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Robotic Sleeve Gastrectomy, Hiatal Hernia Repair and Dor Fundoplication In Patient With Symptomatic Gerd
S38
Video Sessions / Surgery for Obesity and Related Diseases 11 (2015) S35–S42
association with LRYGB is still up for debate. Another complications that requires great technical skill to repair is an incarcarated roux limb in a paraesophageal hernia. We present a case report of a young female who presents with a recurrent roux limb incarceration through her paraesophageal hernia. What are our options to prevent this from occurring multiple times? Case Report This is a case report of a 32yo female who originally underwent a LRYGB with a concomitant primary hiatal hernia repair in May 2010. In 2013 she underwent an internal hernia repair after losing 4 50% EWL. A year later in 2014, she incarcerated part of her roux limb along with colon into her paraesophaeal hernia which was repaired laparoscopically with biologic Alloderm mesh reinforcement. She now subsequently presents with acute incarceration of her entire roux limb once again through the paraesophageal hernia. BMI was 36 kg/m2, presented with acute onset abdominal pain in the left upper quadrant, radiating to her back, associated with sudden onset of shortness of breath, nausea, and vomiting. Past history included lupus, fibromyalgia, and hypothyroidism. She underwent a CT which revealed half of her left lung displaced by her entire roux limb. The herniated roux limb was reduced laparsocpically, the crura was closed with non-absorbable pledgetted sutures, reinforced with a 4x3cm Alloderm mesh, and a Dor-like wrap to add bulk to try and prevent re-incarceration. At 1 month follow-up she has bounced back once again, tolerating stage 4 bariatric diet, but still requiring Prilosec for heartburn symptoms. In this video we demonstrate the difficult challenge of repairing a recurrent problem with a novel apporach. The formation of the "mini-Dor" fundoplication could serve as a partial anti-reflux procedure, but more importantly in this patient, as a barrier to prevent future incarcerations. These difficult operations, even in an acute setting, can still be performed laparoscopically in experienced hands.
A163
ROBOTIC SLEEVE GASTRECTOMY, HIATAL HERNIA REPAIR AND DOR FUNDOPLICATION IN PATIENT WITH SYMPTOMATIC GERD Rena Moon, MD; Andre Teixeira, MD; Muhammad Jawad, MD; Orlando Regional Medical Center, Orlando, FL, USA Introduction: 57 year old female with BMI 39 with severe symptomatic reflux and multiple comorbidities requiring weight loss surgery. Materials and Methods: Veress needle was inserted in left upper quadrant. Abdomen was insufflated. Trocars were inserted. The hiatus was dissected out using hook electrocautery. The pars was dissected off the esophagus and esophagus was mobilized. Te vagus nerves were visualized and protected. A retroesophageal windiw was created allowing the dissection of both the left and right crus. Sleeve gastrectomy performed in usual fashion with stapling along 34 Fr Edlich tube until high on fundus where extra room was left along tube. Hiatal hernia was repaired primarily with figure of eight Ethibond suture. Sleeve staple line was oversewn with 2-0 Polysorb. Anterior fundoplication was performed by tacking remaining fundus over GE junction to right crura. Result: Patient was discharged on POD 1 after UGI did not show leak or reflux. She was readmitted 2 weeks later for nausea and vomiting. UGI showed narrowing of the incisura angularis, but the
contrast passed without difficulty. Patient underwent endoscopic dilation, and had stent placement. Conclusion: In patients with severe reflux with morbid obesity unwilling or unable to undergo gastric bypass, sleeve gastrectomy with Dor fundoplication could be a viable alternative.
