Acute symptomatic transhiatal colonic herniation after total esophagectomy

Mario Masrur, MD, Fabiola Aguilera, MD, Despoina Daskalaki, MD, Kristin Patton, MD, Pier Giulianotti, MD. University of Illinois at Chicago

Introduction

Herniation through the hiatus after a trashiatal esophagectomy is a common clinical situation. Most of the time is asymptomatic and may be incidentally found in abdominal CT. Surgical repair is the treatment of choice for this situation when the patient is symptomatic and the Robotic approach may minimize the morbidity of this operation. We present a video of robot-assisted repair of a colonic hiatal herniation after total esophaghetomy for malignancy.

Methods

A 60 year old female with a history of a previous total esophagectomy and gastric conduit for reconstruction presents with three days of left sided abdominal pain and episodes of nausea and vomiting. Further workout revealed a paramedian hiatal hernia with involvement of the transverse colon on CT scan with contrast. The patient underwent robotic-assisted repair of the hernia and colopexy.

Results

Procedure started with a diagnostic laparoscopy that showed the hiatus clearly enlarged, and the stomach tubulized inside the chest. On the left side of the gastric tube the transverse colon can be seen inside the chest.

The hiatus was repair in a direct fashion with no mesh. Using interrupted stitches of Prolene 2-0 with pledgets, approximating the diaphragm and the left pillar anteriorly to the right pillar, partially closing and decreasing the size of the hiatus. There were no intra- or post-operative complications. Blood loss was minimal. The patient was asymptomatic after the operation and in a follow up visit, two weeks after the hernia repair the patient was tolerating several small meals daily.

Conclusions

This video highlights the technical details of a robotic hiatal hernia repair in a patient with a previous total esophagectomy. The robotic system allows for precise, fine dissection in spite of the presence of adhesions. This technique also permits a better follow of the anatomy inside the chest and accurate reconstruction of the hiatus.