Laparoscopic Reduction of Mesenteroaxial Gastric Volvulus and Gastropexy

Wasef Abujaish, MD, Sarah Lomas, MD, Julie Alosi, MD, Charles Parsons, MD. University of Vermont College of Medicine. Fletcher Allen Health Care


Background: Surgical intervention is considered the treatment modality of choice for acute symptomatic gastric volvulus. Recently, the traditional open surgical technique has been replaced by the recommendation for a minimally invasive approach. Our video describes the use of laparoscopic approach for a relatively healthy woman with acute symptoms stemming from mesenteroaxial gastric volvulus, in which the diagnosis was based on clinical presentation, radiologic findings, and endoscopy. Mesenteroaxial volvulus was later confirmed and treated laparoscopically.

Case Report: The patient is a 61-year-old female with hyperlipidemia and a remote history of colitis, who presented to an outside hospital with upper abdominal pain, nausea, and vomiting. Her working diagnosis upon admission was acute pancreatitis and small bowel obstruction due to a preliminary workup that showed an elevated lipase (1,800 U/L) as well as a bowel obstruction on acute abdominal series. Nasogastric tube placement yielded 1,700 mL of brownish-blood-tinged fluid. An elevated white blood cell count accompanied by low-grade fever and a hematocrit drop prompted a contrast-enhanced CT scan of the abdomen and pelvis. The CT scan revealed gastric distension and gastric wall thickening as well as dense ascites, especially in the left upper quadrant. She was transferred to our institution two days later for further management. Upon arrival, the patient complained of some abdominal fullness but overall she felt well and her abdominal exam was benign except for mild epigastric distension. Secondary read of the initial CT scan and repeat CT scan confirmed a persistent mesenteroaxial gastric volvulus with the gastric fundus located inferiorly and the antrum rotated superiorly. The patient was brought to the operating room after upper endoscopy demonstrated both gastric volvulus and an area of necrotic/ischemic mucosa on the anterior gastric wall of the body/fundus. Diagnostic laparoscopy, reduction of the volvulus, plication of the anterior gastric wall opposite to the necrotic/ischemic mucosal area, and gastropexy were performed. Gastropexy was achieved with a total of four sutures: one was placed between the gastric fundus and the left crus of the diaphragm, while three sutures secured the anterior gastric wall near the greater curvature to the anterior abdominal wall. Notable findings in the operating room included a redundant colon and bloody intraperitoneal fluid in the left upper quadrant, but there were no signs of gangrene or gastric perforation. The patient tolerated the procedure well and her diet was slowly advanced. Follow-up esophagogastroduodenoscopy two months later was normal.

Conclusion: Traditionally an open surgical approach has been used for acute gastric volvulus; however laparoscopic repair is now increasingly advocated. Laparoscopic repair of gastric volvulus, although technically difficult, offers a minimally-invasive approach associated with less pain and a shorter hospital stay. The role of endoscopic reduction is controversial since it offers only a temporary solution. In patients considered high-risk preoperatively, endoscopic detorsion with concomitant percutaneous endoscopic gastrostomy tube offers a suitable solution. Nonetheless, the laparoscopic approach is a safe and effective treatment for gastric volvulus that obviates laparotomy, resulting in minimal overall morbidity, fewer wound-associated complications, and shorter hospital stay as well as shorter recovery.

Session Number: VidTV3 – Video Channel Rotation Day 3
Program Number: V148

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