We would like to acknowledge the Division of Thoracic and Foregut Surgery and the Department of Surgery at the University of Minnesota for helping us proceed with this study.

The protocol and methods described here were approved and followed the ethical guidelines of the Institutional Review Board (IRB) of the University of Minnesota. Described here is a reoperative hiatal hernia repair and takedown of a previous Nissen fundoplication in a 73-year-old woman. The patient presented to the clinic with a history of laparoscopic hiatal hernia repair and a fundoplication 5 years ago at an outside hospital for epigastric pain and fullness after meals. She also complained of significant reflux and dysphagia with solid food intake. Her symptoms had temporarily resolved after the first surgery but had now recurred. Of note, her body mass index (BMI) at the time of consultation was 40. No previous preoperative workup could be obtained prior to the consultation. The patient provided written informed consent before redo&#160;foregut surgery.
1. Patient preparation and operative set-up
<ol>
	<li>Preoperative workup and testing
	<ol>
		<li>Discuss the possibility of reoperation and proceed with a thorough workup as mentioned:
		<ol>
			<li>Perform an esophagram. The esophagram of this patient showed moderate to severe esophageal dysmotility (Figure 1).</li>
			<li>Perform endoscopy. For this patient, upper endoscopy showed no stenosis or strictures but&#160;demonstrated a portion of the stomach herniating upward through the diaphragm on a retroflexed view, which confirmed a hiatal hernia.</li>
			<li>Perform computed tomography of the abdomen. This test also confirmed a herniated wrap (Figure 2).</li>
			<li>Perform wireless esophageal pH testing. This showed a DeMeester score24,25 of 38.4 with borderline symptom association probability for acid reflux.</li>
			<li>Perform high-resolution manometry. In this patient, it showed a nonspecific motility disorder.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Preoperative planning
	<ol>
		<li>Ensure initial recommendations include weight loss and hence referral to a bariatric surgeon if needed. 
		NOTE: The patient did well with the weight loss program and could bring down her weight to a BMI of 32. At this point, she continued to have symptoms, and&#160;her case was discussed at the multidisciplinary esophageal conference for operative planning. The consensus was that the manometric findings were likely due to reflux and hernia and that a reoperative hernia repair with a loose fundoplication would be appropriate.</li>
	</ol>
	</li>
	<li>Anesthesia
	<ol>
		<li>Perform anesthesia following institutional guidelines. Intubate the patient with a single lumen endotracheal tube with rapid sequence intubation because of the risk of aspiration from reflux and a hiatal hernia. She had an arterial line for hemodynamic monitoring.</li>
	</ol>
	</li>
	<li>Positioning
	<ol>
		<li>Position the patient supine with her arms out and a footboard to facilitate steep reverse Trendelenburg positioning26.&#160;The chest and abdomen are always prepped into the field for foregut surgeries to have adequate access to the abdomen and chest if needed.</li>
	</ol>
	</li>
	<li>Port placement and docking
	<ol>
		<li>Use the open Hasson technique27 to enter the peritoneal cavity in the left supra-umbilical space. Insert the camera port here.</li>
		<li>Insert two more 8 mm ports in the left upper quadrant and one 8 mm port in the right upper quadrant. Place the ports about 10 cm above the umbilicus and ensure a handbreadth space between the ports.</li>
		<li>Place the assistant port in the right lower quadrant. Insert the liver retractor (see Table of Materials) through a 5 mm port placed in the extreme lateral portion of the right upper quadrant. 
		NOTE:&#160;It is the authors&#39; preference to place a left-sided chest tube during surgery because the hernia sac tends to be tethered to the pleura, especially in reoperative surgeries.</li>
