Katherine D Gray, MD, Patrick Dolan, MD, Rasa Zarnegar, MD. New York-Presbyterian-Cornell
Patient Presentation: The patient is 58-year-old female who was referred for evaluation of a large paraesophageal hernia after undergoing esophagogastroduodenoscopy for an unrelated complaint. She reported symptoms of heartburn, regurgitation, and occasional post-prandial chest pain. Manometry showed intact esophageal motility and a hypotonic lower esophageal sphincter, and pH monitoring showed reflux. Computed tomography (CT) imaging showed a paraesophageal hernia with 80% of the stomach in the chest. The patient was consented for robotic paraesophageal hernia repair with mesh.
Operative Technique: The patient was positioned supine in steep Trendelenburg. Access was gained to the abdomen using a Veress needle 13 cm caudad to the xyphoid. One 5 mm port was placed laterally for a liver retractor, and an additional four 8 mm robotic ports were placed. The robot was docked. Dissection began through the pars flaccida to identify the right crus. Attention was then turned to the greater curve, and the short gastric vessels were transected using a vessel sealer. Mediastinal attachments were divided until the hernia contents were completely reduced and adequate esophageal length was obtained. The hiatus was re-approximated using interrupted V-loc and 3-0 silk sutures. A keyhole configuration was fashioned from a coated, monofilament bio-absorbable mesh to circumferentially reinforce the diaphragmatic hiatus. This was secured in place using a running V-loc suture in the inner diameter and interrupted 3-0 silk sutures along the outer diameter.
Finally, a Nissen fundoplication was constructed over a 56-French bougie. The wrap was tacked in place to the crus posteriorly and anteriorly using 3-0 silk suture. At three-month follow-up, the patient had resolution of her pre-operative symptoms, and a barium swallow showed that the wrap was well-located.
Conclusions: We present here a novel configuration for mesh repair of a paraesophageal hernia with good short-term results.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87370
Program Number: V213
Presentation Session: Thursday Video Loop (Non CME)
Presentation Type: VideoLoop
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