Ellen Wicker, DO, Evan Liggett, MD, Carlos Lodeiro, BS, Benjamin Clapp, MD. Texas Tech HSC Paul Foster School of Medicine
Introduction: Recurrence after fundoplications is a common surgical problem. Revision of foregut surgery can be very difficult and requires a clear understanding of the previous operation. Currently used fundoplications include the Nissen, Dor and Belsey fundoplications among others. For the surgeon faced with revising a fundoplication, a working knowledge of all of the previous operations is essential. Esophageal lengthening procedures can also be necessary during these revisions.
Description of Video: This video is a case report of a 60-year-old female who underwent a Dor fundoplication 10 years prior. She had a history of GERD, and her fundoplication was complicated by esophageal perforation by the bougie. The surgeon repaired the esophageal perforation but performed a Dor to reinforce this repair. She subsequently had a recurrence of her GERD and hiatal hernia. Repeat endoscopy and upper GI showed a paraesophageal hernia with a partially intact wrap. The video shows the operative approach of converting the Dor to a Nissen fundoplication with an esophageal lengthening procedure and repair of the hiatal hernia with a bio-absorbable mesh. The video highlights some of the technical pearls of this operation including takedown of the previous fundoplication, exposure of both diaphragmatic crura, mediastinal dissection and the importance of intra-operative endoscopy.
Discussion: Revision of foregut surgery is technically challenging. These cases can be approached with a laparoscopic technique by surgeons with an appropriate skill level. It is important that the surgeon reads the previous operative notes, reviews preoperative studies such as upper GIs and should personally perform pre-operative endoscopy. A working knowledge of the common fundoplication techniques and the anatomy of the foregut is essential.
Conclusions: Revisions of fundoplications are technically challenging and complex cases. These operations can be done safely laparoscopically and the surgeon should consider using a bio-absorbable mesh to reinforce their repair.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 91767
Program Number: V297
Presentation Session: Video Loop Day 3
Presentation Type: VideoLoop
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