Medhat Fanous, MD, FACS. Aspirus Health System
Objective: To provide an alternative safe surgical technique for hiatal hernia repair in the presence of an Aberrant Left Hepatic Artery (ALHA).
Summary Background Data: The presence of an ALHA creates significant technical difficulties as it diminishes the operative field and hinders direct access to the right crus. This impairs the hiatal dissection in 29.8% of cases. It results in failed Nissen fundoplication in 6% of patients. It leads to increased incidence of operative bleeding to 4.1%.
Method: We conducted a retrospective chart review of patients who underwent anti-reflux surgery or hiatal hernia repair between March 2016 and August 2017. We reviewed clinical data, operative reports and images, laboratory data and follow-up data. Patients underwent laparoscopic repair of hiatal hernia followed by Transoral Incisionless Fundoplication (TIF). Hiatoplasty was performed with Extracorporeal Sliding Arthroscopic Knots (ESAK). These knots are similar to the preformed knot used in the endoloop device. They are performed extracorporeally and advanced with a knot pusher.
Results: 102 laparoscopic anti-reflux and hiatal hernia repair procedures were performed by a single surgeon at a high volume anti-reflux program. Six patients (5.7%) had an ALHA. All but one was female. The ALHA was preserved in all cases. Average age was 52 (±5.3) years. Average BMI was 30.3 (±4.5). The duration of GERD symptoms ranged between (6-25) years. The average use of anti-secretory medications was 16 (± 7.7) years. DeMeester score averaged 48.6 (± 22).
Five patients had 300 degrees fundoplication and the remainder had 270 degrees. There was no intraoperative bleeding, mortality or postoperative complications. Patients were discharged the following day after surgery. The liver function tests were normal. All anti-reflux medications were discontinued. The average improvement of GERD Health-Related Quality of life (GERD HRQL), Reflux Symptoms Index (RSI), GERD Symptom Score questionnaires (GERSS) was 26.2, 19.4 and 18.4 respectively.
Discussion: The combination of using ESAK employed for tight joint spaces and the natural orifice TIF procedure are well engineered to tackle the space limitation created by the presence of an ALHA. This technique allows precise placement of the knots with single insertion of the knot pusher. TIF enable the surgeon to perform adequate partial fundoplication endoscopically thus avoiding the confined surgical field.
Conclusion: The combination of using extracorporeal arthroscopic knot tying and TIF is safe, preserves an ALHA in a very limited operative field.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86781
Program Number: P464
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster