Robotic Ligamentum Teres Cardiopexy with Hiatal Hernia Repair for GERD following Longitudinal Sleeve Gastrectomy
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Table of Contents
Patients who undergo longitudinal sleeve gastrectomy (LSG) may develop de novo or worsening of existing gastroesophageal reflux (GERD) symptoms, which include postprandial retrosternal burning, food refluxing, or dysphagia. Often patients with GERD following LSG present with a concomitant hiatal hernia. Workup serves to characterize a patient’s GERD disease burden by way of fluoroscopic upper gastrointestinal (UGI) series, pH studies, manometry, or esophagogastroduodenoscopy (EGD). Treatment first involves medical management with lifestyle modifications followed by use of pump inhibitors (PPIs) or Histamine H2-receptor antagonists (H2 Blockers or H2B). If GERD symptoms remain intractable to medical management, surgical intervention can be pursued. Historically patients would undergo a conversion to a Roux-en-Y gastric bypass (RYGB). New data demonstrate comparable outcomes regarding GERD symptoms and improvements in anti-reflux medication use in patients status-post LSG who undergo ligamentum teres cardiopexy with hiatal hernia repair. Here, we describe a robotic ligamentum teres cardiopexy with hiatal hernia repair in an adult patient who previously underwent LSG and was experiencing intractable GERD symptoms despite lifestyle modification and optimization on anti-reflux medications.
Nearly half of patients have baseline gastroesophageal reflux (GERD) symptoms prior to undergoing bariatric surgery, with several patients have worsening or new onset of reflux symptoms following longitudinal sleeve gastrectomy (LSG).1 Historically, conversion to Roux-en-Y gastric bypass (RYGB) has been considered the surgical treatment for GERD management post-LSG. The use of ligamentum teres cardiopexy with concomitant hiatal hernia repair (LT cardiopexy) presents an alternative surgical option for improvement or resolution of GERD symptoms.
Here we present a 48-year-old Spanish-speaking female with a past medical history significant for GERD, anxiety, and obesity who was status-post robotic sleeve gastrectomy and hiatal hernia repair in July 2022. She had a subsequent 88 lbs weight loss with BMI decreasing from 43.2 kg/m2 to 28.6 kg/m2, but experienced worsening of her preoperative GERD symptoms. The patient had GERD prior to LSG, which remained refractory to twice daily 20 mg omeprazole usage despite significant weight loss, dietary changes, and hiatal hernia repair at the time of index bariatric surgery. She underwent fluoroscopic upper gastrointestinal (UGI) series that identified a recurrent hiatal hernia with spontaneous moderate GERD to the level of the distal esophagus. No EGD, manometry, or pH studies were performed.
Options of operative interventions were reviewed with the patient, who opted to pursue minimally-invasive ligamentum teres cardiopexy with hernia repair (LT cardiopexy).
The patient had no other prior abdominal surgeries aside from what is listed above. Her medications included atorvastatin, biotin, calcium carbonate-vitamin D3 tablet, cyanocobalamin tablet, omeprazole, multivitamin. She is a non-smoker and has no known drug allergies. There are no relevant laboratory results to report.
Physical exam revealed a well-nourished, healthy-appearing female in no apparent distress with normal vital signs. Her BMI was 28.6 kg/m2. Abdomen was of overweight habitus, soft, non-distended, non-tender in all quadrants with no palpable masses.
Pre-existing GERD is very common in bariatric surgical patients, with nearly half of patients having GERD symptoms before undergoing any surgical intervention.1 GERD in this patient population develops for a variety of reasons including dietary choices and higher adiposity causing increased intra-abdominal and intra-gastric pressure impacting the gastroesophageal junction (GEJ).2,3 One study found that approximately 9% of patients have worsening GERD symptoms following LSG, and 10% developed new onset GERD.1 Reasons for this have been speculated to include anatomic changes to the stomach with altered angle of His and resection of the sling fibers in the distal part of the lower esophageal sphincter, which result in low esophageal-sphincter pressure and de novo or recurrence of hiatal hernias.4-8
Fluoroscopic UGI series provides real-time view of a patient’s anatomy visualizing barium traveling through the esophagus, stomach, and duodenum as a person drinks. This allows radiologists to visualize contrast refluxing and anatomic abnormalities such as hiatal hernias. Additional studies to evaluate the degree of GERD disease burden include pH studies, manometry, or EGD. A CT scan of the abdomen and pelvis can also identify the presence of a hiatal hernia. This patient underwent UGI series in August 2023 (approximately one year following sleeve gastrectomy), which demonstrated appropriate post sleeve gastrectomy anatomy but recurrence of her hiatal hernia.
Patients who present with GERD symptoms following LSG should first be managed medically in a stepwise fashion, starting with diet change and weight loss. Following this, the addition of medications can be tried, which includes monotherapy or concomitant use of pump inhibitors (PPIs) or Histamine H2-receptor antagonists (H2 Blockers or H2B). If symptoms persist then surgical interventions may be pursued. Compared to the general population, patients who have undergone LSG are not typically candidates for a fundoplication procedure due to loss of natural stomach fundus redundancy utilized in a fundoplication wrap. As such, the surgical intervention typically offered is conversion to a Roux-en-Y gastric bypass (RYGB). Other procedures such as magnetic sphincter augmentation lack long-term safety data, and endoscopic approaches have undetermined longitudinal benefits. The alternative surgical intervention of ligamentum teres cardiopexy with hiatal hernia repair demonstrated in this video is a newer technique available to most patients following LSG with intractable GERD who do not wish to undergo conversion to RYGB.
This patient had undergone a LSG in 2022 and had persistent GERD symptoms despite lifestyle modification, significant weight loss, and being on a long-term PPI. Conversion to gastric bypass was offered; however, the patient did not wish to pursue this due to added long term risks associated with RYGB, and the patient was not interested in additional weight loss. She had undergone fluoroscopic UGI series, which demonstrated recurrence of her hiatal hernia, likely contributing to her symptoms. Magnetic sphincter augmentation was not offered as it is not performed at our institution and would not have addressed the patient’s hiatal hernia. Given her intractable GERD and personal preferences, a hiatal hernia repair with LT cardiopexy was indicated to reduce her hiatal hernia and provide reinforcement at the GEJ. The surgeon chose a robotic approach due to surgeon preference.
In the bariatric world, the risk of developing GERD following LSG is well established. Dupree et al. found that 9% of patients following LSG developed worsening of their GERD symptoms compared to 2.2% who had undergone a RYGB.1 For patients with intractable GERD who had previously undergone LSG, the mainstay surgical treatment has been conversion to RYGB. Additionally, some patients may opt to pursue RYGB conversion not only for reflux symptom improvement, but for the added weight loss that would be anticipated postoperatively. However, despite its benefits, a RYGB comes with a multitude of short- and long-term risks including but not limited to: marginal ulceration, internal hernias, dumping syndrome, and nutritional deficiencies.9 Furthermore, newer longitudinal data has demonstrated the development of reflux and dysmotility disorders years following RYGB, for unclear etiologies, hinting that the improvement in GERD symptoms may not be lifelong.10 Minimally-invasive LT cardiopexy with hiatal hernia repair presents a viable surgical alternative to patients with GERD following LSG who do not wish to undergo RYGB conversion.
LT cardiopexy is performed via minimally-invasive approach and the steps are equivalent whether being performed laparoscopically or robotically. Patient positioning and port placement requires careful consideration and planning to perform adequate exposure and reach of instruments; the patient is placed in reverse Trendelenburg with slight left up tilt throughout the procedure. Pneumoperitoneum is induced typically via the Veress technique at Palmer’s point. A camera trocar is placed in the supraumbilical region. Other port sites are in the left mid-abdomen trocar, and both right and left mid-quadrant. Instruments utilized throughout the procedure included 30-degree scope, monopolar scissor, vessel sealer, Cadiere grasper, fenestrated bipolar grasper, and needle driver. If there is presence of a hiatal hernia, as in this case, then a complete circumferential dissection along the esophagus and the bilateral crura is achieved until 3 cm of intra-abdominal esophagus is mobilized. The ligamentum teres is mobilized from the anterior abdominal wall dissecting towards the major fissure of the liver taking care to preserve as much length as possible. Intraoperative endoscopy was performed in this case to identify the GE juncture, which was below the level of the hiatus as well as confirming the gastric sleeve anatomy was straight without evidence of redundancy or angulation. The hiatus is repaired by reapproximating the crura using two Ethibond mattress sutures and utilizing Bio-A mesh pledgets for reinforcement. Hiatus closure is then typically reinforced with mesh; in this case, a preformed U-shaped Bio-A mesh was placed along the posterior and bilateral crura. The ligamentum teres is delivered posterior to the esophagus at the level of the GE juncture and sutured to the stomach, and occasionally the crus. The remainder of the ligamentum teres is wrapped 270 degrees around the distal left esophagus and sutured to the anterior stomach cardia just distal to the GE junction. Of note, Mackey et al. found that among 60 patients status post sleeve gastrectomy undergoing ligamentum teres cardiopexy, 100% had a hiatal hernia.11 Therefore, surgeons performing ligamentum cardiopexy should be prepared to perform a hiatal hernia repair as a part of the cardiopexy procedure.
Techniques of cardiopexy “technique du collet” was first proposed by Pedinielli for hiatal hernia management. In 1964 this was adapted by Rampal et al. to specifically utilize the ligamentum teres for GE juncture reinforcement for hiatal hernia management.12,13 While the exact physiological mechanism by which the ligamentum teres (LT) cardiopexy counteracts GERD symptoms is unknown, it is thought to serve in a similar function to fundoplication. By securing the LT below the hiatus to the stomach and occasionally the crus, it provides GEJ reinforcement and helps anchor the gastric sleeve in its anatomic position. Research outlining the utilization of the ligamentum teres cardiopexy for the bariatric population as a technique to reinforce the GEJ following hiatal hernia repair to help with GERD symptoms had not evolved until recently.
