Belsey Repair
The main indication for this operation is in a thoracic approach for gastro oesophageal reflux disease
Advantages
A barrier to reflux without disturbing other gullet functions
A tension free return of the terminal oesopahgus to the abdomen may require the oesopahgus to be freed up to the aortic arch.
Previous oesophageal surgery is not a contraindication.
Easier in the obese patient.
Easy extension into abdomen should it be necessary ? oesphageal replacement.
In scleroderma or after myotomy the tightness of the repair can be altered.
Hepatosplenomegally can make an abdominal approach dangerous.
Co existing pathology in the chest can be dealt with.
Disadvantages
Post operative pain
Orringer said "easy to do, difficult to do well"
Adequate exposure of the lower oesophagus and histus is by a left 6th or 7th interspace incision, the higher being used in the obese patient
The inferior pulmonary ligament is divided. Mediastinal pleura medial to aorta is divided to isolate the esophagus. A finger is inserted around the esophagus to include both vagal nerves.
The cardia's attachment to the diaphragm is divided. The two halves of the right crus are approximated with a #0 or #1 non-absorbable suture, and left unknotted.
Removal of the vascular fat pad anterior to the oesophago gastric junction encourages two raw surfaces to adhere together.
Fundoplication is begun by matressing adjacent stomach to stomach fundus, to create a fold between the two vagus nerves. The nerves should not be snared.
The first layer is tied but not to so tight to avoid necrosis. Their is a fine line between superficial sutures on the esophagus that may cause recurrence and deep ones that may cause a fistula.
A second row of 3 sutures is inserted utilising a Belsey spoon to prevent any abdominal organ damage. The reconstructed cardia is placed below the diaphragm
The fundoplication lies below the diaphragm . It should be possible to insert an index finger into the hiatal gap. Too tight a closure will cause dysphagia. An oesophageal bougie can be utilised to guide the tightness.
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This is a cross sectional view to illustrate the stomach fold over ~240 degrees of the oesophgeal circumference.
The final result