A164
UNDO OF GASTRIC PLICATION WITH CONVERSION TO SLEEVE GASTRECTOMY Dip Fernando, MD; David Nguyen, MD; Alex Ordonez, MD; Emanuele Lo Menzo, MD PhD; Samuel Szomstein, MD FACS FASMB; Raul Rosenthal, MD; Cleveland Clinic Florida, Weston, FL, USA Introduction: Gastric greater curvature plication is a relatively new restrictive procedure that could be potentially reversible, involves no removal of tissue, and does not have a significant malabsorptive component. Although early reports are favorable, weight loss following gastric plication remains unclear long term. Methods: We present a case of a 43 year old female, BMI 31.14 kg/m2, with weight regain, failure of weight loss, and epigastric pain after laparoscopic gastric plication 1 year prior at an outside institution. Upper gastrointestinal series and esophagogastroduodenoscopy demonstrated postoperative appearance of the stomach consistent with prior gastric plication. Optical and accessory trocars were placed in subxiphoid area, right, mid, left upper quadrant abdomen as well as in the left mid quadrant abdomen. The liver was cranially retracted. With the pylorus identified and the use of cold scissors, the suture line was transected. The plication was undone without any entrance into the gastric lumen. An intraoperative esophagogastroduodenoscopy was performed to verify that no plication remained. Using the endoscope as the guide, sleeve gastrectomy was performed using 4.1 mm linear stapler from the prepyloric area to the GE junction. The staple lines were oversewn with a running vicryl suture. Fibrin glue was placed over the staple line and a drain placed in the subhepatic space. Results: The patient tolerated the procedure well with minimal blood loss. Upper GI with gastrografin demonstrated no sign of leak. The patient was discharged home on post-operative Day 3 with a pureed diet. Two week follow-up was unremarkable. Conclusion: Although gastric plication is associated with minimal risk of leaks and nutritional deficiency, long-term studies are needed to define the role of gastric plication in treating obesity. In comparing gastric plication and sleeve gastrectomy, literature has demonstrated sleeve gastrectomy to achieve a higher weight loss.
A165
REVISIONAL SADI FOR WEIGHT REGAIN IN SLEEVE GASTRECTOMY David Williams, MD1; Bradley Schwack, MD2; Christine RenFielding, MD2; George Fielding, MD2; Marina Kurian, MD3; 1 NYU, New York, NY, USA; 2NYU SOM, New York, NY, USA; 3NY Minimally Invasive Surgery, New York, NY, USA We present the case of a 37 year old female who has regained weight post sleeve gastrectomy. Her current BMI is 48.6. Her past
Video Sessions / Surgery for Obesity and Related Diseases 11 (2015) S35–S42
association with LRYGB is still up for debate. Another complications that requires great technical skill to repair is an incarcarated roux limb in a paraesophageal hernia. We present a case report of a young female who presents with a recurrent roux limb incarceration through her paraesophageal hernia. What are our options to prevent this from occurring multiple times? Case Report This is a case report of a 32yo female who originally underwent a LRYGB with a concomitant primary hiatal hernia repair in May 2010. In 2013 she underwent an internal hernia repair after losing 4 50% EWL. A year later in 2014, she incarcerated part of her roux limb along with colon into her paraesophaeal hernia which was repaired laparoscopically with biologic Alloderm mesh reinforcement. She now subsequently presents with acute incarceration of her entire roux limb once again through the paraesophageal hernia. BMI was 36 kg/m2, presented with acute onset abdominal pain in the left upper quadrant, radiating to her back, associated with sudden onset of shortness of breath, nausea, and vomiting. Past history included lupus, fibromyalgia, and hypothyroidism. She underwent a CT which revealed half of her left lung displaced by her entire roux limb. The herniated roux limb was reduced laparsocpically, the crura was closed with non-absorbable pledgetted sutures, reinforced with a 4x3cm Alloderm mesh, and a Dor-like wrap to add bulk to try and prevent re-incarceration. At 1 month follow-up she has bounced back once again, tolerating stage 4 bariatric diet, but still requiring Prilosec for heartburn symptoms. In this video we demonstrate the difficult challenge of repairing a recurrent problem with a novel apporach. The formation of the "mini-Dor" fundoplication could serve as a partial anti-reflux procedure, but more importantly in this patient, as a barrier to prevent future incarcerations. These difficult operations, even in an acute setting, can still be performed laparoscopically in experienced hands.
