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Robotic Redo Paraesophageal Hernia Repair Following a Nissen Fundoplication

Tuesday, October 8, 2024

By

Samantha Bale

Bale S, Nischwitz E, Hammar A, Thaqi M, Wiesemann S, Kaifi J. Robotic Redo Paraesophageal Hernia Repair Following a Nissen Fundoplication. October 2024. doi:10.25373/ctsnet.27188571

The patient was a 68-year-old male with a history of type 3 paraesophageal hernia (PEH) recurrence post receiving a Nissen fundoplication and an attempted robotic repair one year prior. The repair was aborted intraoperatively due to respiratory decline and hypercapnia. His past medical history was also notable for Cameron's ulcers, chronic obstructive pulmonary disease (COPD), gastroparesis, gastroesophageal reflux disease (GERD), hypertension (HTN), obesity, and obstructive sleep apnea (OSA). The patient underwent a repeat preoperative work-up, which included a CT scan of the abdomen and pelvis, upper gastrointestinal X-ray with LINX, an esophagogastroduodenoscopy (EGD), and a transthoracic echocardiogram (TTE). Due to the complexity of the case and the requirement for both abdominal and thoracic entry, both general and thoracic surgery teams participated in the procedure. The postoperative course was significant for bilateral parietal watershed infarcts, which required ICU admission. The patient was discharged on postoperative day 11 to an inpatient rehabilitation facility, at which time he tolerated an oral diet. 

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Comments

Submitted by Georges Decker on
Thank you for sharing this highly complex case that raises many questions far beyond any discussion on the utility of robotic support for such REDO paraesophageal hiatal hernia operations. One may hope that the patients symptoms before the index operation were worth this calvary. A few thoughts arise from your video presentation: 1) Gastroparesia was probably du to vagal injury at the initial operation or first aborted REDO. Obviously none of the 2 vagal nerves was visible or salvable/preserved in your REDO hence leading to need for a gastrostomy. 2) As known, the initial biological mesh did nothing to prevent the recurrence but made your reoperation much more difficult. 3) What was the duration of this whole 3 phase-2 team robotic procedure? You mentioned that the initial adhesiolysis during the first phase took already more than 4 hours? 4) Most likely this very long procedure time contributed to the major complication of bilateral cerebral infarction (Clavien-Dindo 4). 5) Rather than merely showing a "robotic heroic act" a more patient-centered follow-up status might have been a worthy addition to your video report. Is he free from another hernia recurrence? Was his clinical status at follow-up better than before this very complex REDO?

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