Enrique F Elli, MD, FACS, Tamara Diaz Vico, MD. Mayo Clinic Florida
A 76 years-old patient, with no surgical background, was found to be anemic while suffering flu-like symptoms. Preoperative studies were performed in order to reach a final diagnosis. There were no pathological findings in the colonoscopy. The EGD showed a mass in the proximal stomach measuring 4 to 5 cm. It was biopsied, demonstrating bland spindle cells with inmunohistochemical features consistent with gastrointestinal stromal tumor (GIST). The upper GI evidenced a paraesophageal hernia, and the mass described in the EGD too.
Patient was selected to undergo a laparoscopic robotic-assisted paraesophageal hernia repair and gastric GIST resection.
The procedure started with a diagnostic laparoscopy, showing a hiatal herniation with migration of the stomach into the mediastinum. A tattooed mass compatible with the description in the EGD came out during the manipulation of the stomach. Short gastric vessels were divided, as well as the gastroesplenic ligament. Left crus was then exposed. Dissection continued by opening the pars flaccida and dissecting the right crus. Then, the hernial sac was carefully dissected on both sides. The vague nerve was isolated and preserved and, once the dissection in the mediastinum was finished, the hernial sac was removed. A retroesophageal tunnel was created and a Penrose drain was passed along for retraction and exposure. An intraoperative endoscopy confirmed the location of the gastric tumor and a 54 Taper bougie was introduced to guide the resection. Then, a gastrotomy was performed and the GIST was exposed. An endoGIA with two white loads were fired across and the staple line was reinforced with 3-0 PDS suture in an interrupted fashion. The gastrotomy was closed with 2-0 V-Loc suture in a running fashion, reinforcing it with interrupted stitches of 3-0 PDS.
Once the closure of the gastrotomy was finished, the pillars of the hiatus were approximated with interrupted stitches of 2-0 Ethibond. An anterior interrupted stitch was placed to restored the anatomy. While performing the fundoplication, several nodules were identified and removed from the distal esophagus. Pathology report confirmed the diagnosis of leiomyomas. Lastly, a Toupet fundoplication was performed using interrupted absorbable sutures.
The operative room time was 330 minutes. No intraoperative complications occurred. The postoperative course was uneventful, and the patient was discharge on postoperative day 3. The upper GI showed no leaks, and the pathology report described a gastrointestinal stromal tumor with a G1 histological grade, and positive CD117 and CD34 in inmunohistochemical studies.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94607
Program Number: V277
Presentation Session: Video Loop Day 2
Presentation Type: VideoLoop