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Laparoscopic reduction of herniated Gastric Sleeve

Rajmohan Rammohan, MD, Nisha Dhanabalsamy, MD, Mandip Joshi, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS. Cleveland Clinic Florida

Introduction:Although LSG is considered a safe operation for the morbidly obese, several surgical complications have been described. The dissection of phreno-gastric and phreno-esophageal ligaments, the tubular shape of the gastric sleeve and the difficulty in anchoring the sleeve to the surrounding structures, although rare, can lead to hiatal hernias. The study objective is to show the operative technique practiced in our clinic for the treatment of hiatal hernia after sleeve Gastrectomy.

Methods: We present a case of a 54 year old female, BMI of 24.62 kg/m2, who presented with persistent high-grade dysphagia after a complicated sleeve Gastrectomy done in an outside facility. After the abdominal cavity was accessed, adhesions between the liver and anterior wall of the stomach were taken down. Meticulous hemostasis was performed in a patient who was a Jehovah Witness and refused to get blood transfusion. The right crus of the diaphragm was identified and dissected. The phrenoesophageal membrane was also taken down and dissection carried out to the left crus of the diaphragm. The greater curvature side of the gastric sleeve was dissected from adhesions to the greater omentum. The dissection was then carried out to the left crus of the diaphragm as well. At that time it was noticed that the proximal part of gastric sleeve was dilated and partially herniated into the chest. With meticulous sharp dissection, ragged dog-ear of the sleeve was brought down from the chest cavity. Once the stomach was completely reduced into the abdominal cavity, an intraoperative EGD was performed that can be advanced all the way up to the pylorus without any signs of obstruction. The hiatus was approximated with non-absorbable barbed sutures.

Results: The patient tolerated the procedure well with minimal blood loss. An upper GI Gastrografin showed no evidence of leak or obstruction. The patient was discharged home on post-operative day 2.

Conclusion: Acute herniation of the gastric sleeve and secondary esophageal obstruction is a possible but under-reported complication. Reduction of the hiatal hernia after sleeve Gastrectomy is a feasible option that showed to resolved the patients’ symptoms of obstruction


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 78900

Program Number: V064

Presentation Session: Friday Exhibit Hall Video Presentations Session 1 (Non CME)

Presentation Type: EHVideo

101

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