Esophageal leiomyoma enucleation after two laparoscopic hiatal surgeries

Esophageal leiomyomas probably account for 70% of all benign tumors of the esophagus. Surgical removal is indicated for symptomatic patients or for a tumor with a progressive increase in size. This is the case of a 36-year-old patient, who had previously undergone a laparoscopic operation for Nissen fundoplication for GERD, in whom an incidental leiomyoma of the distal esophagus was discovered.

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Esophageal leiomyoma enucleation after two laparoscopic hiatal surgeries

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

Esophageal leiomyomas probably account for 70% of all benign tumors of the esophagus. Surgical removal is indicated for symptomatic patients or for a tumor with a progressive increase in size.
This is the case of a 36-year-old patient, who had previously undergone a laparoscopic operation for Nissen fundoplication for GERD, in whom an incidental leiomyoma of the distal esophagus was discovered.

Keywords

Esophageal leiomyoma, enucleation, laparoscopy, hiatal surgery, floppy Nissen fundoplication

Media type

Surgical video

Duration

16'19''

Publication

2011-02

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E-publication

WeBSurg.com, Feb 2011;11(02).
URL: http://www.websurg.com/doi-vd01en3216.htm

Esophageal leiomyoma enucleation after two laparoscopic hiatal surgeries

1. Introduction 00'22''

Esophageal leiomyomas probably account for 70% of all benign tumors of the esophagus. Surgical removal is indicated for symptomatic patients or for a tumor with a progressive increase in size. This is the case of a 36-year-old patient, who had previously undergone a laparoscopic operation for Nissen fundoplication for GERD, in whom an incidental leiomyoma of the distal esophagus was discovered. At the first operation, the incidental finding of a large peri-esophageal mass led the surgical team to decide on a partial posterior fundoplication with the goal to surgically re-explore the patient at 3 months after further diagnostic testing, to enucleate, if possible the lesion. Also, at that time, the location of the lesion in the posterior mediastinum was felt to be unsuitable for a solely transhiatal approach. Three months postoperatively, the patient underwent a second operation by a multidisciplinary team of both GI and thoracic surgeons, with the aim of enucleating the tumor, being identified as a probable leiomyoma at MRI. At the second operation, the surgeons tried to gain access to the hiatus but had to abandon the procedure due to the presence of dense adhesions between the stomach and the liver bed. Here, we show the third hiatal surgical exploration. A 5-trocar technique is used as for Nissen fundoplication with the patient placed in reverse Trendelenburg.

2. Dissection of adhesions 01'49''

The first step consists in taking down adhesions at the inferior surface of the left liver lobe. Only minor adhesions are found and the access to the esophageal hiatus is therefore straightforward. The dissection is carried out using scissors with monopolar cautery. As a general rule for all hiatal surgery, identification of surgical landmarks is a key technical point.

3. Right diaphragmatic pillar dissection 02'11''

The first landmark as shown here is the right diaphragmatic pillar. The identification of surgical sutures placed at the time of the previous surgery can also be helpful in leading the dissection.

4. Identification of cardio-esophageal junction 02'25''

Once this has been performed, the cardio-esophageal junction is identified.

5. Mediastinal dissection 02'29''

Next, the mediastinal dissection is carried out.

6. Identification of leiomyoma 03'54''

The opening of the esophageal hiatus soon allows the visualization of a large lesion in the mediastinum likely originating from the posterior esophageal wall. The macroscopic feature is that of a leiomyoma.

7. Tumor dissection 04'10''

The first step consists in dissecting the tumor away from the esophageal wall and to identify its stalk. The cleavage plane between the lesion and the esophagus is created by gentle blunt dissection. The tumor is dissected away from the esophageal mucosa. The use of cautery is discouraged in order to avoid the risk of perforation due to a delayed burn injury. We proceed with caution to avoid perforating the mucosa. An umbilical tape is placed around the esophagogastric junction in order to optimize the traction without grasping the esophagus and reach the upper limit of the tumor. We then gently peel the tumor away from the mucosa under direct vision. The tumor size appears to be about 3 per 4cm. Esophageal leiomyomas generally do not produce symptoms until they are at least 5cm in size or larger. In this patient, no symptoms related to the bulk of the tumor were reported such as dysphagia. Larger esophageal masses can typically produce symptoms related to obstruction and retrosternal pain.

8. Tumor enucleation 07'13''

At this point, the tumor is completely enucleated. The stalk of the tumor appears to be at the level of the cardia on the posterolateral right esophageal wall. The root of the lesion is selectively divided leaving a small area of exposed mucosa. At least 50% of patients with esophageal leiomyoma remain asymptomatic, and these tumors are usually discovered as incidental findings during endoscopic examination of the upper gastrointestinal tract for unrelated reasons. In this patient, the tumor was discovered at the time of surgery. If such as in this case a leiomyoma of the distal esophagus is found, we recommend either to postpone surgery whenever there is a significant doubt about the benign nature of the lesion, to fully study the patient and to optimize therapy, or to proceed to the excision of the tumor, as shown in this video. Whenever the diagnosis is unclear, no further surgical steps such as fundoplication should be carried out.

9. Closure of esophageal muscle layer 09'05''

To prevent the development of a pseudo-diverticulum, the esophageal muscle layer is carefully closed using an interrupted 3/0 Vicryl suture bridging the muscular gap.

10. Crura approximation 11'36''

The crura are then re-approximated with several non-resorbable 2/0 sutures. The hiatal opening appears quite large. Several sutures are needed to achieve a good closure. Attention is paid to respect the esophageal inlet into the abdominal cavity avoiding kinking and distortion at the gastroesophageal junction (GEJ). The short gastric vessels were previously taken down during the first operation. Only little additional mobilization is needed.

11. Creation of floppy Nissen 13'29''

A short floppy Nissen fundoplication is built. Two sutures are fixing the wrap onto the esophagus at the level of the phrenoesophageal membrane and superiorly.

12. Specimen extraction 13'40''

The specimen is extracted in one piece through the 12mm camera port using an extraction bag. The pathology examination confirmed the diagnosis of leiomyoma. In our experience, the lower esophagus can be routinely mobilized up to the pulmonary vein and higher from the esophagogastric junction by using a transhiatal approach. If the tumor is present within the lower middle esophagus, we prefer a laparoscopic transhiatal approach. The advantages of such an approach are that it is a minimally invasive procedure compared with the open thoracotomy and to the thoracoscopic approach.

13. Hiatal reinforcement using Vicryl mesh 14'55''

An onlay Vicryl mesh was placed on the diaphragm to temporarily reinforce the hiatus and prevent early recurrences. The upper GI series performed on postoperative day 1 revealed no leakage and the patient was started on a liquid diet on postoperative day 1.