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Management of a hiatal hernia during laparoscopic Roux-en-Y gastric bypass: be ready to repair

Here we show the case of a 44-year-old woman with a BMI of 40.5 and a history of gastroesophageal reflux disease. She was presented for a weight reductive surgery evaluation. Preoperative esophagogastroduodenoscopy, barium swallow and esophageal high resolution manometry were performed. They demonstrated a 3cm hiatal hernia as well as a hypotensive lower esophageal sphincter. The presence of a large hiatal hernia (greater than 5cm) is problematic and may prevent successful weight reductive surgery. Laparoscopic Roux-en-Y gastric bypass is an effective procedure to control symptoms and GERD complications in morbidly obese patients. For this reason, Roux-en-Y gastric bypass is a valid alternative to manage morbidly obese patients with symptomatic hiatal hernia and GERD. Bsed on the preoperative work-up, decision was made to perform a concomitant paraesophageal hernia repair and a laparoscopic Roux-en-Y gastric bypass.

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Management of a hiatal hernia during laparoscopic Roux-en-Y gastric bypass: be ready to repair

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S Perretta, J Marescaux

摘要

Here we show the case of a 44-year-old woman with a BMI of 40.5 and a history of gastroesophageal reflux disease. She was presented for a weight reductive surgery evaluation. Preoperative esophagogastroduodenoscopy, barium swallow and esophageal high resolution manometry were performed. They demonstrated a 3cm hiatal hernia as well as a hypotensive lower esophageal sphincter.
The presence of a large hiatal hernia (greater than 5cm) is problematic and may prevent successful weight reductive surgery. Laparoscopic Roux-en-Y gastric bypass is an effective procedure to control symptoms and GERD complications in morbidly obese patients. For this reason, Roux-en-Y gastric bypass is a valid alternative to manage morbidly obese patients with symptomatic hiatal hernia and GERD.
Bsed on the preoperative work-up, decision was made to perform a concomitant paraesophageal hernia repair and a laparoscopic Roux-en-Y gastric bypass.

關鍵字

hiatal hernia, laparoscopic Roux-en-Y gastric bypass

媒體類型

手術影片

期間

13'22''

刊物

2012-01

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最愛

Favorites Media

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副標題

數位出版

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3474.htm

Management of a hiatal hernia during laparoscopic Roux-en-Y gastric bypass: be ready to repair

1. Case presentation and beginning of procedure 00'07''

Here we show the case of a 44-year-old woman with a BMI of 40.5 and a history of gastroesophageal reflux disease. She was presented for a weight reductive surgery evaluation. Preoperative esophagogastroduodenoscopy, barium swallow and esophageal high resolution manometry were performed. They demonstrated a 3cm hiatal hernia as well as a hypotensive lower esophageal sphincter. The presence of a large hiatal hernia (greater than 5cm) is problematic and may prevent successful weight reductive surgery. Laparoscopic Roux-en-Y gastric bypass is an effective procedure to control symptoms and GERD complications in morbidly obese patients. For this reason, Roux-en-Y gastric bypass is a valid alternative to manage morbidly obese patients with symptomatic hiatal hernia and GERD. Here we show the case of a concomitant paraesophageal hernia repair and a laparoscopic Roux-en-Y gastric bypass. Once the trocars have been placed, the procedure begins with the division of the omentum in order to prepare for the Roux limb. The omental division also helps to prepare the exposure of the colon in order to identify the duodenojejunal flexure. The omentum is lifted upwards in order to be divided using the Ligasure™ vessel-sealing device.

2. Identification of duodenojejunal flexure and measurements 01'36''

The division of the omentum has contributed to the exposure of the transverse mesocolon. It helps to easily identify Treitz’s flexure. The biliary limb is measured by being placed entirely in the left hypochondrium. It is about 75cm in length and will be attached to the stomach by a stitch, which is used as a landmark.

3. Jejunojejunal limb measurement 02'09''

The alimentary limb is measured over 150cm. It is fixed to the biliary loop by a stitch to prepare for the anastomosis at the foot of the loop.

4. Jejunojejunal anastomosis 03'20''

The two loops are opened to introduce a 60mm linear stapler, white cartridge, to perform the anastomosis. The remaining enterotomy is closed by a running suture.

5. Closure of the mesenteric gap 04'26''

The mesenteric gap originating from the jejunojejunal anastomosis is re-approximated using a running non-absorbable suture.

6. Hiatal exposure 04'47''

The left lobe of the liver is retracted cephalad and laterally to visualize the hiatus. Following adequate hiatal exposure, the pars condensa of the lesser omentum is opened while making sure to preserve the hepatic branch of the vagus nerve and the left hepatic artery. The initial dissection should identify the essential structures: the diaphragmatic crura, the esophagus, the vagus nerves, the mediastinal pleura, and the aorta. Identification of these landmarks is essential, if not mandatory. The right crus is particularly essential to guide the dissection and needs to be identified before beginning the dissection of the esophagus. It can be particularly challenging in obese patients. A dissection performed blindly could well lead to potential serious injury. The intrathoracic dissection of the esophagus is a fundamental step of the operation, which lengthens the abdominal portion of the esophagus. This portion should be at least 2 to 3cm long without tension. The vagus nerves are identified and protected. Once the esophagus has been fully mobilized over an umbilical tape, a posterior cruroplasty is performed. The esophagus is retracted distally from the crura using the loop that is passed around the gastroesophageal junction. Interrupted non-absorbable sutures are placed on the crura to repair the hiatal defect posterior to the esophagus. An additional anterior stitch is added to complete the repair.

7. Gastric pouch calibration 08'51''

Now to the gastrojejunal anastomosis. The future gastric pouch is calibrated at 25mL to determine the first line of transection. This first line is perpendicular to the axis of the esophagus. The second line is parallel. The dissection of the gastric pouch begins between the first and second vascular arcades on the lesser curvature. The dissection begins on the right edge of the stomach. The lesser omentum is incised, and the posterior gastric surface is dissected over 3 to 4cm, perpendicular to the axis of the esophagus. The linear stapler is introduced through the right hypochondrium port. The stomach is retracted caudally, the gastric tube removed, and the stapler fired. The dissection is then pursued cephalad, towards the angle of His, along the posterior surface of the stomach. The left margin of the left crus has already been exposed and is easily identified. A linear stapler (60mm cartridge, 3.5mm staples) is fired to completely divide the remainder of the stomach. The anesthesiologist pushes the orogastric tube through the esophagus down to the proximal gastric pouch under direct vision. An incision just over the bulging tip of the orogastric tube at the gastric staple line is made a few millimeters in length at the corner between the horizontal and vertical staple line. The tube is then retrieved into the abdominal cavity and extracted through port B until the center rod of the anvil appears. The anvil is freed from the orogastric tube and the gastrojejunal anastomosis is performed using a 25 round stapler. The operation ends with the closure of Petersen’s space.

8. Follow-up 13'33''

A postoperative water-soluble contrast study showed complete reduction of the hiatal hernia and no evidence of contrast extravasation or obstruction. The postoperative course was uneventful. Three months after surgery, the patient has had resolution of her GERD symptoms, and a 40% excess body weight loss. Laparoscopic crural closure in addition to Roux-en-Y gastric bypass can be a valuable option for the synchronous management of morbid obesity and hiatal hernia providing good outcomes in terms of weight loss and control of GERD symptoms.