Introduction: The optimal method to manage a second recurrence of a paraesophageal hernia and a simultaneous gastrobronchial fistula is debatable. This video demonstrates a laparoscopic approach to this complex revisional operation performed on a 62 year old female who presented to our office with this diagnosis.
History: This patient’s surgical history began with a laparoscopic paraesophageal hernia repair performed at an outside institution that recurred immediately. During the reoperation, there was a perforation to the stomach and esophagus that was managed using a left thoractomy to perform both the resection of the perforated portion of the stomach and a Nissen fundoplication. Recovery was prolonged by a left empyema and gastric fistula managed by a chest tube. The drainage stopped after 2 months, but the patient continued to have symptoms of significant dysphagia and a 50 pound weight loss over 10 months. She then presented to our institution, where she also reported the history of a post-prandial cough for the past several months. An endoscpopy showed a benign ulcer in the stomach fundus but her upper GI series showed a second recurrence of a paraesophageal hernia with a slipped Nissen Fundoplication and a left gastrobronchial fistula.
Results: The patient was managed with a laparoscopic revisional surgery. The video demonstates the adhesiolysis required in a reoperative situation as well as the identification and division of the gastrobronchial fistula. The previsous Nissen is then identified and taken down. The redundant fundus is resected, and finally the crural defect is repaired using standard laparoscopic techniques. The patient fortunately had an uneventful recovery and at her 3 month follow up visit reported no dysphagia and had already regained 15 pounds. A post operative upper GI demonstrates the results.
Conclusion: Laparoscopic revisional foregut surgery is feasible, even in the setting of very complex situations such as what is demonstrated here with a second recurrence of a paraesophageal hernia with a herniated Nissen fundoplication and a gastrobronchial fistula. Using laparoscopic techniques in these complicated scenarios can provide the patients the known benefits of minimally invasive surgery.
Session: Podium Video Presentation
Program Number: V033