Baongoc Nasri, MD, PhD, Raja Mahidhara, MD, Vijay Nuthakki, MD, Anthony Ascioti, MD. St. Vincent Indianapolis
Introduction: Postoperative chylothorax is a well described complication after thoracic operations. Chylothorax is a rare complication of paraesophageal hernia with Nissen fundoplication. Extensive intrathoracic dissection of retroesophageal window in paraesophageal hernia repair can expose the thoracic duct to injury. Robotic assisted thoracic duct ligation is an attractive option for definitive management.
Purpose: Case report of right sided robotic assisted thoracic duct ligation following Nissen fundoplication.
Materials and Methods: This is a 76-year-old female underwent Nissen fundoplication for incarcerated paraesophageal hernia repair complicated by persistent chylothorax at outside hospital. She underwent right sided robotic assisted thoracic duct ligation because she failed conservative management for 30 days. The patient was placed in the left lateral decubitus position with, right lung isolation. 3 port technique was utilized. First port was placed at fifth interspace anterior axillary line for camera. Bipolar was docked at arm 3, in the third interspace in the anterior axillary line and cardier forcep was docked at arm 1 in the eighth posterior axillary line. Assistant port was placed between the third interspace port and the fifth interspace port. We began by taking down the inferior pulmonary ligament, incised the mediastinal pleura overlying the esophagus. We identified the vertebral body and there was a lot of fluctuance of chylous fluid coming from that area. Thoracic duct and multiple accessory ducts were identified. All were clipped with Hem-o-lock. We did a standard talcum pleurodesis using 4 grams of talcum powder insufflated into the chest. A 24-French chest tube was placed.
Results: She started clear liquid diet, wean off Octreotide on POD 2. Octreotide and TPN was stopped on POD 3. She tolerated soft diet. She received 1 PRBC for low Hb on POD 5. She had intermittent elevated chest tube output possible from bleeding after decortication versus loculated old pleural effusion. However chest tube output gradually slowed down, triglyceride level was low 33 mg\dl. Chest tube was removed on POD 9. She discharged home in good condition after her medical issues resolved on POD 21.
Conclusion: Thoracic duct injury is a rare complication of Nissen fundoplication. Right sided thoracoscopy is a feasible approach for definitive management for thoracic duct injury. Robotic platform enhances visibility in limited space, facilitates complex dissection even at delayed presentation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93395
Program Number: V407
Presentation Session: Video Loop Day 4
Presentation Type: VideoLoop