		<li>Perform this before starting the dissection to minimize the chances of having to undock and reposition during the operation if there are significant hemodynamic changes from a pneumothorax that develops acutely during dissection.</li>
		<li>Dock the robot (see Table of Materials).</li>
	</ol>
	</li>
</ol>
2. Surgery procedure
<ol>
	<li>Reducing hiatal hernia
	<ol>
		<li>Remove&#160;the adhesions of the bowel to the abdominal wall and open the gastrohepatic ligament&#160;using a robotic bipolar surgical energy device.</li>
		<li>Open the lesser sac by removing adhesions and additional short gastric artery branches.</li>
		<li>Dissect&#160;the hernia sac&#160;circumferentially at the hiatus using a combination of blunt and electrocautery dissection with the robot.</li>
		<li>Dissect the dense adhesions between the liver and stomach carefully with laparoscopic scissors (see Table of Materials).</li>
	</ol>
	</li>
	<li>Takedown of previous fundoplications. 
	NOTE: Some but not all sutures from the previous wrap were visible.
	<ol>
		<li>Perform sharp dissection with laparoscopic scissors and undo the wrap to completely free the stomach.</li>
		<li>Carefully stay in the thin scar tissue to avoid damage to the stomach or esophagus.</li>
	</ol>
	</li>
	<li>Esophageal mobilization
	<ol>
		<li>Mobilize the esophagus transhiatally in the mediastinum. Perform this with a combination of blunt and sharp dissection and minimize the use of energy close to the esophagus.</li>
		<li>Next, confirm at least 3 cm of intraabdominal esophagus length. Use endoscopy to locate the gastroesophageal&#160;junction (GEJ)&#160;and measure the esophagus from the hiatus to the GEJ to confirm the adequate length.</li>
	</ol>
	</li>
	<li>Leak test
	<ol>
		<li>Perform endoscopy and visualize the mucosa clearly to ensure no injuries. Fill the upper abdomen with warm water and&#160;insufflate the esophagus and stomach to ensure no air leakage.</li>
	</ol>
	</li>
	<li>Hiatal repair
	<ol>
		<li>Perform crural repair using 0-silk sutures with two posterior crural stitches and one anterior crural stitch.</li>
		<li>Pass a 56 Fr bougie (see Table of Materials) into the esophagus, and with the bougie in place, pass a grasper comfortably into the hiatus. This is to ensure that the crural repair was not too tight.</li>
	</ol>
	</li>
	<li>Nissen fundoplication
	<ol>
		<li>Bring the fundus across the right side, posterior to the esophagus, and under the vagus nerve.</li>
		<li>Pass a 58 Fr bougie (see Table of Materials) into the esophagus.</li>
		<li>Perform a loose fundoplication over the bougie with three 2-0 silk sutures. 
		NOTE: Endoscopy confirmed a loose stack of coin-like appearance.</li>
	</ol>
	</li>
	<li>Gastropexy and G tube
	<ol>
		<li>Insert a percutaneous endoscopic gastrostomy tube into the stomach to serve as a gastropexy and a venting tube.</li>
	</ol>
	</li>
</ol>
3. Follow-up procedure
<ol>
	<li>Postoperatively, administer antiemetics to minimize the risk of postoperative nausea and vomiting as&#160;retching can disrupt the hernia repair or cause early recurrence.</li>
	<li>Initially, the gastric tube is left open to serve as a vent to prevent gastric distention. Eventually, clamp it on postoperative day 2 or 3 once the patient is tolerating liquids.</li>
	<li>Provide the patient with ice chips on the night of surgery. On postoperative day 1, ask the patient to start with sips of clear liquids with the gastric tube still open. On postoperative day 2, initiate a clear liquid diet and if the patient tolerates well, clamp the gastric tube. 
	NOTE: If tolerating clear liquids while clamped, a full liquid diet is started.</li>
	<li>Finally, instruct the patient on the advancement to a soft diet after 1 week with plans for clinic follow-up in 4 weeks with an esophagram and plans for gastric tube removal if not requiring significant venting.</li>
</ol>

