Sarah Samreen, MD, Crystal M Krause, PhD, Dmitry Oleynikov, MD. University of Nebraska Medical Center
This is a presentation of a robotic Heller Myotomy, showing both a partial anterior (Dor) and a posterior (Toupet) fundoplication. The first case is a 44 year old female who presents with dysphagia and regurgitation. Manometry shows evidence of type I achalasia, and the esophagram presents typical achalasia profile of a bird’s beak appearance. The patient elected to proceed with treatment of a Heller myotomy with a Dor (180° partial anterior) fundoplication. The Myotomy begins by opening the phrenoesophageal ligament and standard mediastinal dissection is performed to mobilize the esophagus. The esophageal fat pad is split, the GE junction and Vagus nerve are identified, and the Vagus nerve is elevated. A lighted 56 Fr Bougie is used to facilitate the robotic dissection. The Myotomy is performed using blunt dissection and hook cautery. The lighted Bougie facilitates identification of the both longitudinal and circular muscle layers as well as the esophageal mucosa. The robot facilitates this due to motion scaling. Once the Myotomy is completed, the Dor fundoplication is started. A permanent O suture is used to secure the angle of His and the fundus to the abdominal wall. The second and third stitches secure the stomach to the cut edge of the myotomy. The Dor is closed with a contralateral stitch to the cut edge of the myotomy to ensure the integrity of the myototmy under the anterior fundoplication of the stomach.
The second case is a 36 year old female who presents with aspiration pneumonia. Patient workup showed a dilated, sigmoid esophagus and manometry consistent with achalasia. The patient elected to proceed with a Heller myotomy and Toupet (270° partial posterior) fundoplication for treatment. Extensive mediastinal dissection is performed for esophageal lengthening and reduction of the hiatal hernia. A Penrose drain is placed around the esophagus and the liver is retracted and proceed with circumferential mobilization of the esophagus away from the hiatus and then extensive mediastinal dissection. Once adequate esophageal mobilization is obtained, the myotomy is performed. The Toupet fundoplication is formed by the placement of permanent sutures at 9:00 and 3:00 positions respective to the esophagus. The Penrose drain is removed, the esophagus is pulled down and secured with stitches to the right and left crura and the cut edge of the myotomy.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95405
Program Number: V223
Presentation Session: Video Loop Day 2
Presentation Type: VideoLoop
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