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.

Theo Sher

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