LAPAROSCOPIC HELLER MYOTOMY FOR TREATMENT OF ACHALASIA

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1 LAPAROSCOPIC HELLER MYOTOMY FOR TREATMENT OF ACHALASIA JL Holihan, LR Hafen, MK Liang, University of Texas Health Science Center at Houston, Houston, TX Background: Achalasia is a rare esophageal dismotility disorder characterized by impaired relaxation of the lower esophageal sphincter and lack of peristalsis of the esophagus due to the loss of enteric neurons. Patients typically complain of dysphagia, weight loss, regurgitation, and/or chest pain. Achalasia can be treated with pneumatic dilation or surgically with Heller myotomy combined with an anti-reflux procedure. This is a case report of a 26 year old male diagnosed with achalasia. Methods: The patient had a 15 year history of dysphagia. He underwent esophagogastroduodenostomy (EGD) which revealed a tortuous, dilated esophagus that was filled with fluid despite being NPO for 12 hours. Manometry was attempted, but the scope could not be passed through the lower esophageal sphincter. He also had an esophagram that showed a dilated esophagus with no peristalsis, confirming the diagnosis of achalasia. He underwent pneumatic dilation of the esophagus which improved his dysphagia, but symptoms returned after a few months. The decision was then made to treat his achalasia surgically. Results: The patient was taken to the operating room, where he underwent a laparoscopic Heller myotomy, cruralplasty, partial fundoplication, and abdominal and thoracic omental flap. The patient had an esophagram on post operative day 1 which showed no leak. By post operative day 3, he was tolerating a regular diet and was discharged home. Conclusion: Heller myotomy and partial fundoplication is an acceptable option for the treatment of achalasia. To prevent progressive esophageal dilation and sigmoid esophagus, early definitive treatment is needed. It is the preferred treatment for young patients and in patients who have failed medical management.

2 LAPAROSCOPIC MORGAGNI HERNIA REPAIR Hafen LR, Liang MK, UT Health Science Center at Houston, Houston, TX Background: Congenital diaphragmatic hernias (CDH) occur between 1 in 2,000 to 5,000 births. The exact pathophysiology is unknown but likely related to genetic and environmental factors. The vast majority of these hernias are of the Bochdalek variety (either right- or left-sided posterolateral defects) and manifest prenatally or immediately after birth due to pulmonary hypoplasia and pulmonary hypertension. Less than 2% of CDH are of the Morgagni variety, located anteromedially near the junction of the central tendon and anterior thoracic wall. Morgagni hernias often present incidentally, later in life. Surgery is indicated due to symptoms or to prevent the risk of incarceration and strangulation. Methods: A 55 year-old patient presented for bilateral total hip arthroplasty and became hypoxic prior to surgery. Chest computed tomography angiogram was performed revealing a right Morgagni hernia with a 6 cm diaphragm defect containing a large amount of omentum. There was compression of the right atrium and atelectasis of the right middle lobe. The patient was scheduled for elective repair of his CDH. Results: A laparoscopic repair was performed. The falciform ligament was divided and the entire greater omentum was reduced from the hernia sac. The peritoneum was incised around the defect and the hernia sac was completely excised. Trans-fascial sutures were placed to reattach the diaphragm to the anterior abdominal wall. A 15 cm round mesh coated with an antiadhesion barrier was used to reinforce the defect repair. The mesh was secured with transfascial sutures and titanium tacks. The patient was discharged on post-operative day 1 and returned to clinic in two weeks for routine follow-up. Conclusion: Adult presentation of a primary diaphragmatic hernia is uncommon. Laparoscopic repair is safe and feasible. Key technical components include complete sac excision, primary repair of the diaphragmatic defect, and mesh reinforcement.

3 ROBOT ASSISTED RESECTION OF INFLAMED GIANT SUBCARINAL BRONCHOGENIC CYST V Fikfak, P Gaur, M Kim, Houston Methodist Hospital, Houston, TX Background: Operative resection for bronchogenic cysts is reserved for symptomatic lesions which are most commonly large and inflamed and as such may pose a significant operative challenge. We present the utility and advantages of robotic assisted resection of large bronchogenic cysts when compared to open thoracotomy. Methods: We evaluated two patients with an inflamed giant subcarinal bronchogenic cyst. The first is a 49 year old man who presented to an outside hospital with symptomatic atrial fibrillation and CT scan findings significant for 6x7cm subcarinal mass compressing the left atrium. The second patient was a 59 year old woman who presented with persistent caught. A workup including a CT and an MRI of the chest revealed an inflamed subcarinal bronchogenic cyst which had increased in size to 6cm in diameter from 3.9cm four years prior. Results: Due to the size and proximity to the surrounding tissues we approached the subcarinal cyst in the 49 year old male patient through a posterolateral thoracotomy. The patient tolerated the procedure well and was discharged home on postoperative day 4, however was readmitted for pain control one week later. He required pain medication for two months. Robotic assisted resection of the subcarinal cyst was performed in the 59 year old patient. Using five robotic ports the pleura overlying the cyst was divided and after resection of the dome of the cyst, the cyst was decompressed allowing resection of the posterior wall. The patient tolerated the procedure well and was discharged home on postoperative day two requiring minimal pain medication. Conclusion: Robot assisted resection of large inflamed subcarinal bronchogenic cysts with intraoperative cyst decompression presents a good alternative to posterolateral thoracotomy and results in shorter length of stay and decreased requirement for pain medication.

