Concomitant Total Robotic Paraesophageal and Intrapericardial Hernia Repair in an Orthotopic Heart Transplant Recipient

Ehsan Benrashid, MD, Linda M Youngwirth, MD, Jacob N Schroder, MD, Sabino Zani, MD. Department of Surgery, Duke University Medical Center

Introduction: Intrapericardial hernias (IPH) are a rare entity which frequently result from complications of incidental or surgical trauma, such as in the setting of a pericardial window or CABG. The most common complaints on presentation include pain localized to the chest and upper abdomen, with more serious presentations being bowel obstruction or cardiac tamponade. Although cases of laparoscopic repair have been described in the literature, we present, to the first of our knowledge, robotic repair of an IPH after orthotopic heart transplantation (OHT), with concomitant robotic Nissen fundoplication and paraesophageal hernia repair.

Case: The patient is a 60-year-old male with a past medical history significant for ischemic cardiomyopathy resulting in left ventricular assist device (LVAD) placement complicated by tamponade physiology requiring postoperative pericardial window. He was bridged via LVAD to OHT approximately 1 year prior to presentation. He was noted to complain of persistent chest pain, recurrent cough, and reflux type symptoms. He underwent extensive workup including computed tomography, esophagogastroduodenoscopy, esophageal manometry and barium swallow which revealed a sliding-type hiatal hernia with a concomitant large IPH containing transverse colon (Figures 1&2). Due to his symptomatology and concern for obstruction, he was taken to the operating room where he underwent successful total robotic reduction of abdominal contents from the pericardium with primary paraesophageal hernia repair, Nissen fundoplication, and diaphragmatic repair with 12 cm Parietex mesh (Covidien, Dublin, Ireland) (Figure 3). He had an uncomplicated postoperative stay and was discharged on postoperative day 6 on a full liquid diet. On follow up in clinic approximately 4 weeks later his symptoms of dysphagia and reflux were noted to be resolving (Figure 2), with resumption of a normal diet. To our knowledge this is the first report of successful total robotic repair of a paraesophageal and intrapericardial hernia in an OHT patient.

Figure 1: Preoperative computed tomography demonstrating transverse colon adjacent to heart, without evidence of obstruction. (A) Axial view of intrapericardial-type diaphragmatic hernia. (B) Coronal view of hernia defect, arrow demonstrates transition of transverse colon through diaphragm. (C) Sagittal view of hernia defect.

Figure 2: Intraoperative images of robotic IPH. (A) Reduction of omentum and transverse colon through diaphragmatic hernia. (B) Representative image post reduction of intrabdominal contents from thoracic cavity, heart border seen to lower left of defect. (C) Following mesh placement for repair of diaphragmatic hernia.

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