Robotic Transoral Incisionless Fundoplication Takedown, Esophageal Diverticulum And Hiatal Hernia Repair.
John K. Sadeghi, MD1, Nosayaba Enofe, MD, MPH2, Roman Petrov, MD, PhD, MBA3, Zubair Malik, MD1, Charles T. Bakhos, MD, MBA1.
1Temple University Health System, Philadelphia, PA, USA, 2Fox Chase Cancer Center, Philadelphia, PA, USA, 3The University of Texas Medical Branch, Galveston, TX, USA.
BACKGROUND: Complications from transoral incisionless fundoplication (TIF) including TIF herniation and esophageal diverticulum are rarely reported and can be difficult to manage when they occur. We describe our experience with a rarely reported TIF complication using a minimally invasive surgical approach.
METHODS: A 69-year-old man with pulmonary fibrosis and COPD underwent a left lung transplant. The patient also had GERD and was found to have a 2 cm hiatal hernia by high resolution manometry. He underwent a TIF procedure but developed worsening symptoms and reflux after 6 months. He was then found to have a distal esophageal diverticulum with a 1 cm hiatal hernia, severe reflux on pH impedance, and concern for TIF herniation. We review the key steps to a robotic TIF takedown and esophageal diverticulum repair in this complex patient.
RESULTS: Key steps include: Intra-operative esophagogastroduodenoscopy and distal esophageal diverticulum identification. Division of the gastrohepatic ligament and identification of the right crus. Circumferential hernia sac dissection and identification of the left crus. Identification of the polypropylene TIF fasteners with extensive peri-hiatal adhesiolysis from the post-TIF inflammatory process. Identification and protection of the Vagi nerves. Greater curvature mobilization and short gastric transection. TIF hernia reduction and wrap take down. Intrathoracic esophageal mobilization and dissection to ensure at least 3 cm of intra-abdominal esophagus without tension. False esophageal diverticulum with wide neck about 2 - 3 cm long exposure. Muscle imbrication over the diverticulum to avoid introducing a staple line in an immunocompromised patient. Cruroplasty and gastropexy to recreate the angle of HIS. No fundoplication due to the diverticulum in the lumen of the esophagus and concern for mechanical obstruction potentially leading to future worsening of the diverticulum.
CONCLUSIONS: TIF may not be an adequate option for patients with GERD in the setting of small (up to 2 cm) hiatal hernias. Patient selection is key to avoiding serious complications which can be successfully managed with a robotic-assisted approach. In our practice, we currently reserve TIF to patients with GERD and no documented hernia on the pre-operative work-up.
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