4 LAPAROSCOPIC REPAIR OF FLUOROSCOPIC GUIDED GASTROSTOMY TUBE PLACEMENT THROUGH THE TRANSVERSE COLON Patrick Nguyen; Edward Shipper; Richard Peterson, University of Texas Health Science Center at San Antonio, San Antonio, TX Background: Percutaneous fluoroscopic gastrostomy tube placement has been found to be safe and simple in establishing a method of providing enteral nutrition. Additionally, it has been theorized as a safer alternative to percutaneous endoscopic gastrostomy tube placement in patients with head and neck cancers. Methods: A 66-year-old man with a history of throat cancer is presented documenting a complication of percutaneous fluoroscopic gastrostomy tube placement through the transverse colon requiring operative management. Results: A 66-year-old man with head and neck cancer with dysphagia and failed modified swallow study underwent percutaneous fluoroscopic gastrostomy tube placement. On postprocedure day two, pneumoperitoneum was noted on chest x-ray status post intubation for respiratory failure. Prior to intubation the patient had no complaints of abdominal pain. A CT scan of the abdomen revealed the gastrostomy tube traversing the transverse colon. The patient was taken to the operating room for a diagnostic laparoscopy with repair of the two colotomies and replacement of the gastrostomy tube endoscopically under laparoscopic assistance. The patient tolerated the procedure well and was discharged to rehab. Conclusion: Percutaneous fluoroscopic gastrostomy tube placement has a described 99% success rate. Major complications as defined by procedure-related mortality, complications that require surgery or intensive care, or bleeding that require specific treatment are rare with a 1.4% incidence. Colonic injury after percutaneous fluoroscopic gastrostomy tube placement is extremely rare. When recognized early primary laparoscopic repair is a feasible and safe option in the treatment of this unfortunate complication.

5 INTRODUCTION OF CADAVERS INTO LAPAROSCOPIC SKILLS TRAINING J Uecker, A Miller, UT-Southwestern Austin General Surgery Program, Austin, TX Background: The spectrum for surgical resident laparoscopic skills training outside of the operating room is very broad. Low-fidelity trainers are cheap, but often fail to recreate anatomy. High-fidelity simulators offer tactile feedback and display anatomy, but can be prohibitively expensive. We sought to create a laparoscopic skills training program that would recreate the operative experience within a moderate budget. Methods: During quarterly cadaveric labs, the general surgery residents watch a video of an operation performed by an attending surgeon. Then they complete the same procedure, which is recorded using the technology present in the operating room. The PGY-1s completed a laparoscopic cholecystectomy, while the PGY-3s and PGY-5s performed laparoscopic splenectomy and laparoscopic Heller myotomy respectively. An attending-level surgeon watches the live video feed and provides real time recorded audio feedback and critique on surgical technique. This video is then returned to the resident for review. Results: Feedback has been overwhelmingly positive, prompting a formal study for which data collection is in progress. Initial data collected from pre and post lab surveys of the resident participants suggests they were significantly more comfortable with many steps of the operations after just one lab. At an annual cost of approximately $5000, covering two cadavers for four labs, this training model is far cheaper and more realistic than high-tech simulators. Conclusion: This program was developed to provide surgical laparoscopic simulation at a price point significantly lower than other high-fidelity trainers. Our initial impression is that this is an efficient and meaningful way to spend our resident learners education time. We get the added benefit of direct feedback from experienced surgeons in a recorded audio and video format that is easily edited for future teaching. Given the positive feedback, we plan to expand this model both within our program and to other residency programs in the region.

6 ROBOTIC-ASSISTED HEINEKE-MIKULICZ PYLOROPLASTY AND GASTRIC ELECTRICAL STIMULATION (ENTERRA ) THERAPY FOR DIABETIC AND POST-SURGICAL GASTROPARESIS: A CASE REPORT Kent R. Van Sickle, MD, FACS, Morgan Floyd, MS, University of Texas Health Science Center San Antonio, San Antonio, TX Background: We present a case of a 57 year-old woman with a 10-year history of Diabetes Mellitus (DM), hypertension (HTN), anxiety and arthritis who underwent a laparoscopic Nissen fundoplication and hiatal hernia repair with biologic mesh that developed post-operative dysphagia, nausea, vomiting, inability to tolerate oral intake and weight loss. Evaluation of her symptoms included a barium swallow, CT scan with oral contrast, upper endoscopy, gastric emptying study, esophageal manometry and ph monitoring. Work-up demonstrated retained food in the stomach on EGD, delayed gastric 4hrs with post-prandial hyperglycemia and normal CT scan and esophageal motility. The patient was offered a gastric emptying procedure and the gastric electric stimulator (Enterra ) for gastroparesis. The procedure was performed robotically, with a Heineke-Mikulicz pyloroplasty and intra-operative EGD to confirm successful Enterra lead placement. The patient recovered uneventfully and has shown improvement in symptoms in the early post-operative period. Methods Results Conclusion