Enrique F Elli, MD, FACS, Tamara Diaz Vico, MD. Mayo Clinic Florida
We present the case of a 54-years-old female presenting with left upper quadrant and dysphagia for one year. Preoperative studies were performed. A CT scan and an upper GI showed an epiphrenic diverticulum; a manometry evidenced esophagogastric outflow obstruction with elevated lower esophageal sphincter pressure. The endoscopy confirmed the diagnosis.
Patient was selected to undergo a robotic excision of epiphrenic diverticulum and Heller myotomy with Dor fundoplication.
The procedure started by opening the gastrohepatic ligament and dissecting the hiatus. Short gastric vessels were divided and a retroesophageal tunnel was created to pass along a Penrose drain for retraction and exposure. Once the pillars of the hiatus were clearly identified, the esophagus was then circumferentially dissected into the mediastinum in order to find and isolate the epiphrenic diverticulum. An intraoperative endoscopy was performed to confirm the location of the diverticulum. Using monopolar hook and scissors, the vague nerve was identified and preserved. The diverticulum was completely isolated and dissected off from the mediastinum. It was a wide mouth diverticulum about 3 cm from the gastroesophageal junction. A 54 Taper bougie was introduced to guide the resection without strangling the esophagus. An endoGIA white load was fired across and the staple line was reinforced with 3-0 PDS suture in an interrupted fashion. Then, a myotomy was performed, extending it 5 cm up into the esophagus and 3 cm down into the stomach. Longitudinal fibers were carefully dissected, and the mucosa was identified. An intraoperative endoscopy was performed, without any evidence of leaks, and a wide open gastroesophageal junction. In order to keep the myotomy opened, several stitches were placed in between both the left and right crus and the same side of the myotomy. Lastly, A Dor fundoplication was performed.
The postoperative upper GI showed good passage through the esophagogastric junction and no evidence of leaks. The patient was asymptomatic and she was discharged on postoperative day 2.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94606
Program Number: V339
Presentation Session: Video Loop Day 3
Presentation Type: VideoLoop
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