Reoperative Hiatal Hernia Repair

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A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+transoral+incisionless+fundoplication+(TIF)+on+subjective+and+objective+GERD+indices:+a+systematic+review+of+the+published+literature.">Impact of transoral incisionless fundoplication (TIF) on subjective and objective GERD indices: a systematic review of the published literature.</a> Surgical Endoscopy. 27 (10), 3754-3761 (2013).</li><li>Parker, B., Reavis, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Benign+Esophageal+Disease.">Benign Esophageal Disease.</a> , 71-89 (2021).</li></ol>

The authors have nothing to disclose.

Reoperative foregut surgery is technically challenging but can be performed safely with a well-planned and thoughtful surgical approach. A thorough preoperative evaluation is essential to determine the etiology of symptoms and to guide diagnostic adjuncts. It is of utmost importance to determine the correct diagnosis prior to reintervention in order to determine the proper surgery and approach. For example, in patients undergoing redo&#160;anti-reflux&#160;surgery (ARS) after Nissan fundoplication, one should understand the primary symptoms the patient is experiencing.&#160;In those who have gas-bloat symptoms, pain and dysphagia as their primary problems, some studies have demonstrated that conversion to a Toupet fundoplication may reduce postoperative dysphagia and gas-bloat symptoms28,29.&#160;Similarly, in patients with altered esophageal motility after previous foregut surgery, a partial wrap such as a Toupet may be preferred over a complete wrap like a Nissen30. In another example, when treating pseudoachalasia, one must determine the underlying etiology of dysmotility - if secondary to malignancy, this may involve esophagectomy versus redo anti-reflux surgery in the case of an improperly constructed wrap31,32,33. Failure to recognize this may result in increased complexity and morbidity, particularly during redo foregut surgery.
Even with a complete preoperative evaluation, it is impossible to predict every challenge that will be faced intraoperatively; therefore, the foregut surgeon must be familiar with various access techniques and surgical approaches. Multiple studies have demonstrated the safety of various redo foregut procedures via a minimally invasive approach5,6,34,35. Regardless, the foregut surgeon should be ready to convert to an open approach or consider it from the onset if dictated by the case. In some instances, it may be necessary to use an alternate approach. Using complex recurrent hiatal hernias as an example, in order to achieve adequate intra-abdominal esophageal length, a transthoracic approach, such as a Belsey Mark IV repair, may be necessary to adequately mobilize the esophagus36.
Other times, a different surgical procedure might be necessary depending on previous surgery or intraoperative complications. The hiatal mesh may be associated with a more complex resection, including the esophagus or stomach, and thus require major reconstruction9,10. While redo fundoplication is the most common approach after failed anti-reflux surgery, there is an increased likelihood of alterations in the regional blood supply from previous dissection; therefore, hollow viscus injury, GEJ devascularization, and vagal nerve division are more likely37. Roux-en-Y reconstruction rather than fundoplication may be needed in these cases where there is injury, severe scarring precluding fundoplication, esophageal dysmotility or delayed gastric emptying38.
Endoluminal therapies have become an attractive option for treating foregut diseases such as achalasia and reflux. Although transoral incisionless fundoplication (TIF) has increased in popularity, it has demonstrated less complete control of GERD versus laparoscopic fundoplication12,39 and therefore may require revisional surgery. In TIF, the use of multiple full-thickness fasteners can result in traction diverticula and be a source of leak if removed. To minimize this, these fasteners should be sharply divided rather than pulled out and diverticula resected or imbricated to prevent leaks12,13,40. Although the foregut surgeon may not routinely perform these advanced endoscopic procedures, a thorough understanding is necessary if attempting to revise surgically.
In conclusion, reoperative foregut surgery presents a significant technical challenge. The surgeon must be adept in abdominal and thoracic surgery, open and minimally invasive approaches. Furthermore, with advances in endoscopic techniques, the surgeon must be familiar with these procedures before re-intervention. An exhaustive preoperative workup is essential. It is important to establish a clear indication that reoperation will likely benefit the patient and improve the quality of life.

