Charlotte Horne, MD, Alisan Fathalizadeh, MD, John Rodriguez, MD, Kevin El-Hayek, MD, Jeffrey Ponsky, MD. Cleveland Clinic
This case presentation involves a 52-year-old female that underwent a laparoscopic sleeve gastrectomy in 2011. At this time, she was also noted to have a hiatal hernia but this was not repaired. Her medical comorbidities include diabetes mellitus, pulmonary embolus, diastolic heart failure, gastroesophageal reflux disease, hypertension and hyperlipidemia. She originally did well after her sleeve gastrectomy, however in 2016 she had worsening intermittent abdominal pain that progressed in severity and eventually necessitated numerous hospital admissions. Imaging at this time showed a large type three paraoesophageal hernia with her previous sleeve gastrectomy twisted into her chest. Due to her worsening symptoms, the decision was made to proceed with surgical repair.
This video demonstrates the many technical challenges that are associated with revisional surgery and paraoesophageal hernia repairs. Due to her previous surgery, dense intra-abdominal adhesions as well as adhesions to the hiatus and in the mediastinum were encountered. These were managed using careful sharp dissection and meticulous detail to maintain the appropriate plane. As the identification of operative anatomy can be challenging in revisional cases, other adjuncts can be used to facilitate identification of important structures. In this case, correctly identifying the gastroesophageal junction proved challenging. To determine its position, we utilized intra-operative endoscopy to ascertain the appropriate anatomical landmark as well as to facilitate appropriate dissection. In paraoesophageal hernia repairs, ensuring complete mediastinal dissection is imperative to facilitate complete reduction of the hernia and decrease recurrence. The mediastinal dissection in this case became increasingly challenging because the reduced fundus had become massively dilated. Providing appropriate downward retraction on the redundant fundus, in order to facilitate complete reduction of the hiatal contents, became technically difficult. To overcome this challenge, the stomach was divided after the left gastric artery was identified. The division of the stomach improved visualization and allowed for complete reduction of the previous sleeve gastrectomy from the chest. Lastly, the decision of how to repair the hiatal defect and appropriate reconstruction patients on patient factors and co-morbidities must be considered. Due to the patients current BMI of 45 kg/m2 as well as multiple medical co-morbidities the decision was made to proceed with a Roux-en-Y reconstruction.
Overall, this video demonstrates multiple technical challenges to re-operative paraoesophageal hernia repairs and unique solutions to these challenges.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94827
Program Number: V056
Presentation Session: Bariatric II – Revisions
Presentation Type: Video