with Dr. Salvadora Delgado, Dr. Dulce Momblán
A 64 year old male patient with previous history of Nissen fundoplication by laparoscopy and diagnosis of Adenocarcinoma of distal esophagus, which by clinical staging was a T3N1 lesion, received neoadjuvant therapy and then underwent an Ivor Lewis procedure by minimally invasive approach.
At surgery the Nissen was twisted. The pathology revealed a T2N1 tumor and received adjuvant therapy.
Three months after surgery the patient complained of dysphagia, nevertheless upper GI series showed good progression of the contrast.
Six months later the dysphagia was persistent and the study was amplified with a CT Scan which described an hiatal hernia containing the small bowel and a portion of the transverse colon at the left thorax.
Programmed surgical treatment was proposed but the patient continued presenting pain despite analgesia and went to the emergency room, after evaluation a CT Scan was performed showing bowel suffering (edematous wall of the guts and liquid) and required emergency surgical treatment.
The operation was performed by laparoscopy with the patient in supine position. Five trocars were placed, using the same location than the abdominal time of the Ivor Lewis procedure. Two of 12 mm, one in the supra umbilical position and the other in the left side Three of 5 mm, one on each side and the last one in the epigastrium.
At surgery there was mild dilation of the colon and some free abdominal fluid. The goal of the surgery is to restore the bowel to its anatomical position.
Traction of the major epiplon is accomplished with the help of laparoscopic DeBakey clamps, step by step the transverse colon is pulled into the abdomen. These should be smooth movements to avoid unexpected injuries.
Transhiatal exploration was made to identify a loop of small bowel and continue with the reduction of the hernia. The assistant surgeon helps with the manipulation of the small bowel shortening the surgical time.
There was edema of the guts and some ecchymosis at the mesenterium due to the compression inside of the hernia. One of the clamps was placed through the hiatus amplifying the defect and improving the maneuvers of traction.
The Ligasure™ is used to take down some adhesion of the epiplon to the crura leaving the hiatus exposed for evaluation. The surgeon corroborates that the crura and the diaphragm can be used to close the defect.
Three knots were performed with silk suture, the assistant helps with the needle-holder to avoid losing the tension of the first one. A drain was placed for postoperative surveillance.
The surgery took 85 minutes, there were no complications.
The patient started oral intake 2 days after surgery and left the hospital at the 4th postoperative day.
The last follow-up was 1 month after surgery with a CT Scan that ruled out relapse.
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