Over the past century, improvements in the understanding and diagnosis of foregut disorders have led to the evolution of better procedures and surgical approaches. This innovation brings new challenges related to complications and reoperation for the foregut surgeon. Surgical reinterventions are particularly challenging from a technical perspective due to multiple factors, including dense adhesions, scarring, obliteration of tissue planes, and altered anatomy1,2,3,4,5. These redo foregut surgeries&#160;have increased morbidity in patients with higher incidences of esophageal perforation, delayed gastric emptying, and vagal nerve injury1,6,7,8. Mesh repairs at the hiatus complicate reintervention further, having higher rates of major resection requiring complex reconstruction9,10. The advent of advanced endoscopic therapies creates ever-evolving challenges for foregut surgeons when dealing with their associated complications or failures11,12,13. Furthermore, redo foregut operations are associated with worsening success rates and patient satisfaction with successive reoperations compared with primary intervention14,15,16,17. This highlights the importance of patient selection and accurate diagnosis prior to redo surgery for optimal outcomes.
While traditionally performed using an open approach, laparoscopic approaches to redo foregut surgery are safe and efficacious14,18. However, due to the greater difficulty associated with altered anatomy and adhesions, conversion to open surgery is still a possibility. With the emergence of robot-assisted surgery in urology and gynecologic surgery19,20, the superior visualization and dexterity compared to laparoscopy would appear to likely have some benefit in redo foregut surgery as well. Indeed, emerging research has shown safety and improved outcomes, including less conversions to open surgery and decreased hospital stays compared with the laparoscopic approach for redo foregut surgery21,22,23.
Although it is ultimately up to the foregut surgeon to determine the safest procedure, this article aims to demonstrate the approach and technical considerations for redo foregut surgery to provide a &#34;framework&#34; when confronted with this challenge. While a robotic-assisted approach is described, the principles described could be similarly applied to laparoscopy.

<table><tbody><tr><td>Bravo calibration-free reflux testing system</td><td>Medtronic</td><td>FGS-0635</td><td>Wireless esophageal pH testing system</td></tr><tr><td>Cadiere forceps</td><td>IS</td><td>470049</td><td>Used as a grasper</td></tr><tr><td>da Vinci Surgeon Console</td><td>IS</td><td>SS999</td><td>Used to control surgical robot</td></tr><tr><td>da Vinci Vision Cart</td><td>IS</td><td>VS999</td><td>Houses advanced vision and energy technologies to provide communication across the platform components</td></tr><tr><td>da Vinci Xi</td><td>IS</td><td>K131861</td><td>The surgical robot</td></tr><tr><td>da Vinci Xi Endoscope with Camera, 8 mm, 30&amp;deg;</td><td>IS</td><td>470027</td><td>The camera for the da Vinci robot</td></tr><tr><td>Lapro-Flex Articulating Retractors</td><td>Mediflex</td><td>91682</td><td>Used as liver retractor</td></tr><tr><td>Large needle driver</td><td>IS</td><td>470006</td><td>Used as a needle driver</td></tr><tr><td>Maloney Tapered Esophageal Bougie, 56 Fr</td><td>Pilling</td><td>507956</td><td>Esophageal bougie for hiatal repair</td></tr><tr><td>Maloney Tapered Esophageal Bougie, 58 Fr</td><td>Pilling</td><td>507958</td><td>Esophageal bougie for wrap creation</td></tr><tr><td>Mega SutureCut needle driver</td><td>IS</td><td>470309</td><td>Used as a needle driver</td></tr><tr><td>Monolithic FlexArm Plus</td><td>Mediflex</td><td>99045-QC</td><td>Used to hold liver retractor to OR bed</td></tr><tr><td>Round tip scissors</td><td>IS</td><td>470007</td><td>Used for cutting</td></tr><tr><td>Shiley Hi-Lo oral/nasal endotracheal tube cuffed, 8.0 mm</td><td>Covidien</td><td>86113</td><td>Endotracheal tube for intubation</td></tr><tr><td>SynchroSeal</td><td>IS</td><td>480440</td><td>Used for dissecting, vessel sealing, and dividing</td></tr><tr><td>Tip-Up fenestrated grasper</td><td>IS</td><td>470347</td><td>Used as a grasper</td></tr></tbody></table>

technical considerations and approach to redo foregut surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

