V-OG03 Robotic Epiphrenic Diverticulectomy, Myotomy And Hiatus Hernia Repair

Background Oesophageal epiphrenic diverticulum’s are rare; reported in less than 0.5 per cent of the population. They are noted however in 1–3 per cent of patients complaining of dysphagia. They are almost always associated with a motility disorder of the oesophagus. Surgery is generally the only solution to help with the symptoms of dysphagia and reflux. Methods This video highlights a case of a moderate sized diverticulum causing dysphagia and significant reflux. The procedure was performed on the DaVinci X system; to my knowledge, this is the first time this technique has been performed on the DaVinci X in the UK. A 4 arm technique was used, utilising two right arms and one left. Instruments used were cadiere forceps, hook and sureform stapler. The 12 mm port was docked with arm 3 and sited on the patients left. A stapled diverticulectomy was performed with the Sureform blue cartridge. An endoflex was used to retract the liver. Results The procedure was successfully performed in 150 minutes and involved resection of the diverticulum, hiatal repair and short myotomy up to the neck of the diverticulum. Conclusion The robotic platform allows for better visualisation of the hiatal structures and vagal nerves and the enhanced magnification make for a safer myotomy. The articulating instruments permit safer dissection of the diverticulum. A 4 arm technique makes the myotomy easier and safer to perform.

LINX: How I Do It and Why

The LINX device consists of a “bracelet” of magnetic beads in titanium cases, connected by individual wires placed noncompressively around the distal esophagus during laparoscopic surgery. This augments the native lower esophageal sphincter’s (LES) ability to resist reflux by increasing yield pressure and resisting shortening of the LES. Magnetic sphincter augmentation (MSA) was conceived as a safe, stomach sparing, minimally invasive, reversible implantable device for patients seeking an alternative to laparoscopic Nissen fundoplication. Though initially studied in patients with limited hiatal hernias, its use has expanded to include patients with large and even giant or paraesophageal hernias with excellent results. The author’s techniques of complete esophageal dissection, precise hiatal repair, current concepts on noncompressive sizing and placement of the MSA device are reviewed in this article. MSA can be considered first-line surgical therapy for GERD patients with adequate peristalsis regardless of hernia size.

Partial Fundoplications (270° Toupet, 90° Dor)

Partial fundoplication such as the Toupet posterior 270° and the Dor anterior 90° to 180° wraps were developed with the aim of providing long-term GERD control as with the successful Nissen fundoplication, but with reduced post-operative side effects such as dysphagia and gas bloat. Randomized controlled trials with long-term follow-up show this to be the case. Failure of a fundoplication occurs along a predictable anatomical course with posterior herniation almost universal. This informs our method of dissection, hiatal repair, and wrap construction using fundopexy to the diaphragm. We present the indications and our techniques for partial fundoplication, including tips on how to reduce the incidence of fundoplication failure and recurrent reflux.

Does Mesh Augmentation of the Hiatal Repair with Gore Bio-A® Improve Symptomatic Outcomes in Laparoscopic Fundoplication?

Introduction: Laparoscopic fundoplication is performed for the management of symptomatic hiatus hernias and gastro-oesophageal reflux disease (GORD) refractory to medical therapy. We adopted the use of Gore Bio-A® for selected laparoscopic hiatus hernia repairs in 2011 and with this case series aimed to establish whether mesh augmentation affects symptomatic outcomes. Methods: A retrospective review of prospectively collected data from all laparoscopic fundoplications performed by a single surgeon between October 2011 and January 2013 was performed. Patient specific data were entered into a proforma and analysed using Microsoft ExcelTM. Patient reported outcomes were assessed with a system specific quality of life questionnaire (GORD-HRQL) both pre and post-operatively. Results: Twenty-three patients underwent laparoscopic fundoplication during the study period. Gore Bio-A® re-enforcement of the hiatal repair was used in 14 patients and was the preferred option for those with pre-operative evidence of a large hiatus hernia. Whilst overall there was a statistically significant difference between pre and post-operative scores (21 vs 0, p=<0.0001, Mann-Whitney U test), there was no clear difference observed in pre-operative scores (22 vs 20, p=0.21, Mann-Whitney U test), postoperative scores (0 vs 0, p=0.92, Mann-Whitney U test) or symptom improvement (21 vs 20, p=0.24, MannWhitney U test) between the mesh and non-mesh groups. Conclusions: Augmentation of the hiatal repair with biosynthetic mesh is safe, feasible and may contribute to improved symptomatic outcomes in selected cases with a large hiatus hernia. We suggest a further assessment with a larger randomised sample and long term follow-up for definitive evaluation.

Asymmetrical elevation of esophagogastric junction pressure suggests hiatal repair contributes to antireflux surgery dysphagia

ABSTRACT The radial distribution of esophago-gastric junction (EGJ) pressures with regard to troublesome dysphagia (TDysph) after antireflux surgery is poorly understood. Before and after antireflux surgery, end-expiratory and peak-inspiratory EGJ pressures were measured at eight angles of 45° radial separation in patients with reflux disease. All 34 patients underwent posterior crural repair, then either 90° anterior (N = 13) or 360° fundoplication (N = 21). Dysphagia was assessed prospectively using a validated questionnaire (score range 0–45) and TDysph defined as a dysphagia score that was ≥5 above pre-op baseline. Compared with before surgery, for 90° fundoplication, end-expiratory EGJ pressures were highest in the left-anterolateral sectors, the position of the partial fundoplication. In other sectors, pressures were uniformly elevated. Compared with 90° fundoplication, radial pressures after 360° fundoplication were higher circumferentially (P = 0.004), with a posterior peak. Nine patients developed TDysph after surgery with a greater increase in end-expiratory and peak-inspiratory EGJ pressures (P = 0.03 and 0.03, respectively) and significantly higher inspiratory pressure at the point of maximal radial pressure asymmetry (P = 0.048), compared with 25 patients without TDysph. Circumferential elevation of end-expiratory EGJ pressure after 90° and 360° fundoplication suggests hiatal repair elevates EGJ pressure by extrinsic compression. The highly localized focal point of elevated EGJ pressure upon inspiration in patients with TDysph after surgery is indicative of a restrictive diaphragmatic hiatus in the presence of a fundoplication.