Huynh et al. demonstrated a 62% decrease in antisecretory medication requirements in patients who had undergone RYGB.14 Conversely, a single-site study by Mackey et al. investigated the effects of a hiatal hernia repair with LT cardiopexy on GERD symptoms and found 81% of patients were able to decrease the dose or stop their antisecretory medications (H2B or PPI) at 1 year post-op.11 Other single-site studies have demonstrated between 80.0–86.6% of patients had improvement or resolution of their GERD symptoms following LT cardiopexy.4,15 These patient additionally had decreased postoperative complications when compared to patients who underwent RYGB conversion. A recent abstract presented at the American Society for Metabolic and Bariatric Surgery Summer 2024 meeting found that more patients had a decrease in PPI usage at 1 year following LT cardiopexy compared to patients who underwent RYGB conversion for intractable GERD following LSG.16 From a safety profile, Mackey et al. identified reoperation rates of 3.4% for patients who underwent LT cardiopexy compared to published numbers of 6.7% who underwent conversion to RYGB.11 Additionally, length of stay is approximately 1.3–1.5 days for a LT cardiopexy. While longitudinal data is limited, we believe that minimally-invasive hiatal hernia repair with LT cardiopexy presents a safe alternative to RYGB conversion for patients with intractable GERD following LSG.
GERD symptoms are prevalent in the bariatric population, with many experiencing the development of symptoms, or worsening of symptoms following LSG that persists despite lifestyle modifications and antisecretory medications. Minimally-invasive hiatal hernia repair with LT cardiopexy is a safe, effective surgical option for improving GERD symptoms; however, further research is encouraged to evaluate its effectiveness.
This surgery was performed using the DaVinci Xi robotic platform (Intuitive Surgical, Sunnyvale, CA). Hiatus was closed utilizing Bio-A Mesh (GORE Medical, Newark, DE).
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
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- Baumann T, Grueneberger J, Pache G, et al. Three-dimensional stomach analysis with computed tomography after laparoscopic sleeve gastrectomy: sleeve dilation and thoracic migration. Surg Endosc. 2011;25(7):2323-2329. doi:10.1007/s00464-010-1558-0.
- Oor JE, Roks DJ, Ünlü Ç, Hazebroek EJ. Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: a systematic review and meta-analysis. Am J Surg. 2016;211(1):250-267. doi:10.1016/j.amjsurg.2015.05.031.
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Cite this article
. Robotic ligamentum teres cardiopexy with hiatal hernia repair for gerd following longitudinal sleeve gastrectomy. J Med Insight. 2024;2024(468). https://doi.org/10.24296/jomi/468Procedure Outline
Table of Contents
- 1. Introduction
- 2. Robot Setup
- 3. Adhesiolysis and Ligamentum Teres Mobilization
- 4. Stomach and Esophagus Mobilization and Reduction of Hernia
- 5. Ligamentum Teres Harvesting
- 6. Further Mobilization of the Esophagus
- 7. Gastroscopy to Determine Location of Gastroesophageal (GE) Junction
- 8. Getting Appropriate Length on Esophagus
- 9. Reapproximation of Posterior Hiatus
- 10. Ligamentum Teres Cardiopexy 270-Degree Wrap
- 11. Closure
- 12. Post-op Remarks
Transcription
CHAPTER 1
Hello, my name is Nicole Cherng. I'm a general surgeon here at UMass Memorial Hospital. What you're about to see is a case that I recently did. It's a robotic-assisted laparoscopic hiatal hernia repair on a patient who had a prior sleeve gastrectomy. This is a patient who had, she's a 48-year-old woman who had a sleeve gastrectomy for morbid obesity approximately 18 months ago, when she first presented to me. At that time, she underwent a fairly standard sleeve gastrectomy. She did very well with weight loss. She lost approximately 90 pounds. Her BMI is now 28, and she presented primarily with increasing reflux over the last few months. She reports that she's now on twice a day PPI and she still has breakthrough symptoms. I therefore then did an upper GI series, which shows reflux up to the level of the upper esophagus. She had normal sleeve anatomy; however, it had herniated through the mediastinum and there was clearly a paraesophageal hernia, so the top portion of the sleeve had herniated within the mediastinum. So given these findings and her symptomatology, I had a discussion with her regarding fixing the hiatal hernia, and our decisions at that time were we could do the hiatal hernia repair alone, and then she had a fairly normal sleeve so I would not do any sort of sleeve revision, but also have the addition of a ligamentum teres cardiopexy, given that she does not have the redundant fundus to do a fundoplication. The other option that we discussed was potentially converting her to a gastric bypass with a concurrent hiatal hernia repair. Given that she wanted more of a minimal approach and she also didn't wanna take the risks of a gastric bypass, she was very hesitant of a bypass when we had discussed her index surgery 18 months ago for weight loss. She wanted to move ahead with the hiatal hernia repair with the ligamentum teres cardiopexy. So the plan for the surgery - I elected to do this robotically. That's primarily surgeon preference. It could definitely be done laparoscopically, which I've done many as well. So I like to do a standard four-port setup for the robot, and then I also use the liver retractor to elevate the left lobe of the liver. This case I knew would have additional added difficulty, because in her sleeve gastrectomy she had a small hiatal hernia at that procedure, which was repaired, and so I knew that the hiatus itself would have a fair amount of scar tissue. So I knew that in order to identify the caudate lobe and then both crura, there would be a fair amount of scar tissue. In order to dissect the proximal sleeve and the distal esophagus off of the crura, I knew that the key would be to get adequate intraabdominal length, making sure not to injure the esophagus. I would also evaluate the shape of the sleeve. While the upper GI did look like a fairly normal sleeve anatomy, I would also be prepared, if needed, to do some sort of a sleeve revision or anything like that. Once I achieved adequate intra-abdominal esophageal length, I would then reapproximate the posterior crura and then I would mobilize the round ligament off of the anterior abdominal wall and perform a - ideally, a 270-degree wrap of the ligament, posterior and lateral, to the distal esophagus.
