AUTOLOGOUS POSTERIOR RECTUS SHEATH AS A VASCULARIZED ONLAY FLAP: A NOVEL APPROACH TO HIATAL HERNIA REPAIR

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.