Society: SSAT

53-year-old female with a past medical history of hypertension, hiatal hernia and gastroesophageal reflux disease (GERD) presented with daily heartburn (improved by PPIs), regurgitation, and chronic cough. Upper endoscopy revealed 7 cm hiatal hernia, LA class C esophagitis and hill-grade 3-4. Esophageal biopsies were negative for eosinophilic esophagitis. Manometry showed IRP 4.9 mm and weak or absent contractility. Gastric emptying study revealed no delay. Patient underwent laparoscopic hiatal hernia repair with concomitant transoral incisionless fundoplication (cTIF). Postoperative endoscopy showed created omega shape valve. Patient was discharged postoperative day 1 without complications.

Esophageal diverticula are a rare pathology afflicting a small number of patients. This is a unique case of a robotic assisted excision of an epiphrenic diverticulum with a Heller Myotomy in a 45 year old female diagnosed with Achalasia. While Achalasia is the most common of the esophageal motility disorders, it is still a rare pathology and much more so when associated a diverticulum. The patient presented to clinic with complaints of dysphagia, weight loss, regurgitation, and sensation of food becoming stuck at the level of her upper chest. The video demonstrates the approach to an epiphrenic diverticulectomy and the associated Heller Myotomy.

A 42-year old female patient presented with dysphagia. Computer tomography showed an 41mm x 45mm mass in the thoracic esophagus. Endosopic ultrasound diagnosed a round tumor originating from the submucosa, suspicious of a leiomyoma. A robotic enucleation was performed with the daVinci Xi-System. Pleura and esophageal muscle was incised longitudinally, the leiomyoma was dissected, the mucosa remained intact. Subsequently, the muscle and the pleura both were reconstructed with a 3x0 running suture. Operation time was 65 minutes, the blood loss was 0. Postoperative course was uneventful and the patient was discharged on postoperative day 3.

Successful paraesophageal hernia (PEH) repairs are a challenge with high recurrence rates despite use of mesh and other techniques. Here we report the novel use of the posterior rectus sheath as a vascularized flap to repair a recurrent paraesophageal hernia.

We hypothesize the use of a large fascial patch provides dynamic tensile strength with a peritonealized surface to reconstruct the hiatal complex, while reducing risks of adhesions, strictures, and erosion with mesh. This technique can further be enhanced with diaphragmatic relaxing incisions as shown in this video. We believe this technique shows promise to enhance repairs of difficult PEH with minimal deviation from standard repairs.

The vacuum-stent is a novel device for treatment of anastomotic leakage after esophagectomy, combining benefits of endoscopic vacuum therapy and an intraluminal stent. During vacuum-stent treatment, patients can use a soft diet.

A 66-year-old male developed anastomotic leakage after Ivor Lewis esophagectomy. Endoscopy showed a defect at the intrathoracic anastomosis, with access to the mediastinum. A vacuum-stent was placed over the defect and exchanged after one week. After a total of two weeks, it was removed and defect closure was confirmed by CT-scan with oral contrast. After three months follow-up, the patient had normal intake and no signs of stenosis.

This video depicts a robotic THE undertaken in a 72-year-old woman with a severe esophageal stricture. Dissection in the mediastinum was undertaken and circumstantially around the esophagus. A pyloromyotomy was undertaken utilizing a robotic hook-cautery. The stomach was opened proximally along the ventral surface and the migrated stents were removed.
An incision along the sternocleidomastoid muscle was made and the carotid artery and internal jugular vein were retracted. The esophagogastrostomy anastomosis was completed with robotic stapler and the defect was closed with interrupted silk sutures. THE can safely be undertaken robotically with minimal blood loss, reaping the benefits of MIS.

We present a case of refractory gastroesophageal reflux disease in patient with four previous anti-reflux operations. The patient is a 34-year-old female with a history of cystic fibrosis. Surgical history includes two Toupe fundoplication’s, a Nissen fundoplication and an open hiatal hernia repair with gastropexy. Preoperative work up was consistent with gastroesophageal reflux disease. We took the patient to the operating room for a subtotal gastrectomy with a Roux-en-Y reconstruction. The abdomen and hiatus were hostile leading to a difficult dissection. The patient did well post operatively.

We demonstrate a successful robotic approach to a massive epiphrenic diverticulum. The patient is a 75 year old female presenting with dysphagia and GERD. Pre-operative manometry was diagnostic for achalasia and timed barium swallow, along with upper endoscopy, demonstrated a large epiphrenic diverticulum in the distal esophagus. The patient underwent a robotic, laparoscopic-assisted diverticulectomy, heller myotomy and hiatal hernia repair with omental flap buttress over the myotomy. Post-operative esophagram showed no evidence of leak or perforation. The patient had no complications and experienced symptomatic improvement.

Introduction: Leiomyomas are excised by enucleation. Method: A large mediastinal esophageal leiomyoma was diagnosed in a 69-year-old male with dysphagia to solids. Results: the mass was excised laparoscopically. It was mobilized from the pericardium and the aorta. Enucleation was performed. The operation lasted 2 hours 49 minutes with minimal EBL. The patient was discharged the same-day of surgery, tolerating liquids. At 6-months he’s free of symptoms and eats as desired. Final pathology confirmed leiomyoma. Conclusion: Excision of a large mediastinal esophageal leiomyoma can be performed laparoscopically in the same-day surgery setting with good outcomes.

We demonstrate the successful repair of a Type IV paraesophageal hernia using a robotic laparoscopic-assisted approach. A 73 year-old female presented with intermittent pain in the lower right abdominal quadrant. CT imaging revealed a Type IV paraesophageal hernia with herniated stomach and a portion of transverse colon. Collis gastroplasty and diaphragm release were performed in order to obtain adequate intra-abdominal esophageal length and repair of the diaphragm crus without tension. The repair was reinforced with mesh, Toupet fundoplication, and gastropexy were performed. Post-operatively, the patient had symptomatic improvement without complication.

Dominique Cook

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LARGE PARAESOPHAGEAL HERNIA REPAIR: SURGICAL PEARLS

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