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Laparoscopic re-operation for severe dysphagia following fundoplication and prosthetic reinforcement of the hiatus

Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported with no apparent relationship between mesh type and mesh configuration. The aim of this video is to show a case of mesh repair complication. A 50-year-old woman presented with severe dysphagia and important weight loss one year after redo laparoscopic Nissen fundoplication with prosthetic crural repair. At re-operation, important esophageal stenosis and angulation was found arising from the key-hole-shaped polypropylene mesh with pseudodiverticular dilatation of the distal esophagus. The esophagus was freed from the dense fibrotic capsule surrounding the prosthesis and a myotomy was performed.

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Laparoscopic   re-operation   for   severe   dysphagia   following   fundoplication   and   prosthetic   reinforcement   of   the   hiatus

作者群
B Dallemagne, S Perretta, J Marescaux
摘要
Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported with no apparent relationship between mesh type and mesh configuration. The aim of this video is to show a case of mesh repair complication.
A 50-year-old woman presented with severe dysphagia and important weight loss one year after redo laparoscopic Nissen fundoplication with prosthetic crural repair. At re-operation, important esophageal stenosis and angulation was found arising from the key-hole-shaped polypropylene mesh with pseudodiverticular dilatation of the distal esophagus. The esophagus was freed from the dense fibrotic capsule surrounding the prosthesis and a myotomy was performed.
分類
complex cases
關鍵字
Laparoscopic reoperation, severe dysphagia, fundoplication, prosthetic reinforcement, hiatus
媒體類型
期間
18'24''
刊物
2009-03
普通的
最愛
Favorites Media
音訊
en fr
副標題
en
數位出版
WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2518.htm

Laparoscopic   re-operation   for   severe   dysphagia   following   fundoplication   and   prosthetic   reinforcement   of   the   hiatus

3. Adhesiolysis 01'11''
The adhesiolysis was performed meticulously using scissors in order to preserve the different cleavage planes as much as possible. The trocars in this case are positioned in a usual fashion, the only difference being that we usually approach these abdomens via an open Hasson’s technique, or by a trocar in the left hypochondrium. By systematically freeing these adhesions, we manage to recreate different planes and to get access to the diaphragmatic hiatus. As soon as these adhesions are freed, we can see that the prosthetic material is covering the diaphragm. The prosthesis that was used in the previous procedure seems to be a double-sided mesh. The adhesions situated near the prosthesis are obviously packed tightly together and we can imagine that there is also an important fibrotic phenomenon around the esophagus. Here you see that a double-sided prosthesis does not prevent the formation of adhesions, the only difference being that these adhesions are usually easier to take down in comparison to conventional prosthesis. The freeing of the left lobe’s inferior surface is performed in the same meticulous way, scissors with monopolar coagulation are used and are usually the best instrument for this operative step. When performing these re-operations, it is important to be able to find the main landmarks, especially for surgery on the lower esophagus; these landmarks are the diaphragmatic crura, on the left or on the right. Depending on how easy the dissection is, we will tend to work more to the right or to the left side, but generally we will try to find the easiest access route, especially with such dense adhesions. The sutures are found as in this case; this is also a good guide and helps to orientate the dissection. In fact, the sutures are usually placed around the fundoplication wrap. The dissection of the left lobe’s inferior surface and the identification of the segment 1 of the liver that we can see here is important because we know that just superior to it lies the right diaphragmatic crus. Once again, the adhesions are tightly packed together around the liver’s inferior surface. We continue the diaphragm’s freeing, while on the left of the screen, we can see the position of the vena cava: we realize just how close the vena cava is to the prosthesis, and how that may lead to serious complications.
6. Circumferential esophageal dissection 06'03''
Because the distal obstruction of the esophagus is caused by the prosthesis, we will free all the circumference of the esophagus from the adhesions. This freeing is sometimes difficult and the view of the different cleavage planes is therefore very important: the only option we have in these types of re-operations is to remove these extremely dense fibrotic bands. We can see just how tightly it surrounds the esophagus and we can guess that it would eventually cause erosions of the esophageal wall and, in some cases, migration phenomenons at the level of the lumen. On this part of the dissection, the adhesions are very dense, and the contact between the esophageal wall and the prosthesis is very clear. The way the prosthesis has been placed and tailored is probably the least recommended: the prosthesis, in fact, surrounds the esophagus completely when we know that the retraction phenomenon that the prosthesis will undergo will undeniably impact on the esophagus. We therefore recommend to use U-shaped prosthesis, and especially posterior ones as they are less dangerous. We can see here that the mesh is being freed from the liver’s segment 1. It is obvious that we are trying not to leave too many prosthetic elements in the peritoneal cavity, especially after seeing just how close the prosthesis is to the inferior vena cava. The hiatal orifice is gradually enlarged; the dissection continues to resect anything that may be in contact with the esophagus. The aim is to restore a muscular contact between the esophagus and the hiatal orifice. Using other types of material such as biological prosthesis at the level of the diaphragm seems to reduce the formation of adhesions, or even the migration phenomenon at the level of the esophagus.