Laparoscopic re-operation for severe dysphagia following fundoplication and prosthetic reinforcement of the hiatus

Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported with no apparent relationship between mesh type and mesh configuration. The aim of this video is to show a case of mesh repair complication. A 50-year-old woman presented with severe dysphagia and important weight loss one year after redo laparoscopic Nissen fundoplication with prosthetic crural repair. At re-operation, important esophageal stenosis and angulation was found arising from the key-hole-shaped polypropylene mesh with pseudodiverticular dilatation of the distal esophagus. The esophagus was freed from the dense fibrotic capsule surrounding the prosthesis and a myotomy was performed.

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Laparoscopic re-operation for severe dysphagia following fundoplication and prosthetic reinforcement of the hiatus

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported with no apparent relationship between mesh type and mesh configuration. The aim of this video is to show a case of mesh repair complication.
A 50-year-old woman presented with severe dysphagia and important weight loss one year after redo laparoscopic Nissen fundoplication with prosthetic crural repair. At re-operation, important esophageal stenosis and angulation was found arising from the key-hole-shaped polypropylene mesh with pseudodiverticular dilatation of the distal esophagus. The esophagus was freed from the dense fibrotic capsule surrounding the prosthesis and a myotomy was performed.

Classification

complex cases

Keywords

Laparoscopic reoperation, severe dysphagia, fundoplication, prosthetic reinforcement, hiatus

Media type

Surgical video

Duration

18'24''

Publication

2009-03

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Subtitles

E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2518.htm

Laparoscopic re-operation for severe dysphagia following fundoplication and prosthetic reinforcement of the hiatus

1. Clinical case presentation 00'09''

This video shows the case of a 50-year-old woman with severe dysphagia for solids and liquids, along with significant weight loss following a laparoscopic Nissen procedure with prosthetic hiatoplasty. The preoperative CT-scan shows a tight stenosis at the level of the diaphragm; considering the patient’s previous history and the prosthetic reinforcement of the cruroplasty during the previous Nissen procedure, we think that either a fibrotic stenosis had happened, or that the mesh at the lower part of the esophagus are coming into contact. The intraoperative endoscopy shows a dilation of the distal esophagus with cardial stenosis.

2. Intraoperative endoscopic gastric exploration 00'50''

The gastric exploration, especially in retroflexion, shows that the fundoplication is still correctly placed in a sub-diaphragmatic position, and that there are no erosions at the level of the lower esophagus. At laparoscopy, dense adhesions are found. In fact, the patient had been re-operated by an open procedure at the second operation.

3. Adhesiolysis 01'11''

The adhesiolysis was performed meticulously using scissors in order to preserve the different cleavage planes as much as possible. The trocars in this case are positioned in a usual fashion, the only difference being that we usually approach these abdomens via an open Hasson’s technique, or by a trocar in the left hypochondrium. By systematically freeing these adhesions, we manage to recreate different planes and to get access to the diaphragmatic hiatus. As soon as these adhesions are freed, we can see that the prosthetic material is covering the diaphragm. The prosthesis that was used in the previous procedure seems to be a double-sided mesh. The adhesions situated near the prosthesis are obviously packed tightly together and we can imagine that there is also an important fibrotic phenomenon around the esophagus. Here you see that a double-sided prosthesis does not prevent the formation of adhesions, the only difference being that these adhesions are usually easier to take down in comparison to conventional prosthesis. The freeing of the left lobe’s inferior surface is performed in the same meticulous way, scissors with monopolar coagulation are used and are usually the best instrument for this operative step. When performing these re-operations, it is important to be able to find the main landmarks, especially for surgery on the lower esophagus; these landmarks are the diaphragmatic crura, on the left or on the right. Depending on how easy the dissection is, we will tend to work more to the right or to the left side, but generally we will try to find the easiest access route, especially with such dense adhesions. The sutures are found as in this case; this is also a good guide and helps to orientate the dissection. In fact, the sutures are usually placed around the fundoplication wrap. The dissection of the left lobe’s inferior surface and the identification of the segment 1 of the liver that we can see here is important because we know that just superior to it lies the right diaphragmatic crus. Once again, the adhesions are tightly packed together around the liver’s inferior surface. We continue the diaphragm’s freeing, while on the left of the screen, we can see the position of the vena cava: we realize just how close the vena cava is to the prosthesis, and how that may lead to serious complications.

