Laparoscopic Salvage of Herniated Gastric Plication by Stapled Resection

Nathan M Bolton, MD, William S Richardson, MD. Ochsner

Surgical options for morbid obesity have expanded greatly over the last several decades with the popularization of laparoscopic gastric banding (LGB) and laparoscopic sleeve gastrectomy (LSG). A more recent addition, laparoscopic greater curve plication (LGCP), is a restrictive procedure that has risen in popularity, although it is still considered investigational by the American Society of Metabolic and Bariatric Surgery guidelines. The purported benefits of LGCP include a reduction in staple line leaks associated with LSG, lack of gastric resection, and lack of foreign implants as in LGB and possibly lower risk of bleeding. However, the procedure is not without its own unique early risks which include herniation of the gastric fundus through the plication, overly tight plication causing obstruction, leaks and perforations. Our case is of late gastric herniation and strangulation through the plication suture line in a patient presenting with acute onset fever, epigastric abdominal pain, and leukocytosis one year after LGCP. We describe a laparoscopic approach to salvage by resection of the herniated stomach and over-sewing the staple line with the gastric plication.  The patient tolerated the procedure well, his diet was advanced and he was discharged home on post-operative day 4 without complications.  Although we considered gastric resection with conversion to gastric bypass this may be a preferred procedure for late plication disruption.