CHAPTER 2
11 blade, Veress, gas on. Okay. Good. All right, so while we're insufflating, we'll talk about the patient. So this is a 40-something-year-old woman, who about 18 months ago, underwent a robotic sleeve gastrectomy for obesity. She's had substantial weight loss. She's lost nearly a hundred pounds and she's had well over 10 BMI points. Her weight today - her BMI is about 26, 28. In the last six months, she's been complaining to me about fairly significant reflux. She's been maxed out on PPI, she's on twice a day Protonix and still has breakthrough symptoms. So I got her an upper GI series, which shows significant reflux up to the level of the upper esophagus as well as a hiatal hernia. So it does look like that her proximal sleeve has slid up into the mediastinum. It's not too surprising just given how substantial of a weight loss she's had. So given that I talked to her about her decisions that we could either do a hiatal hernia repair with a ligamentum teres cardiopexy, or do the hiatal hernia repair with a conversion to a gastric bypass. Since she's had very good weight loss, she really didn't wanna move forward with a gastric bypass with all the possible risks that come with that. And she felt that doing the hiatal hernia repair itself with the ligament would be sufficient 'cause her primary issue was heartburn and reflux and not, you know, more weight loss. So... We should probably wait a little longer. She healed great. Yeah, she healed really well. I can't even see her line. 11 blade. Eight port. Oh, butter. Okay, I'm in her omentum there. Hold the camera - knife to me, a little off. Next eight port. You connect the gas back to the... Oh, fair amount of adhesions from her last surgery. 11 blade. Let's do the camera port last, let's go 12 on this one. Yeah, you felt the good pop through. Fix the drape, 11 blade. Marie, can I have some positioning? So let's do 13 degrees reverse Trendelenburg and a three-degree roll towards me. Can I have the operator for the eight? That's funny 'cause her ligament is right there. Do you see what I mean? All right, let's do the liver, come through here now. All right, so we're doing four-port setup, and then we're also gonna do a liver retractor. Bed's all the way down. Do you want me to just leave it? Yeah, leave it. Loose and then have you... Then you can take it down and I can... Let's do that. I'm just trying to see if I can even have a lift 'cause I need like a hand for the retraction. That should be okay. And then I'll reposition? I think so, because I want you to have enough room so that when the robot comes in... Okay, ready for the robot. Stop next to the head. Ryan? Yep. All right. Can you unlock the bed and go south because the robot at the angle that's coming in back's come towards me just a little bit and then we just have to go south about like six inches. Stop, that's good, re-lock. All right, back. Can I see the cross hairs come towards me? That's good. Okay. You think we should clear the adhesion first? Let's see what it looks like though. Swing your arm out just a little bit. That's like a good enough to start. This is gonna be kind of strange - vessel sealer then in four. I am like stuck, there you go. Okay, I think I'll leave that there. Yep. Okay, let's start with that.
CHAPTER 3
She has a fair amount of adhesions from her - the only surgery that she's had is actually the sleeve. And so here you can see that her omentum has adhesed up to both falciform as well as the liver edge. So traditionally I do put the camera in arm two, but for this I am gonna start with a camera in arm three so I can have a better view. Sometimes I do do this to mobilize the round ligament, which we're gonna do, you can do at any point in the case. But I'm gonna opt to do it first, given that I already have this camera set up. So... So it's a little bit working backwards. So the round ligament usually gets mobilized all the way up as close as you can get to the level of the umbilicus to get as much length as you can to bring it into the upper abdomen. It's a little bit extra, but I am gonna take it and use it. I think here's good. Oh, can I get a smoker evac on please? All right, so we're just gonna kind of leave that to the side. We can always take it down a little bit more, but I don't - this adhesion just gonna get in the way of arm two, and while it's not totally prohibitive, I just think it's a cleaner operative field. Okay, I think that's better, okay. Well that aesthetically looks a lot better. After we take this off the liver, I'm gonna have you hop the camera back. So then that way it's just more like natural to our eyes for how we wanna do the liver. Okay so you're gonna see right away your sleeve is herniated up into the - oof. Okay, all right, let's take out arms two, three, and four. Let's put the camera in arm two. Let's clean that. And then I'm gonna have Cadiere go on four, vessels sealer back in three, and I'll stay still, while Mackey fixes the liver. All right, good view there, let me straighten out. Yep, good, yep. Okay, you're good where you are. Okay, all right, Emily, I'm gonna stay still.
