Laparoscopic Take-down of Fundoplication, Closure of Crural Defect and Resection of Gastric Fundus in a Patient With Recurrent Hiatal Hernia for Slipped Nissen Fundoplication

Carolina Ampudia, MD, Andre Teixeira, MD, Rena Moon, MD, Samuel Szomstein, MD FACS FASMBS, Raul Rosenthal, MD FACS FASMBS. Cleveland Clinic Florida


 Introduction: A considerable percentage of patients who undergo Nissen Fundoplication and other forms of repair for hiatal hernias will show residual or re-incident hiatal hernias, and the approach in their management is crucial.

Materials and Methods: A 73 year old female presented to our service with dysphagia 7 months after undergoing repair of a hiatal hernia with biologic mesh and Nissen fundoplication at an outside institution.

Preoperative GI series shows images suggestive of a slipped Nissen and a small residual hiatal hernia.

Patient underwent a laparoscopic reoperation to attempt to repair this residual hiatal hernia. Intraoperative findings included a large number of adhesions between the left lobe of the liver and the anterior wall of the stomach, which were sharply taken down; a large number of Ethibond sutures adhered to the esophagus, gastric fundus and diaphragmatic crus. The biologic mesh was transected and some of the tackers used by the previous repair were removed. The gastric fundus was ischemic, so the decision was made to resect it. The diaphragmatic crus was closed with prolene quills sutures in figure-of-eight fashion.

Result: The recovery of the patient was uneventful, with resolution of the dysphagia and absence of GERD in postoperative visits.

Conclusion: In these cases, a careful approach in the repair of the diaphragmatic defects becomes crucial and somewhat more complicated here due to adhesions from the previous surgery. We present in this video the technical pitfalls of a complex hiatal hernia repair.

Session Number: VidTV1 – Video Channel Rotation Day 1
Program Number: V098

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