A163
ROBOTIC SLEEVE GASTRECTOMY, HIATAL HERNIA REPAIR AND DOR FUNDOPLICATION IN PATIENT WITH SYMPTOMATIC GERD Rena Moon, MD; Andre Teixeira, MD; Muhammad Jawad, MD; Orlando Regional Medical Center, Orlando, FL, USA Introduction: 57 year old female with BMI 39 with severe symptomatic reflux and multiple comorbidities requiring weight loss surgery. Materials and Methods: Veress needle was inserted in left upper quadrant. Abdomen was insufflated. Trocars were inserted. The hiatus was dissected out using hook electrocautery. The pars was dissected off the esophagus and esophagus was mobilized. Te vagus nerves were visualized and protected. A retroesophageal windiw was created allowing the dissection of both the left and right crus. Sleeve gastrectomy performed in usual fashion with stapling along 34 Fr Edlich tube until high on fundus where extra room was left along tube. Hiatal hernia was repaired primarily with figure of eight Ethibond suture. Sleeve staple line was oversewn with 2-0 Polysorb. Anterior fundoplication was performed by tacking remaining fundus over GE junction to right crura. Result: Patient was discharged on POD 1 after UGI did not show leak or reflux. She was readmitted 2 weeks later for nausea and vomiting. UGI showed narrowing of the incisura angularis, but the
contrast passed without difficulty. Patient underwent endoscopic dilation, and had stent placement. Conclusion: In patients with severe reflux with morbid obesity unwilling or unable to undergo gastric bypass, sleeve gastrectomy with Dor fundoplication could be a viable alternative.
A164
UNDO OF GASTRIC PLICATION WITH CONVERSION TO SLEEVE GASTRECTOMY Dip Fernando, MD; David Nguyen, MD; Alex Ordonez, MD; Emanuele Lo Menzo, MD PhD; Samuel Szomstein, MD FACS FASMB; Raul Rosenthal, MD; Cleveland Clinic Florida, Weston, FL, USA Introduction: Gastric greater curvature plication is a relatively new restrictive procedure that could be potentially reversible, involves no removal of tissue, and does not have a significant malabsorptive component. Although early reports are favorable, weight loss following gastric plication remains unclear long term. Methods: We present a case of a 43 year old female, BMI 31.14 kg/m2, with weight regain, failure of weight loss, and epigastric pain after laparoscopic gastric plication 1 year prior at an outside institution. Upper gastrointestinal series and esophagogastroduodenoscopy demonstrated postoperative appearance of the stomach consistent with prior gastric plication. Optical and accessory trocars were placed in subxiphoid area, right, mid, left upper quadrant abdomen as well as in the left mid quadrant abdomen. The liver was cranially retracted. With the pylorus identified and the use of cold scissors, the suture line was transected. The plication was undone without any entrance into the gastric lumen. An intraoperative esophagogastroduodenoscopy was performed to verify that no plication remained. Using the endoscope as the guide, sleeve gastrectomy was performed using 4.1 mm linear stapler from the prepyloric area to the GE junction. The staple lines were oversewn with a running vicryl suture. Fibrin glue was placed over the staple line and a drain placed in the subhepatic space. Results: The patient tolerated the procedure well with minimal blood loss. Upper GI with gastrografin demonstrated no sign of leak. The patient was discharged home on post-operative Day 3 with a pureed diet. Two week follow-up was unremarkable. Conclusion: Although gastric plication is associated with minimal risk of leaks and nutritional deficiency, long-term studies are needed to define the role of gastric plication in treating obesity. In comparing gastric plication and sleeve gastrectomy, literature has demonstrated sleeve gastrectomy to achieve a higher weight loss.
A165
REVISIONAL SADI FOR WEIGHT REGAIN IN SLEEVE GASTRECTOMY David Williams, MD1; Bradley Schwack, MD2; Christine RenFielding, MD2; George Fielding, MD2; Marina Kurian, MD3; 1 NYU, New York, NY, USA; 2NYU SOM, New York, NY, USA; 3NY Minimally Invasive Surgery, New York, NY, USA We present the case of a 37 year old female who has regained weight post sleeve gastrectomy. Her current BMI is 48.6. Her past