CHAPTER 4
So here you see the liver retractor, now that we've taken on the adhesion to the undersurface, while you're gonna be elevating the left lobe of the liver off the level of hiatus. Perfect there, and so here right away you see caudate lobe and then you see the obvious hiatal hernia and the proximal sleeve has herniated up in there, which correlates with upper GI. That's good Mackey. Just tightening but we're good. Yep. Okay, all set. Okay. So, oftentimes for these patients as well, so we see our sleeve - decent-sized antrum. This is the start of our staple line, we'll climb up. So, so we know that this area on the left crus is gonna be significantly more scarred in 'cause of staple line. So we'll start on the right. In her index surgery, she did have a hiatal hernia repair. So this is also gonna be a little scarred in, I can tell right away the presence of a previously-placed stitch that she had. Okay. So it is gonna be scarred in, this is to be expected. So this is the level of the right crus coming down. It's just kind of finding, oh, she's gonna be easy, I can feel it. Just coming along the anterior crus. At some point we'll get into more native tissue that hasn't been operated on. We're not there yet though. Jen Martin, two-thirds, one-third on the Penrose, and then the slit about an inch in on the two-third side. There it is, okay. So because she's already had a prior hial hernia repaired in her index surgery, you do need to be very careful about what your structures are. Okay, all right. So to come into the left crus, we'll need to kind of reenter, lesser sac is no longer, well the new lesser sac from when she had the prior surgery. So we'll enter around here. I like a - I don't like to go right up against the staple line just 'cause that's where it's fused and I don't want any risks of disrupting the staple line even though it's fairly scarred in. So I choose about a third of the way down just so I can have adequate mobility. So this is - left crus is here. And then that's going into the lift crus. And you can see here that's the posterior. So this is about four o'clock on the hiatus. And then I'm just gonna elevate, there you go. Hm. This is very scarred right here, do you see that? It's like... So not surprising, it's like the most scarred in at the left side because of the dissection that you do in a sleeve gastrectomy up to the level of crus as well as the staple line. So I think it's like to be expected, so... I don't like that. That's preaortic fascia. Okay, let's come back over here. So that's through. It should be safe, thin it up. So you can tell here those are esophageal fibers. So we have caudate lobe, right crus, left crus, we're clearly through - very dense adhesions but - preaortic fascia. So I'm just slowly kind of making my way around being absolutely sure where I can see esophagus and stomach. See I'm stripping this off of the crus. Can you take out arm three? Can you drop me in two lit ones and then the penrose, please. Just open them once, Jen. All right and then the penrose, the two-third side with the slit cut in and then you can bring me that. That'd be great. Yeah, I'll take the vessel sealer back. So I like to get the Penrose as high on the GE junction esophagus as you can for hiatal hernia repairs. I think you have the best retraction. And just mop up a little bit. So I can tell right away that this is now a plane that hasn't been dissected in and so it just feels much softer, so I just need to kind of get to through all the scar. And I'm safe as long as I can continue to see esophagus well, it's mainly scar tissue. I don't like to use, I know it's still bipolar, but I don't wanna get too much cautery. I don't want any thermal injuries. So here, dropping the right pleural cavity off of the right esophagus, coming up. Okay. Okay, and you can see the - this white outline is the right pleural cavity. Okay. So 6 to 9 o'clock, or - 9 to - 6 to 9 is okay. So now we have to kind of figure out anterior. Hmm. It's coming up. So I'm just circumferentially making my way around the hiatus. I'm gonna go Bioway. Bioway, no polypropylene though. Single-armed Ethibonds. Six - load three of them with a single pledget, and then I - all them cut to eight inches, 'cause I'll need it for the ligament as well. Yep. So here I'm just trying to dissect the anterior esophagus from the mediastinum. You can see the lymph node there. So my dissection from 6 to 12 o'clock from off the right crus is pretty good. So, we know it's gonna be the most sticky coming off of the left crus just because of the reasons we've already talked about. So I think... I'm gonna accept a little bit of oozing here 'cause I don't wanna use too much cautery Clearly off esophagus. That's pretty free. It's pretty fused, the serosa. I'm gonna hug right on the muscle of the left crus. I think it's safer. So Mackey? Yeah? Sorry, I know I'm supposed to be - but so what happens that this has become peritonealized. Yeah. So it's like, functioning like a hernia sac. Do you see what I mean? Yeah. So you like have to take this layer or else like you can get into more trouble I think if you don't, do you see what I mean? Like this has essentially become fused to the serosa, but it's like essentially - it has peritoneal, like she's so far out it has peritonealized. So this is essentially like in a true, like a native like paraesophageal chronic, this is what we would still call like the sac. Do you see what I mean? So it just... I think 'cause - I think it would be wrong to try to go into that other plane. Yeah. And so on this side it probably was less developed because it wasn't - there's like not as much scarring but on this side you can see more of like the obvious boundaries. Mm, okay, not loving that at all, but it's okay. It's really stuck here. Okay, so there's esophagus pericardium is above us. Oh don't bleed. Uh, lymph node. Okay, oof. Okay, there's some progress there. So we're just trying to get it off this left crus. Very, very sticky. So basically the goal is just to get the entire sleeve obviously below, but you would want the GE junction 2-3 cm below, below the hiatus, so... Okay, reset. All right, so this is proximal sleeve. That's pretty good length, staple line goes up to here. So you, if the staple line goes up to here, you have to imagine GE junction was, it's probably closer to here. I - Becks, I am gonna, I need Mac - can you set up a gastroscope for me? Sorry. Yeah, yeah if you could, I think you should Mackey, just to help me with the anatomy. I'm almost certain, I just - a gastroscope can always help you delineate the anatomy, especially if you haven't... This sleeve looks fairly straight, but I wanna make sure that it is. So we'll get again an upper endoscopy. So these are clearly esophageal fibers here. So now we just need to work on getting enough length. Yeah so I just have to sort out this stuff. I think a lot of that is sac. I'm gonna thin it out though. Lemme know when we're good with the gastroscope? I think that's pretty good posterior and on the right, now anterior we just need to make sure we have enough length. And then with the gastroscope we'll confirm our anatomy and then we'll get sewing. Beck? Yeah? Are we able to set up TilePro? I'm still working on getting you the... Oh yeah, yeah, I think Val does know how to set it up though. All right, the anterior is pretty good, now it's just this left crus. It's just a little congested, okay. So I'm trying to give as much space. You see the left pleural cavity here, you can see the lung field within. We're not in the chest cavity, but you can see we're pretty - it's just one cell airway. Okay, that's pretty good length. The next is then looking at your sleeve anatomy. Her sleeve staple line goes up too - gonna loosen this up. All right, so the sleeve stabilizing comes up to right about here. Hard to tell, well we'll get a better idea when we do the gastroscope.
