • The fundoplication can slip, dehisce, or a new hernia can form. Symptoms of GERD may return.
  • Management: Medical therapy (PPIs). Further investigations (EGD, barium swallow, pH/manometry) may be needed. Reoperation is considered for significant symptomatic recurrence.
• Stricture Formation: Late narrowing at the repair site.
  • Management: Endoscopic dilation.
• Mortality: Perioperative death is rare but possible, often related to pre-existing severe comorbidities or major complications like myocardial infarction.

Management of Complications:

Management is tailored to the specific complication and its severity. It ranges from conservative measures (observation, medication, dietary changes) to endoscopic interventions (dilation, stenting) or further surgery. A multidisciplinary approach involving surgeons, gastroenterologists, and other specialists is often beneficial for complex complications. Routine postoperative follow-up, including contrast studies if indicated, helps in early detection and management of certain issues.