Enrique F Elli, MD, FACS, Tamara Diaz Vico, MD. Mayo Clinic Florida
We present the case of a 47 years-old female with history of kidney transplantation, who underwent a paraesophageal hernia repair with mesh in 2009. The patient complained about progressive dysphagia and heartburn for the last months. Preoperative studies were performed in order to reach a final diagnosis. The upper GI showed an image compatible with achalasia. An upper endoscopy showed esophagitis, a stricture and stenosis of the distal esophagus. The manometry was not conclusive, and the patient failed to endoscopic dilation. Finally, decision was made to undergo an intraoperative evaluation.
Two 12-mm and three 5-mm robotic trocars were placed in a wide “v”. The procedure started with a diagnostic laparoscopy, showing adhesions in between the stomach, the liver, and the previous mesh. Using monopolar hook, adhesions were carefully taken down. Mesh was identified constricting the esophagus at the level of the hiatus. This dense material was attached to the distal esophagus too at the level of the esophagogastric junction. Also, the stomach was completely detached from the liver and from the previous mesh. The mesh was detached completely from the hiatus. Dissection continued posteriorly to the esophagus and a Penrose drain was placed around. The robotic third arm was used for retraction and exposure. Using monopolar scissors, the esophagus was dissected from the mesh inside the mediastinum. Then, an intraoperative endoscopy was performed, showing that the restriction at the distal esophagus was resolved and the previous fundoplication was intact.
Once the mesh was removed and the stenosis of the distal esophagus was resolved, the pillars of the hiatus were approximated with interrupted stitches of 2-0 Ethibond to restored the anatomy.
The operative room time was 120 minutes, with no intraoperative complications. Patient was asymptomatic after the surgery, with good oral tolerance. She was discharged on postoperative day 3, and no evidence of recurrence was noticed.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94586
Program Number: V298
Presentation Session: Video Loop Day 3
Presentation Type: VideoLoop