CHAPTER 5
Okay, so while that's getting set up, I'm gonna come back to our ligament, try to get as much length as we can. So ligamentum teres cardiopexies stem from the idea that, you know, this ligament carries, the idea is not to create a fundoplication, which you can't in a patient who's had a sleeve gastrectomy, but more the idea is to help anchor the sleeve within the abdominal cavity so it doesn't wanna try to jump back into the mediastinum. That's... That's pretty good. So that's, and everyone has a pretty variable in terms of its length. All right, that's pretty good.
CHAPTER 6
All right, how are we doing on the gastroscope setup? Okay, no worries, so oftentimes these patients, when they've had substantial weight loss and then they complain of reflux, their workup includes an upper GI series. I think it's one to see if they have a hiatal hernia. But also you wanna make sure that there's no mal-shapen sleeves. You know, if the entire fundus hasn't been mobilized, then you'll have this sort of extra gastric cells in the fundus that's producing acid and that's what's back washing the distal esophagus. So those patients also need a sleeve revision in which that excess fundus will need to be shaved off because that's, you know, the source of the acid. This patient does not have that as we can see, you know, the sleeve itself, there's no big bulky fundus over here. And so I have had patients where during the procedure I've also had to do a sleeve revision and in that scenario I would place, you know, some sort of sizing bougie and then staple it off. She fortunately does not have that. But we're also gonna do the endoscopy just to confirm the anatomy. In counseling these patients, we discuss either doing the hiatal hernia repair with the ligamentum, if they haven't had as much substantial weight loss, I think it's more than reasonable and you know, probably more favored at that point to do a conversion to a Roux-en-Y gastric bypass, and so, but for her she's had very good weight loss, she's very happy with it., you know, she's somebody who really wants to come off of medications, and so I think, you know, I thought she was a very good candidate for a ligamentum teres cardiopexy. I guess we'll do more mediastinal dissection while we're waiting. We're very high up. Okay Dr. Cherng, it's ready. Oof, okay. Do we have TilePro setup? If we don't, it's not a big deal Becks. No, not now. Okay, that's fine. Mackey, just gimme a little bit, you can start coming down. Just lemme know when you are. Mackey, I'm occluded like pretty high. So let me know when you're mid-esophagus.
CHAPTER 7
All right. I'm coming down. Okay, I'm releasing the Penrose. You're distally occluded. I'm gonna occlude you at the antrum because I just wanna see how, how well it feels as well. Oh. Can I get a quick camera clean? Hold on, gimme a second. You're at GE junction? Yep. Do you see me bouncing? What'd you say? I just need a better view. Where - I see you. Where's that? Right up at the top of the sleeve. Okay. All right, is it a straight shot down to scope? Yep, straight shot. So go all the way, keep going, you're mid-sleeve now, all right, so you're distal. I'd slowly draw back so it looks pretty straight, right? It looks very. Okay, all right, keep, keep drawing back, keep going, good, there you are. Keep going, you're there, keep going. All right, proximal sleeve is what you're in, right? Yep. Keep going back. Proximal sleeve. Lemme know when you just - yeah. GE junction is right there. Yes... I think I know where you are. Okay. Right here, right? Right where your light is? Right where I am right now is GE junction. Okay. That's pretty good actually, can you look at the distal esophagus wall? Yep. Go to about mid-esophagus, just make sure it looks okay, then come back and suction out the sleeve. Yes, the esophagus wall is good. Okay. Come back in, yep. Keep sucking - draw back and come and drop in more. I don't think I was occluding you - suction. That's my fault. Very good, keep suction in, looks better. All right, draw back and suction. Keep drawing back, there you go. All right, we need a little bit more. Okay, everything is off now. Okay. All right, you can come out. Thank you. Okay, coming out.
CHAPTER 8
So it is kind of what I expected. So you see here, you can see the lung there in the left chest. We're paralyzed, right? Okay, thank you. Okay, that's... Oh, I just need a little bit more length. Okay, I dunno why the right pleura is like really adherent. Am I - Jen? Yeah? Arm three, am I stuck on the drape or anything? Do I have more length? Oh, you're hitting arm four. Is that what it is? Okay, I know what it is, okay. Okay, I'll take a camera clean real quick. Okay, all right, we gotta commit to something here. So that's the lung, that's like weirdly stuck. Okay, this needs to go up higher. It needs to be tighter. That's the lung that's like... I just have - I think I just like have to, you know? How much more length do you need? I just need this 'cause it's just stuck there. Everything else is like so high up that I just need like this to get down. This is wild. That's better, I don't know, it's - I don't know if it's from her index surgery that it's this adherent, you know, this isn't normal. Okay, I think that's much better now, let's see. All right, can we take out the vessel sealer? All right, let's do Litwin exchanges. Yeah, that's much better. All right, vessel sealer coming out on three. Yeah. That's pretty good length. Yeah, that looks good. Yeah, all right, one for one. And open, close. Jen, you can take out the reducer for this one. I'm gonna get set up the sono. Yeah, I'll take out the reducer 'cause I'm gonna have you bring in needles next too. Why don't you bring another Litwin. I wanna switch out this. Open, close. Good, all right, so can you bring me two single arms with a pledget and then two free pledgets? Well, all right, let's bring in needles then we gotta clean the camera. That's not the cleanest. Good, open, good. And then two free's. Good. Good, got it. Take the driver and then I'll take a quick clean.