4. Identification of the hiatal orifice 05'36''

The hiatal orifice is gradually identified; the perioperative endoscopy also allows to orientate the dissection by identifying the different structures.

5. Identification of the esophageal stenosis 05'47''

We see that at the level of stenosis indicated by endoscopy does indeed exist a stenosis of the esophagus, which is surrounded by the prosthesis. In this case, it is a U-shaped prosthesis that completely surrounds the esophagus.

6. Circumferential esophageal dissection 06'03''

Because the distal obstruction of the esophagus is caused by the prosthesis, we will free all the circumference of the esophagus from the adhesions. This freeing is sometimes difficult and the view of the different cleavage planes is therefore very important: the only option we have in these types of re-operations is to remove these extremely dense fibrotic bands. We can see just how tightly it surrounds the esophagus and we can guess that it would eventually cause erosions of the esophageal wall and, in some cases, migration phenomenons at the level of the lumen. On this part of the dissection, the adhesions are very dense, and the contact between the esophageal wall and the prosthesis is very clear. The way the prosthesis has been placed and tailored is probably the least recommended: the prosthesis, in fact, surrounds the esophagus completely when we know that the retraction phenomenon that the prosthesis will undergo will undeniably impact on the esophagus. We therefore recommend to use U-shaped prosthesis, and especially posterior ones as they are less dangerous. We can see here that the mesh is being freed from the liver’s segment 1. It is obvious that we are trying not to leave too many prosthetic elements in the peritoneal cavity, especially after seeing just how close the prosthesis is to the inferior vena cava. The hiatal orifice is gradually enlarged; the dissection continues to resect anything that may be in contact with the esophagus. The aim is to restore a muscular contact between the esophagus and the hiatal orifice. Using other types of material such as biological prosthesis at the level of the diaphragm seems to reduce the formation of adhesions, or even the migration phenomenon at the level of the esophagus.

7. Prosthesis migration 09'06''

On this part of the dissection, we observe that there is a migration of the prosthesis at the level of the longitudinal external muscular fibers of the esophagus, and that leaving the prosthesis for any longer would have exposed the patient to risks of stenosis, esophageal erosion and migrations into the esophageal lumen.

8. Intraoperative endoscopic control 10'22''

The endoscopy is now repeated and here we can see that the removal of the prosthesis led to the resection of a segment of the muscle of the esophagus but there is no mucosal perforation. However, this partial myotomy of the esophageal wall can lead to dilation of the lower esophagus. In order to avoid this, we decide to extend this iatrogenic myotomy and perform myotomy similar to those that we perform in case of achalasia. The fundoplication wrap that had been performed earlier on is entirely taken down and we will only leave a small Toupet-type posterior valve that should be sufficient to control any reflux. In these patients, it is contraindicated to perform a second time a complete Nissen fundoplication due to the risk of recreating an obstacle in the lower part of the esophagus and a recurrence of the clinical signs.

9. Esophageal myotomy 12'15''

We extend the myotomy zone by a surgical myotomy. We perform the myotomy using cold scissors. And the endoscope peroperatively allows to guide us during the myotomy: this shows the utility of having an endoscope when performing a myotomy for achalasia. Using cold scissors is recommended in these types of procedures when considering the fragility of the tissues and the risk of thermal injury that can be caused by electrocoagulation and the various ultrasonic scalpels.

10. Myotomy completion under endoscopic control 13'59''

Endoscopy is repeated and allows to complete the division of a few residual muscular fibers, especially those situated at the level of the gastric portion of the lower esophageal sphincter. This myotomy will allow to avoid the formation of a pseudo-diverticular dilation of the distal esophagus and will facilitate the esophageal and gastric emptying compensating a little bit for the peristalsis loss that inevitably follows when the esophagus begins to gradually dilate.

11. Postoperative control 15'30''

The hiatal orifice is left widely open, and the postoperative follow-up shows the satisfying opening of the cardio-esophageal junction and the complete resolution of the obstacle that had been assessed preoperatively.