The patient had an uneventful postoperative course. She slowly advanced to a full liquid diet over a period of 3 days and was then discharged on a liquid diet with instructions to advance to a soft diet after 1 week.
By virtue of being a quaternary referral center and a major university hospital, we frequently manage patients needing reoperative foregut surgery. Our data from the last 5 years with 43 patients undergoing reoperative hiatal hernia repairs showed a mean length of stay of 7 days and a 23% 30-day complication rate. The outcomes are summarized in Table 1. Most published data on reoperative hiatal hernias show similar outcomes1,2,6,18.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65532/65532fig01.jpg" /> 
Figure 1: Esophagram demonstrating moderate to severe esophageal dysmotility. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65532/65532fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/65532/65532fig02.jpg" /> 
Figure 2: Abdominal CT scan demonstrating a herniated Nissen fundoplication wrap. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65532/65532fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Value</td>
			<td>Total</td>
			<td></td>
		</tr>
		<tr>
			<td>N</td>
			<td>43</td>
			<td></td>
		</tr>
		<tr>
			<td>Age (years)</td>
			<td>58.9</td>
			<td>&#177; 15.5</td>
		</tr>
		<tr>
			<td>Average length of stay (days)</td>
			<td>7</td>
			<td>&#160;&#177;&#160; 5.7</td>
		</tr>
		<tr>
			<td>30 day mortality (n, %)</td>
			<td>1</td>
			<td>2.30%</td>
		</tr>
		<tr>
			<td>30 day morbidity</td>
			<td>10</td>
			<td>23.20%</td>
		</tr>
		<tr>
			<td>Return to operating room</td>
			<td>2</td>
			<td>4.70%</td>
		</tr>
		<tr>
			<td>Other invasive procedure</td>
			<td>2</td>
			<td>4.70%</td>
		</tr>
		<tr>
			<td>Pneumonia</td>
			<td>3</td>
			<td>7.00%</td>
		</tr>
		<tr>
			<td>Respiratory failure</td>
			<td>3</td>
			<td>7.00%</td>
		</tr>
		<tr>
			<td>Surgical site infection</td>
			<td>3</td>
			<td>7.00%</td>
		</tr>
		<tr>
			<td>Transfusion</td>
			<td>4</td>
			<td>9.30%</td>
		</tr>
		<tr>
			<td>Post-operative atrial fibrillation</td>
			<td>2</td>
			<td>4.70%</td>
		</tr>
		<tr>
			<td>30 readmission rate&#160;</td>
			<td>4</td>
			<td>9.30%</td>
		</tr>
		<tr>
			<td colspan="3">Continuous data summarized as mean &#177; SD; Categorical data expressed as frequency and percentage</td>
		</tr>
	</tbody>
</table>
Table 1: Postoperative outcomes after redoing hiatal hernia repair. Continuous data are summarized as mean &#177; SD; categorical data are expressed as frequency and percentage.

Watch this Scientific Journal Video about Technical Considerations and Approach to Redo Foregut Surgery at JoVE.com

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

technical-considerations-and-approach-to-redo-foregut-surgery

Nanyang Technological University

Research

JoVE Journal

Medicine

416 Views.  University of Minnesota. Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Video: Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Roux-en-Y Gastric Bypass Operation in Rats