CHAPTER 9
Here's the driver. Thank you, all right, so we're gonna get ready to sew and then we're gonna reapproximate the posterior hiatus. Go ahead, so for this part I always use, you can clean the camera. This part I always use permanent suture, I always use Ethibond. Partially it's just how I was trained. I know a lot of people like to use silk, so I always use Ethibond. I always do mattress sutures to really decrease the tension. And then I reinforce with pledgets. I make my pledgets from the GORE BIO-A preformed hiatal hernia mesh. I've used regular pledgets as well, I do like them. I think it takes the tension off. This is how I close most of my hiatal hernias. So we're gonna do that first and then we will figure out the ligament. So decent fight of the right crus. These are cut at eight inches. I like to have extra - plenty of tail so I don't need to worry about that. Then I have these pledgets that are precut and then I just go through and through them. I'm just gonna go through, again, big bite here. The crura itself is a little bit beat up from me, so I'm just gonna take a decent-sized bite. I just wanna make sure that it's not twisted, and it is. All right. This is up. That's how it should look. I do a slip knot. So I close all my hiatal hernia paraesophageals, I do not do it over a Bougie, I know many people do. It just stems from my training. So how do you want it to slip, or how tight is it? Well 'cause normally in like a normal Nissen you would use like a 52 to 60 French Bougie. But I know that the sleeve and then based off the scope, you know it's an appropriate size. For our sleeves we do a 40 French Bougie, which I could easily place, but I think for me I go based off visual. And so for this - GE junction's like clearly below, I think she has a lot of laxity up here, but it still looks pretty loose. So I think I will go one more, but I like to let go. I like to loosen the Penrose to really get a good sense of what it'll sit like in the resting state. Sometimes if I feel like there's too many in the posterior cura, I'll place one at the anterior hiatus, 'cause you don't want it to go over like a ridge of tissue down at the cura. I think this is kind of loose though. Just a single though, what do you think? But for this one, I'm just gonna do... Instead of a full mattress stitch, I think I'm just, I'm just gonna do a single one just to tighten it up. It still looks big though. What do you think Mackey? Just a single. You would just do a single? I think it needs - yeah, that's the thing. Oh I could have thrown these forehand, habit. That bite can be better, there we go. Can you... Jen, you can take out arm three. I'm gonna hand you some needles in those Litwins back while we set up for the next part, and that's pretty good, take out the reducer. Let's do needles first. Open, close. All right, empties - close. All right, one Litwin - close. Yep, and then I'm gonna hand you the next one. The other Litwin, can you precut the BIO-A for me? To the rainbow? I'm gonna hand the slit one back first, then the BIO-A, I would give it a dip, good, I think we have enough length. Okay, I'll take the BIO-A. So I like to use a preform - the GORE BIO-A mesh. It's like preform specifically for the hiatus. I think it's absorbable as well, but it's nice for, you know, short-term recurrences. You'll see it sits very nicely in the hiatus. So, and then how many more single-armed Ethibonds, no pledgets do you have? I have 1, 2, 3, 4. All right, I'm gonna take three. Okay. You want them all together? Yeah, you can do that, that's fine. This is... I think that's good. Whenever you're ready, I can... Oh yeah, come on in. Great. Good, can I hand you the Penrose - open, close, good. I think the reducer and then the needle driver back and then whoever's up top, I just need about 20 minutes left, I didn't know - just about.
