Key Points

• The principle of the Belsey Mark IV is the restoration of the distal esophagus into the high pressure zone below the diaphragm with a posterior buttress for counter pressure.
• The transthoracic approach allows maximal mobilization of the thoracic esophagus, resulting in maximal gain of length where necessary in order to obtain a tension-free intra-abdominal reduction of the distal esophagus invested by the fundoplication.
• In contrast to a 360-degree fundoplication, the partial 240-degree fundoplication is less prone to undesired side effects (e.g., dysphagia, gas bloating, and flatulence).
• In spite of the popularity of laparoscopic antireflux surgery, the Belsey Mark IV procedure remains of added value to the armamentarium of antireflux procedures, in particular, when treating complicated failures after laparoscopic fundoplication or complex giant paraesophageal hernias.

The popularization of laparoscopic surgery in the early 1990s dramatically and forever changed the practice of antireflux surgery since 1991 when Dallemagne introduced the laparoscopic Nissen antireflux procedure to the surgical community. The minimally invasive approach made this rather complex surgical procedure now much more acceptable to not only the patients but also physicians and gastroenterologists, lowering the threshold for referral to the surgeon. Within a few years the incidence of antireflux interventions, now almost exclusively performed through the laparoscope, had at least tripled.

The type of intervention almost invariably used nowadays is the Nissen antireflux operation. Indeed it appeared that this technique was the most suitable and most effective one to perform and to be taught. On the contrary, all other accepted interventions used in open surgery (i.e., the Belsey Mark IV, the Hill, and the Toupet procedures) proved to be too difficult for a routine application through the laparoscope or thoracoscope. Although the usefulness and the advantage of the Belsey Mark IV antireflux operation have been well documented, its application has decreased substantially worldwide. It is no longer used as a preferred technique for primary antireflux surgery in the majority of patients, with the laparoscopic Nissen operation being the first choice.

Overenthusiasm resulting in ill-devised patient selection, insufficient experience, the tendency to fit all patients into one single type of intervention (i.e., the Nissen operation), and lack of understanding of the physiopathology have recently tempered this enthusiasm as a result of some disastrous complications and bad results. As a result, an increasing number of failures and repeat surgeries have been noted in literature.

It appears that the Belsey Mark IV technique is now used more to treat complications of laparoscopic fundoplications. Given the rising incidence of “redo” antireflux surgery, it is of paramount importance to keep the Belsey Mark IV operation within the armamentarium of every surgeon dealing with the different aspects of gastroesophageal reflux disease (GERD). The aim of this chapter is therefore to describe in detail the different technical steps of this particular intervention. As a note of historical interest, all perioperative photographs used for the illustration of this chapter were taken by one author (T. L.) during his training period in Bristol, England, with Ronald Belsey being the surgeon.