P69 INTRAOPERATIVE ENDOSCOPY IS OF A GREAT IMPORTANCE IN COMPLEX REVISIONAL UPPER GI SURGERY. CASE PRESENTATION OF RECURRENT ACHALASIA PREVIOUSLY TREATED WITH 3 LAPAROSCOPIC HELLERS CARDIOMYOTOMIES.

Aim To demonstrate the ability to perform increasingly complex revisional surgery utilising minimally invasive techniques and synchronous endoscopy for recurrent achalasia. Background & Methods We present a case of recurrent achalasia previously treated with 3 laparoscopic Hellers cardiomyotomies. Traditionally such a case would be considered for either open revisional surgery or oesophagectomy. In this case a fourth laparoscopic Hellers cardiomyotomy was succesfully performed using 3D laparoscopy combined with synchronous intraoperative endoscopy. The 3D video footage we present demonstrates the added safety provided by depth perception and high resolution imaging in revisional laparoscopic surgery. Synchronous endoscopy confirms altered anatomy, pathology and luminal change from extraluminal interventions resulting in prompt recognition of LES and subsequent efficient gastric myotomy. Results After a laborious adhesiolysis using the advantages of 3D imaging system we faced difficulties recognizing the exact LES location, in order to proceed with the gastric myotomy. In our opinion this could be the reason for previous treatment failures. At this point the use of synchronous flexible endoscopy enabled the recognition of cardia, so we could safely and efficiently complete a fourth laparoscopic Hellers cardiomyotomy including repair of a distal oesophageal diverticulum and a substantially lengthened gastric myotomy. This resulted in a substantial improvement in dysphagia symptoms with the patient resuming consumption of liquid and solid food as well. Conclusion Early adoption of technological advancements facilitates organ preserving revisional surgery and the avoidance of significant patient morbidity. These techniques radically increase the safety profile of minimally invasive surgery by facilitating anatomic recognition and provisioning for tailored intervention.