Paraesophageal Hernia With Migration of the Adjustable Gastric Band Towards the Gastroesophageal Junction

S Ayloo, MD FACS, F Gheza, MD, M Masrur, MD, S D’ugo, MD, L Milone, MD, P C Giulianotti, MD FACS. Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA

Introduction
Severe dysphagia can be an early or late complication of adjustable gastric band but is rarely associated to a massive passage of the gastric fundus through the band with migration of the gastroesophageal junction into the thorax after 7 years of its placement.
We present herein a video of a robotic-assisted hiatal hernia repair in a patient with an adjustable gastric band though which the fundus herniated.
Methods
A 65-year old obese woman with current BMI of 35, presented 7 years after her laparoscopic adjustable gastric band with 7 month history of GERD, severe dysphagia to solids and liquids. A chest X-ray and a CT scan showed herniation of about 5 cm of the gastroesophageal junction in the thorax. Patient elected for Robotic approach to correct the herniation with an intention for keeping the band.
Results
A diagnostic laparoscopy revealed extensive adhesion of the gastrophrenic ligament with confirmation of migration of band towards the hiatus and presence of a hiatal hernia.
A careful dissection was done to delineate the pillars of the crura on the left, and then entered the gastrohepatic ligament on the right. Complete mobilization was performed at the GE-junction and the esophagus. Circumferential dissection at the distal esophagus was done to mobilize and reduce that portion of the stomach that has herniated into thorax. Once this was done, the crura was approximated with 2-0 Prolene using pledgets, which was snug but not tight, and the band was left alone. The operative time was 90 minutes. There were no intraoperative complications. Postoperative UGI showed reduction of the hernia with good passage of contrast and resolution of dysphagia. Patient was discharged on postoperative day 2.
Conclusions
The robotic approach is safe and feasible in revisional procedures allowing for accurate, delicate and precise dissection in complex redo-interventions