Take Down of Nissen Fundoplication and Completion of Prior Sleeve Gastrectomy

Kelvin Higa, MD FACS, Saber Ghiassi, MD MPH, Ruby Gatschet, MD, Keith Boone, MD FACS. University of California, San Francisco, Fresno

Patient is a 52 year-old woman with history of chronic abdominal pain and vomiting since laparoscopic sleeve gastrectomy at an outside hospital one year ago. That hospitalization was complicated by early postoperative small bowel obstruction that required open exploration, lysis of adhesions and small bowel resection. Past surgical history is also significant for laparoscopic Nissen fundoplication for treatment of reflux three years ago, open cholecystectomy and appendectomy, and total abdominal hysterectomy and bilateral salpingo-oophorectomy, followed by radiation therapy for ovarian cancer 30 years ago. Upper endoscopy was suspicious for intact fundoplication and CT scan revealed chronic partial small bowel obstruction. She was taken to the operating room for diagnostic laparoscopy. After Optiview entry, several ports were placed to take down the dense abdominal wall adhesions. All adhesions to anterior abdominal wall were taken down, with particular attention to the area of the chronic bowel obstruction on imaging. In doing so, inadvertent injury to the transverse colon was made. This was repaired with interrupted 3-0 Vicryl suture. The dense adhesions underneath the liver to the stomach and around the esophageal hiatus were taken down. The Nissen fundoplication was almost entirely intact, with pledgets remaining, and it had not been taken down during the previous sleeve gastrectomy. The right and left crura of the diaphragm were dissected and the fundoplication was taken down. Upper endoscopy was then performed to ensure that the wrap was completely undone. The endoscope was left along the lesser curve and the gastric fundus was transected with an endoscopic stapler to complete the sleeve gastrectomy. The staple line was suture imbricated and air leak test was negative. Drains were placed along the staple line and transverse colon. Patient was started on clear liquids on postoperative day one. She was discharged home on postoperative day seven due to pain management. Drains were removed prior to discharge. Her symptoms had resolved on follow-up visit in the clinic.