Society: SSAT

To achieve adequate surgical exposure of the third portion of the duodenum, the Cattell-Braasch maneuver or right colon mobilization is generally required. However, completing right colon mobilization via a robotic approach is technically demanding, and the surgical view of the duodenum is often limited. The transmesocolic approach utilizes an avascular window on the right side of the mesocolon, between the middle or right colic artery and the ileocolic artery, and can achieve excellent exposure of the third portion of the duodenum. In this video, we demonstrate our robotic transmesocolic approach, which we used in three cases of duodenal operations.

Background: Pericardial hernia is a protrusion of abdominal viscera into the pericardial sac.

Case Presentation: 71-year-old male with idiopathic cardiomyopathy who underwent left ventricular assist device (LVAD) placement and subsequent heart transplant presented with nonspecific chest discomfort. On computed tomography, he was found to have a giant pericardial hernia containing transverse colon. He underwent robot-assisted laparoscopic pericardial hernia repair with Goretex mesh.

Conclusions: Pericardial diaphragmatic hernia is a rare complication of LVAD placement. A robot-assisted platform can be used to reduce the abdominal viscera and repair the diaphragmatic defect with mesh.

A 25 year old male with left side abdominal pain, on evaluation was found to have left posterolateral diaphragmatic hernia of defect size 7.1X 8.5 cm. There was herniation of stomach, spleen, splenic flexure of colon, omentum, body and tail of pancreas. He underwent robotic diaphragmatic hernia repair. Omentum, small bowel loops and large bowel loops were reduced. There was difficulty in reducing spleen, the defect was enlarged and spleen reduced. Defect was closed primarily with barbed suture. The defect was reinforced with composite mesh fixed with absorbable mechanical fixation device. Post procedure was uneventful.

This is a case of a 66-year-old man with recent diagnosis of pancreatic adenocarcinoma, currently, on chemotherapy, who presented for diagnostic EGD due to concerns for poor PO intake. He was found to have a gastric ulcer within the fundus with confirmed Mucormycosis on further testing. As a result, the patient's Whipple was placed temporarily on hold until this infection could be cleared. He was placed on a course of Posaconazole and surgery was ultimately consulted for definitive management where he underwent laparoscopic proximal partial gastrectomy with paraesophageal hernia repair. The patient tolerated the procedure well without any notable complications.

A 75-year-old woman presented with a 2cm iatrogenic esophageal perforation near the GEJ after a laparoscopic paraesophageal hernia repair, resulting in a 11x7x6cm intrathoracic abscess cavity. After an initial period of esophageal stenting, the patient underwent treatment with endoscopic vacuum assisted therapy. With twice weekly vacuum exchanges, the defect was closed after 3 weeks. The patient tolerated the procedures well, is tolerating a diet, and avoided the risks associated with major surgery.

The Jaboulay pyloroplasty is a well described procedure but has been a less common choice for pyloroplasty in recent years. We present that it is a safe and well tolerated form of stricturoplasty completed laparoscopically in appropriate patients. The patient is an 84 year old female with known hiatal hernia who was found to have organoaxial volvulus. She had a robotic hiatal hernia repair with Dor fundoplication. UGI was repeated due to worsening nausea and showed minimal gastric emptying. EGD showed fibrosis and narrowing of the pylorus and first portion of the duodenum. After discussion, we proceeded with laparoscopic Jaboulay which the patient tolerated well without complication.

A 60-year-old female with a prior transverse rectus abdominis flap for breast reconstruction presented for robotic repair of a recurrent incisional hernia. We began by taking down dense adhesions in the midline and right lower quadrant. Along the midline, we found a 3 x 3 cm hernia containing bowel where there was a previous mesh placement. We took down this hernia and closed the dead space of the eventration, fully reapproximating the area. We secured a 15 cm Symbatex mesh to the abdominal wall between the closure of the eventration and peritoneal flap. There were no complications, and the patient had no recurrence and was doing well on outpatient follow-up.

We present the case of a 75-year old male with a giant 5 cm gastric diverticulum incidentally found on CT enterography. Based on its size, we recommended laparoscopic diverticulectomy. Gastric diverticula are among the rarest gastrointestinal diverticula, with prevalence estimated at 0.02% by autopsy series. Most patients are asymptomatic, but gastric diverticula > 4 cm are typically resected due to higher rates of complications such as ulceration, bleeding, and malignancy. The video demonstrates the laparoscopic resection of the large posterior fundal diverticulum. The patient was discharged home on postoperative day 1 without complication. Pathology demonstrated no evidence of malignancy.

We present a case of a 47 year old woman with a 2.5cm submucosal mass located at the gastroesophageal junction. Given the location right at the junction and involving her flap valve, a stapled gastrectomy was not a viable approach, and therefore she required enucleation. This video presents our technical approach with both laparoscopy and endoscopy, key points in regard to successful enucleation of the entire mass, and strategies to avoid full thickness mucosal injuries. The patient did well post-operatively with no dysphagia and was discharged home post-operative day 1.

This is a 41-year-old woman with a history of a sleeve gastrectomy and re-sleeve in 2021 for weight regain, complicated by an early post-operative leak requiring exploration and drain placement. She had undergone multiple failed endoscopic approaches and presented to us with a chronic leak with a peri-splenic abscess, gastro-colonic, as well as gastro-bronchial fistulae. She required initial ICU care for pneumonia and sepsis before undergoing takedown of the gastro-bronchial fistula by thoracic surgery, followed by this case: conversion to a Roux-en-Y gastric bypass and repair of the colonic fistula. Post-operatively, she developed a controlled colonic leak managed by percutaneous drainage.

A 41 yo nonverbal male with Tetralogy of Fallot was referred for transfusion requiring GI bleeding. Endoscopy and colonoscopy did not reveal a bleeding source, and a video endoscopy capsule was placed; the capsule did not identify an active bleeding source and was retained. His hemoglobin stabilized but weeks later, KUB suggested the capsule was retained in his colon, overlying his liver. Colonoscopy did not encounter the capsule. Cross-sectional imaging was obtained and identified the capsule in an unusual portion of ileum positioned cephalad to the liver. We describe the surgical procedure to identify the anatomy and bleeding source, retrieve the capsule, and resect the bleeding source.

Cascade stomach is an uncommon anatomical variant. With a biloculated gastric body and a retroflexed, superior and posterior fundus on fluoroscopy or intraoperatively, it may present with symptoms of dysphagia, gastroparesis, obstruction, dyspepsia and reflux. Often, however, it is asymptomatic and difficult to diagnose. The true incidence is unknown. Due to the paucity of literature, management of symptomatic cascade stomach includes gastropexy, sleeve gastrectomy, gastro-gastrostomy, gastrojejunostomy, and fundoplication. We present a symptomatic patient with cascade stomach treated with ambulatory laparoscopic Nissen fundoplication.

Mark Reiner

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