CHAPTER 10
Okay, so I don't sew the BIO-A in, I know some people do, I do not. So for the ligament, I bring it around posterior and I do a 270-degree wrap. At our institution, we've been doing this now for about four years and we've had very good results from it in terms of weight loss - in terms of getting patients off of reflux medications, and so when we initially started doing these, we were doing a lot of 360 and then we actually found that those were too tight. So now we've been doing 270 with the idea is that it's being anchored to the GE junction to basically act like an anchor to hold it within the abdominal cavity. So we've been doing more of that 'cause our initial results - and so right now it looks like it's on a lot of stretch, but when we take down the liver retractor, that tension will come down from the liver. So I'm not as worried about that. Now I know this is on the stomach, I'm gonna bring it up to sit at the GE junction in a second. But right now I just wanna first sew this to the GE junction. Can you hold them closed for Mackey for the end of the case? Yeah, I'm not. I do like to sew on to the left side. Some people will sew this to the crus as well. This is right about... Where GE junction is. So the idea is that this really just kind of tethers this into the abdominal cavity. And some people have more robust ligaments, and some I've had ones where they haven't had much for whatever reason if they've had other surgeries and they had to mobilize it or whatnot, and so in those patients, you know, I think you take what you can get. I mean the heart of the surgery I do believe is the hiatal hernia repair and getting well intra-abdominal length. I don't disagree with that. I think this is just sort of an extra measure because we can't do some form of a wrap. And so, I think this is a good kind of extra step that we can do for patients. You know, in terms of why not just convert to a gastric bypass. That is the big, I would say what everyone always kind of questions when we advocate for this and you know a lot of these patients, you know, they don't want a gastric bypass. They didn't want a gastric bypass when they first came through the bariatric program. They wanted a sleeve, you know these, a lot of these patients also, you know, they mainly want to come off of medications and depending on your institution, many gastric bypass patients still have to remain on some form of antacid to prevent marginal ulcers. And so - and also additionally for her who's already had substantial weight loss, she wasn't looking to have any further weight loss. And so, we're not looking to do it as a restrictive procedure. You know, if her BMI was, if her weight loss was suboptimal and her BMI was still obese and she wanted more weight loss, I think conversion to a gastric bypass is more than reasonable, but in her with the weight loss that she's had, I think this is, you know, worth doing, knowing that she has a very obvious hiatal hernia to be fixed well and then also taking the extra measure. So, okay, let's do arm three out, reduce her out. I'm gonna have you take some needles out and I am gonna take a fresh Litwin just to mop up. So right now it looks like tight, but it's, once that liver comes down, that tension will come down. So it's not, although it looks like it's being pulled over maybe a little bit. It's really not too bad.
CHAPTER 11
Let's do some needles first. Open, close, good. Open close, two needles. Mackey, can you scrub back in? Yeah, perfect, yeah, come on in, open. Can you flip your, okay, hold on. Let's just make sure nothing's bleeding, all right. So all needles should be out. And let's just do some Litwins, bring me in a second one. I just wanna make sure - it just seems oozier than I would like over here. So it looks okay, I think it's just all dependent. That looks better. All right, I'm gonna enclose the 12 port, but the where port number two is in, yeah, that's like a small hernia. So we need to like lyse that one with a figure-of-eight. Okay, Litwin and needle check. All right, so sleeve, you know, still very straight, ligament right at GE Junction, you know we have good, at least 2 cm of intra-abdominal esophageal length, hiatus is closed appropriately, reinforced with BIO-A mesh or - yeah. All right, everything out. Yeah, that arm port two I think is a small hernia. So, we should close it. Becks, I'm gonna have you go south first. Huh? I'm gonna have you go south first with the robot. Let's see the best view, let's take out the liver first. Looks pretty good actually. Yeah, can you come through arm four? Find this part? Yeah, yeah, you're fine, yeah, it's like a small hernia. Not gonna be, I don't think like the Enclose I think is gonna be hard on that. Yeah. Mackey, help me? Yeah, that's the, oh, it's huge. Can I have a snap? It's like surprisingly very large. Yeah, if I back off, but is that the umbo? How's that look? Yeah, you gotta check that. I think she has an umbilical hernia. Yeah, I think that's good, okay, you wanna hand to me and then Enclose? Does that work? Yeah, okay. So postoperatively she's gonna stay, she'll be on a liquid diet and I do a swallow study for all my hiatal hernias. So she'll get a swallow study tomorrow just for baseline anatomy. And then she'll go on - I put 'em on like a modified bariatric diet. So she'll be on protein shakes and liquids for only about a week opposed to three weeks 'cause it's, once again it's not for weight loss and so then she'll get advanced to sort of soft foods for about a month's time. I stop all their antacids right away 'cause it usually has an effect that quickly, so... Needle. I'll take another 10? Yeah, I think we've done about 75 of these. And like I said, our results have been favorable, needle. I'll take a stitch. Oh, very oozy, and then I would do standard hematocrits though for her. You would, okay. I know I didn't do a resection, but... Needle. Oozy. Dry. Ugh. Pressure, make can look nice. Yeah. And then the - I have to get the little stab that I did inside the belly button.
CHAPTER 12
The case I think ultimately went very well. However, it was fairly scarred down from the prior hiatal dissection. And so given that on the right side, I specifically saw that the pleural cavity had likely either been entered in the first procedure or I entered it because I was able to visualize the lung. It's not too surprising given that it was a redo dissection. Besides that difficulty, I think otherwise it did come together quite well. The sleeve itself looked very good. I didn't have to do a revision there. And so then I did re-approximate the posterior cura. I thought it she had very good muscle quality, so that was in her favor. For her, fortunately, her ligamentum teres was of good quality and was also adequate length. It reached nicely into the upper abdomen posterior and then lateral coming to the anterior portion of the distal esophagus, and then this was secured in place. I have seen cases where for whatever reason that ligamentum teres is foreshortened from either prior surgeries or just the patient's baseline anatomy and we're not able to perform that portion of the procedure. For this case, it's really important I think, to really counsel the patients on what it is that they want and expectations. Many patients we're seeing now that sleeve gastrectomy is the most commonly performed bariatric surgery in the country and reflux is an issue for some of these patients. I think it's important to counsel their options while, you know, traditionally it has always been a conversion to gastric bypass, we have these other surgical options, particularly if they have a very large or evident hiatal hernia on preoperative studies. And I think this is a good surgical option for patients who don't wanna take the additional risk of a gastric bypass and who don't necessarily, I would say, need the benefits of a gastric bypass, such as if they've had suboptimal weight loss and they wanted, you know, the conversion for a bypass for also to help them with their weight.