Robot-Assisted Laparoscopic Re-Do Paraesophageal Hernia Repair With Nissen Fundoplication

In this video, we present a patient with a recurrent paraesophageal hernia who underwent robot-assisted laparoscopic re-do paraesophageal hernia repair with Nissen fundoplication. The patient is a 76M with a past medical history significant for longstanding and symptomatic GERD, status post laparoscopic paraesophageal hernia repair and Stamm gastrostomy. He had a series of workups that ultimately demonstrated irregularities consistent with Barrett’s esophagus and a large type III paraesophageal hernia. The patient was taken to the OR for a robotic redo paraesophageal hernia repair with Nissen fundoplication.

Port placement is as follows: 15 cm inferior to the xiphoid process, four 8 mm ports are placed. The left-most port (arm 4) is placed just superior to the colon. Arm 2 is placed slightly to the left and superior to the umbilicus, and varies depending on the distance between the xiphoid process and the umbilicus. Arm 3 is placed between ports 2 and 4. Arm 1 is 10 cm to the right of arm 2. The assistant port is an airseal port in the right lower quadrant.

The operation begins with Hassan cutdown technique for the assistant port. Airseal is set to 12 mmHg, as we have observed extensive post-operative subcutaneous emphysema when 15 mmHg is used. In this video, we are using a Nathanson retractor for liver retraction. Robot instruments are: fenestrated bipolar in 1; camera in 2; vessel sealer in 3; cadiere in 4. We have since changed technique and now use a cadiere in 1. The operation begins by trying to establish normal anatomy and planes. Given the re-do nature of this operation, there was significant scar tissue which made identification of tissue planes challenging. The initial focus is on identifying the right crus. Once the right crus is identified a plane is dissected between the hernia sac and the right crus. The peritoneal lining is maintained on the right crus during dissection to maintain tissue integrity for the eventual crural closure.

Dissection continues anteriorly. Downward and inferior retraction facilitates entry into the space between the hernia sac and the mediastinum. When the fibroalveolar plane is seen, this confirms dissection in the correct space. Dissection through this space continues circumferentially and superiorly, thus mobilizing the shortened esophagus. The vagus nerves are preserved and if identified are kept on the esophagus.

As this point, the right crus is visible, as is the left crus. The esophagus is circumferentially dissected and a 1” penrose is passed around it to facilitate retraction. Next, the short gastrics and gastric-pancreatic tissue are divided to mobilize the fundus to allow for a complete Nissen fundoplication with minimal tension.

The gastric fat pad was dissected off anteriorly and then posteriorly, preserving the vagus nerves. The dissection plane is right on the esophagus, which allows for accurate identification of the GE junction and will also allow for the wrap to be positioned correctly on the distal esophagus. After adequate mobilization of each of the crura, the crural repair begins. 0 ethibond sutures are used with pledgets. A 54Fr bougie is in place. The first stitch is performed with a safe needle angle away from the aorta. A slip knot is used to tie the knot under tension.

To begin the fundoplication, an area that is 6 cm distal to the angle of his and 2 cm posterior to the short gastrics is marked with a stitch to approximate the right side of the Nissen wrap. The fundus is pulled anteriorly through the previous window created during fat pad mobilization. Once this is completed, a shoe-shine maneuver is performed. The Nissen wrap is to be completed around the 2 cm of distal esophagus, just proximal to the GE junction.

For the Nissen wrap, 0 ethibond suture without pledgets is used. A 54Fr bougie is in place. The first stitch is stomach to stomach; a slip knot is used to tie the knot under tension. Having the bougie in place prevents a wrap that is too tight that can cause post-operative dysphagia. Additional sutures are placed superiorly and inferiorly. All additional sutures incorporate esophageal muscle fibers. The ideal length of the wrap is 2 cm, and is located directly around the distal esophagus, just proximal to the GE junction. Following the wrap, the fat pad is re-positioned over the suture line. The nathanson retractor and all ports are removed. The assistant port site is closed with interrupted 0 vicryl sutures, with remaining incisions closed with 4-0 monocryl.

Post-operative course was notable for development of shortness of breath and increasing oxygen requirements on POD2. He was transferred to ICU and was treated with antibiotics for pneumonia and diuresis. A CT chest to rule out pulmonary embolism demonstrated no evidence of esophageal leak and reduction of previous paraesophageal hernia. He ultimately clinically improved and discharged home on soft diet on POD7. At follow-up visit in clinic, reflux had resolved and he had minimal dysphagia.

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