with Dr. Salvadora Delgado, Dr. Ainitze Ibarzabal
A 50 year old female with a previous history of HBP (treated with two drugs) T2DM (treated with oral antidiabetics) and dyslipidemia. She suffered from morbid obesity and had a BMI of 52 Kg/m2. She had tried diet and exercise and lost only 5 kg.
Surgical treatment was proposed. During the preoperative evaluation she complained of heartburn and acid reflux. Further study revealed a hiatal hernia with a preserved mucosa.
The patient was placed in the supine position with opened legs. The leading surgeon stood between the patient´s legs with one assistant at each side.
A total of 5 trocars are recommended. The classic configuration is a 12mm port in the supra umbilical position for a 30º scope, two additional 12-mm ports at each flank to serve as the working channel for the leading surgeon, two 5mm ports located at the epigastrium for retraction of the liver, and a final more lateral port at the left flank to perform traction of the omentum and the stomach.
The first stage of the procedure is quite similar to the dissection required to prepare the stomach for a Nissen fundoplication. A small window was opened at the gastro-phrenic membrane and other at the gastro hepatic ligament
By means of blunt dissection a tunnel was created to communicate these two windows, then a penrose was passed through. It is used to perform traction of the gastroesophageal junction and expose the crura.
There was abundant fatty tissue, which made it difficult to achieve good exposure. The fat pad was resected to improve the visualization of the angle of His and also to prevent it from crossing the stapler line.
The surgeon should always check before sectioning the tissues. Unexpected injuries to the esophagus are potentially fatal, especially in morbid obese patients. One trick is to perform traction of the fatty tissue and compress it with the Ligashure™. With this maneuver the avascular plane becomes clear improving the safety of the dissection.
Now the left crus can be clearly seen. Blunt dissection continues in order to individualize the right crus. Once again the fatty tissue was in the way and had to be resected. The hook is used for sharp dissection. The attachments of a large lipoma arising from the lesser sac had to be sectioned. The left gastric artery must be preserved.
Now the Penrose is seizing the lipoma, which was removed to continue with the surgery. The limit between the fatty tissue and the stomach becomes more clear and the anatomization of the hiatus continues.
The hook makes it possible to dissect layer-by-layer. It provides sharp and blunt dissection. The anterior wall of the esophagogastric junction was gradually released. The LigaSure™ may be used when the limits of the esophagus are clear. It saves surgery time.
The assistant surgeon performs traction of the gastric fundus. This is essential to improve and maintain the exposure. Placement of a foucher bougie helps to delimit the esophagus, giving more security to the surgeon to continue the laborious individualization of the anatomical structures.
Finally the hiatus was released from the fatty tissue. Cranial traction of the stomach makes it possible to evaluate the diaphragmatic crura. The surgeon checks hemostasis and tissue tension. Separate knots of 2-0 silk were used to close the hiatus. We recommend going in and out with the needle one each crus at a time.
The posterior approach is better to expose an adequate surgical field and avoid esophageal stenosis due to the knots. A total of 3 knots were made achieving the closure of the hiatal defect
The rest of the procedure was a standard sleeve gastrectomy.
Surgery took 115 minutes and was uneventful. Oral intake started 24 hours after the procedure and the patient left the hospital on the second postoperative day.
The last follow-up took place 30 months after the surgical treatment, The patient had lost 51 Kg achieving a BMI of 30 Kg/m2 and the resolution of her comorbidities.
So far there has been no relapse of the hiatal hernia.
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