Currently, the most effective therapy for the treatment of morbid obesity to induce significant and maintained body weight loss with a proven mortality benefit is bariatric surgery1,2. Consequently, there has been a steady rise in the number of bariatric operations done worldwide in recent years with the Roux-en-Y gastric bypass (gastric bypass) being the most commonly performed operation3. Against this background, it is important to understand the physiological mechanisms by which gastric bypass induces and maintains body weight loss. These mechanisms are yet not fully understood, but may include reduced hunger and increased satiation4,5, increased energy expenditure6,7, altered preference for food high in fat and sugar8,9, altered salt and water handling of the kidney10 as well as alterations in gut microbiota11. Such changes seen after gastric bypass may at least partly stem from how the surgery alters the hormonal milieu because gastric bypass increases the postprandial release of peptide-YY (PYY) and glucagon-like-peptide-1 (GLP-1), hormones that are released by the gut in the presence of nutrients and that reduce eating12.
During the last two decades numerous studies using rats have been carried out to further investigate physiological changes after gastric bypass. The gastric bypass rat model has proven to be a valuable experimental tool not least as it closely mimics the time profile and magnitude of human weight loss, but also allows researchers to control and manipulate critical anatomic and physiologic factors including the use of appropriate controls. Consequently, there is a wide array of rat gastric bypass models available in the literature reviewed elsewhere in more detail 13-15. The description of the exact surgical technique of these models varies widely and differs e.g. in terms of pouch size, limb lengths, and the preservation of the vagal nerve. If reported, mortality rates seem to range from 0 to 35%15. Furthermore, surgery has been carried out almost exclusively in male rats of different strains and ages. Pre- and postoperative diets also varied significantly.
Technical and experimental variations in published gastric bypass rat models complicate the comparison and identification of potential physiological mechanisms involved in gastric bypass. There is no clear evidence that any of these models is superior, but there is an emerging need for standardization of the procedure to achieve consistent and comparable data. This article therefore aims to summarize and discuss technical and experimental details of our previously validated and published gastric bypass rat model.

Numerous studies using gastric bypass rat models have been recently conducted to uncover the underlying physiological mechanisms of Roux-en-Y gastric bypass operations. This article aims to demonstrate and discuss the technical and experimental details of our published gastric bypass rat model to understand advantages and limitations of this experimental tool.

Currently, the most effective therapy for the treatment of morbid obesity to induce significant and maintained body weight loss with a proven mortality ...

An Ivor Lewis Esophagectomy Designed to Minimize Anastomotic Complications and Optimize Conduit Function

We describe a novel esophagogastric anastomotic technique (&ldquo;side-to-side: staple line-on-staple line&rdquo;, STS) for intrathoracic anastomoses designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply. This technique aims to minimize the incidence of anastomotic leaks and strictures, which is a frequent source of morbidity and occasional mortality after esophagectomy. We analyze the results of this STS technique on 368 patients and compared outcomes to 112 patients who underwent esophagogastric anastomoses using an end-to-end stapler (EEA) over an 8-year time interval at our institution.
The STS technique involves aligning the remaining intrathoracic esophagus over the tip of the lesser curve staple line of a stomach tube, created as a replacement conduit for the esophagus. A linear stapling device cuts through and restaples the conduit staple line to the lateral wall of the esophagus in a side-to-side fashion. The open common lumen is then closed in two layers of sutures.
There was a total of 12 (3.8%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis. Two of eight patients (25%) had anastomotic leaks after esophagectomy for end-stage achalasia as compared to a 2.8% leak rate (10/336) after esophagectomy for other conditions. Eighteen (5.2%) patients required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of patients undergoing STS anastomoses following hospital discharge. In contrast, patients undergoing EEA anastomoses demonstrated anastomotic leak and stricture rates of 16.1% and 14.3% respectively (p&lt;0.01). Time analysis of postoperative contrast studies following the STS technique typically demonstrated a straight/uniform diameter conduit with essentially complete contrast emptying into the small bowel within 3 minutes in 88.4% of patients.
The incidence of esophagogastric anastomotic leaks and strictures were extremely low using this novel anastomotic technique. Additionally we believe that based on time and qualitative analyses of postoperative contrast studies, this technique appears to optimize postoperative upper gastrointestinal tract function; however, further comparative studies are needed.

We describe a novel intrathoracic esophagogastric anastomotic technique designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply to minimize the incidence of anastomotic leaks and strictures. Construction and orientation of the stomach conduit designed to optimize upper gastrointestinal tract function is also described.

We describe a novel esophagogastric anastomotic technique (&ldquo;side-to-side: staple line-on-staple line&rdquo;, STS) for intrathoracic anastomoses ...

Cancer Research

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Robotic Myotomy and Partial Fundoplication for Achalasia

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller myotomy has emerged as an alternative approach to traditional laparoscopy due to three-dimensional (3D) visualization, fine motor control, and improved ergonomics provided by the robot. 
Although there is a lack of randomized controlled trials, robotic-assisted Heller myotomy seems to be associated with lower rates of intraoperative perforations compared to the laparoscopic approach. A robotic approach may also improve surgical outcomes by providing a more complete myotomy. 
Here, we describe the detailed steps of robotic myotomy and partial fundoplication for achalasia.

Surgical myotomy with a partial fundoplication may be used in selected patients as a definitive treatment for achalasia. This article provides a step-by-step description of a robotic myotomy and partial fundoplication in a 32-year-old patient with megaesophagus.

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller ...

Surgical Treatment of Gastroparesis

Gastroparesis and intestinal dysmotility are life-altering diagnoses with no cure. Lifestyle changes, pharmacological, and surgical interventions are combined in a multidisciplinary fashion to improve the quality of life in this patient population. Starting with lifestyle changes, adjustments are made to the types and amounts of food consumed, medical conditions are optimized, and the use of narcotic pain medications as well as smoking is discontinued. For many, these changes are not enough, and antiemetics and promotility agents are used to control symptoms. Finally, when these measures fail, patients turn to surgery, which can include surgical alterations to the stomach, implantation of a gastric stimulator, placement of drainage tubes, and possibly even the complete removal of different organs, including the stomach or gallbladder. In our clinic, patients not only see a surgeon but also a gastroenterologist, dietitian, and psychologist. We strongly believe in a multidisciplinary approach to this condition. The goal is to provide patients with hope and help them live fuller and happier lives.
The study primarily addresses technical considerations and the surgical approach for patients diagnosed with gastroparesis. It outlines the entire process, starting from preparations before the surgery, encompassing the preoperative work-up, and detailing the steps involved in the surgical procedure. One of the key diagnostic challenges faced in treating gastroparesis patients is determining the underlying cause of the condition, as this information is critical for selecting the appropriate surgical intervention. Once the patient&#39;s condition has been categorized based on the cause, the medical team engages in a discussion with the patient regarding potential treatment options, which may include endoscopic procedures, minimally invasive techniques, or open surgery.

Gastroparesis is a condition in which the stomach does not empty properly. While it is initially managed with lifestyle modifications and medications, some patients eventually require surgical intervention. This study focuses on the technical considerations and surgical approaches for dealing with gastroparesis patients, which include endoscopic, minimally-invasive, and open surgical techniques.

Gastroparesis and intestinal dysmotility are life-altering diagnoses with no cure. Lifestyle changes, pharmacological, and surgical interventions are ...

Robotic Vagus-Sparing Total Gastrectomy for CDH1 Gene Mutation Treatment

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric cancer and is nearly impossible to detect by screening gastroscopy. The recommended preventative treatment is a total gastrectomy. Robotic surgery facilitates the use of minimally invasive surgical (MIS) techniques for anastomoses and posterior vagus preservation to potentially reduce adverse functional outcomes. An asymptomatic 24 year old male with the CDH1 gene mutation proven by genetic testing and a family history of a brother having a total gastrectomy for HDGC was treated with this technique. This video case report demonstrates the techniques and pitfalls of robotic surgery in terms of the patient positioning and port placement, posterior vagus-preserving dissection, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy. While these techniques are demonstrated in the case of prophylactic gastrectomy, many of them can be applied to other benign and bariatric foregut and general surgery types.Robotic surgery can facilitate the foregut MIS technique, as described in this case of a vagus-sparing total gastrectomy.

This article focuses on robotic vagus-sparing total gastrectomy. The techniques and pitfalls of vagus preservation, sutured esophagojejunostomy, jejunal pouch formation, and Roux-en-Y reconstruction with a staple-stapled jejunojejunostomy are discussed.

Hereditary diffuse gastric cancer (HDGC) caused by the CDH1 gene mutation is an inherited cancer syndrome that increases the risk of diffuse gastric ...

Treatment of Achalasia by Robot-Assisted Heller Myotomy

Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the failure of the LES to relax. Patients typically complain of dysphagia, chest pain, and regurgitation. They often report drinking liquids with solids intake to help propel food boluses into the stomach. The diagnosis of achalasia is typically confirmed with an esophagogram and a motility study (esophageal manometry). An esophagogram classically shows the bird beak sign with tapering in the distal esophagus. The treatment for achalasia includes both surgical and non-surgical options. Surgical treatment is associated with a lower rate of recurrences, high clinical success rate, and durability of symptom relief. The current gold standard of surgical technique is myotomy, or the dividing of the muscle fibers of the distal esophagus. Surgical myotomy can be accomplished via a laparoscopic or robotic technique; per-oral endoscopic myotomy is a new alternative intervention. Due to the theoretical risk of gastroesophageal reflux following a myotomy, an antireflux procedure is sometimes performed. We reviewed the approach to a robotic heller myotomy for the treatment of achalasia.

Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia

The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia.

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the ...

Surgical Management of Persistent or New Symptoms After Hiatal Hernia Repair

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. These may include recurrent reflux, dysphagia, regurgitation, weight loss, or deteriorating quality of life. While nonoperative management can be pursued in some patients, reoperation may be the only option in select patients. A thorough preoperative workup, including a repeat esophagram, upper endoscopy, +/- chest computed tomography (CT) scan, manometry, pH probe, and/or gastric emptying study, is warranted to better understand the pathophysiology of the presenting symptoms. If a recurrent hernia, slipped, or migrated wrap is identified, surgery is considered. Pseudoachalasia must also be ruled out if obstructive symptoms are observed at the hiatus. Such an exhaustive workup is indeed necessary to ensure accurate diagnosis and optimal outcome. In addition, an understanding of the factors that may have led to the recurrence will increase the chances of a successful reoperation. Although a technically demanding procedure, redo hiatal hernia repair utilizing a minimally invasive approach is increasingly being employed with promising outcomes. Herein, the steps of a redo hiatal hernia repair via a minimally invasive approach will be outlined and detailed.

Redo foregut surgery is challenging in today's clinical practice and is fraught with increased morbidity and reportedly a lower 'success' rate than the index procedure. Here, we present a protocol for a redo hiatal hernia repair via a minimally invasive approach.

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. ...

Single Incision Plus One Port Laparoscopic Proximal Gastrectomy with Double Channel Anastomosis for Gastric Cancer Treatment

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for treating proximal gastric cancer. This technique includes comprehensive laparoscopic resection of the proximal stomach, lymph node dissection, and double-tract anastomosis. By integrating single-port laparoscopic surgery with an auxiliary operating hole, SILT-DT reduces procedural difficulty while facilitating the placement of an abdominal drainage tube. Compared to the traditional five-port laparoscopic gastrectomy, SILT-DT requires fewer ports and results in shorter incision lengths, contributing to reduced postoperative pain and faster recovery. A thorough preoperative evaluation was conducted to ensure procedural success, with factors such as tumor size, stage, location, and patient BMI carefully considered. This comprehensive assessment allowed for optimal patient selection and surgical planning. Postoperative follow-up demonstrated no significant complications, underscoring the safety and efficacy of SILT-DT. This innovative technique offers a promising minimally invasive alternative for managing proximal gastric cancer while maintaining excellent clinical outcomes.

The single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis was initially employed for the radical resection of proximal gastric cancer. This study demonstrated the feasibility of the procedure and laid a foundation for further research.

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for ...