Cardiothoracic Surgery: Cardiology and Cardiothoracic Surgery |

Concurrent Robotic-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair With Nissen Fundoplication and Robotic-Assisted Video-Thoracoscopic Pulmonary Lobectomy for Lung Cancer: A Case Report FREE TO VIEW

Eric Toloza, MD; David Straughan, MD; Jonathan Hernandez, MD; Joseph Garrett, ARNP-C; Maki Yamamoto, MD; Tannous Fakhry, MD; Carla Moodie, PA-C; Kenneth Meredith, MD
Author and Funding Information

Moffitt Cancer Center, Tampa, FL

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A45. doi:10.1016/j.chest.2016.02.048
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SESSION TITLE: Cardiology and Cardiothoracic Surgery

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Stage-3A non-small cell lung cancer (NSCLC) is generally treated with induction chemotherapy and radiation therapy (chemo-RT), followed by surgery, possibly by minimally invasive approach. Paraesophageal hiatal hernia complicated by gastric volvulus should be surgically repaired, preferably via laparoscopy. We describe a case of concurrent robotic-assisted paraesophageal hernia repair with Nissen fundoplication and robotic-assisted pulmonary lobectomy.

CASE PRESENTATION: A 64-year-old diabetic man, with 160-pack-year tobacco history, was diagnosed with 6.3-cm right upper lobe (RUL) lung mass, with enlarged hilar and subcarinal lymph nodes (LNs), but without distant metastasis. Needle biopsies of the RUL lung mass and para-azygous LNs revealed CK7-positive/TTF1-positive adenocarcinoma, confirming stage-3A NSCLC. Gastric volvulus, complicating his paraesophageal hernia, was treated non-surgically but delayed initiation of induction therapy. He then underwent induction carboplatin/paclitaxel chemotherapy x7 weeks, with concurrent 50-Gy XRT in 35 fractions. Laparoscopic reduction of paraesophageal hernia and resection of hiatal hernia sac, followed by robotic-assisted laparoscopic crurapexy and Nissen fundoplication. Under same anesthesic, he underwent robotic-assisted thoracoscopic RUL lobectomy and mediastinal LN dissection. Total operative (skin-to-skin) time was 545 min, with 341 min for paraesophageal hernia repair and 204 min for lobectomy, with estimated blood loss of 360 mL. Postoperative course was complicated by pulmonary embolus on postoperative day (POD) #3, atrial fibrillation with rapid ventricular rate on POD#5, dysphagia requiring repeated swallow evaluations and slow advance to regular diet, prolonged air leak, and enlarging right pneumothorax after chest tube removal, requiring CT-guided right pleural pigtail catheter. Pathology revealed 4-cm poorly-differentiated carcinoma, 99% necrotic or fibrotic, with all 13 hilar and mediastinal LNs uninvolved by NSCLC. On POD#17, he was discharged home on therapeutic dalteparin, with pigtail catheter connected to Pneumostat valve, removed on POD#26.

DISCUSSION: Robotic-assisted paraesophageal hernia repair with Nissen fundoplication and robotic-assisted pulmonary lobectomy have each been reported as feasible and safe, but both procedures under the same anesthesia has not been reported. Our patient’s comorbidities and induction chemo-RT likely contributed to postoperative complications, but he successfully underwent these 2 complex procedures.

CONCLUSIONS: We report the first known concurrent robotic-assisted paraesophageal hernia repair with Nissen fundoplication and robotic-assisted pulmonary lobectomy. Combined complex abdominal and thoracic robotic-assisted operations are feasible and safe.

Reference #1: Seetharamaiah, R., et al. JSLS 17(4):570-577, 2013.

Reference #2: Park, B. J., et al. J Thorac Cardiovasc Surg 143(2):383-390, 2012.

Reference #3: Park, B. J. Thoracic Surgery Clinics 24(2):1-113, 2014.

DISCLOSURE: The following authors have nothing to disclose: Eric Toloza, David Straughan, Jonathan Hernandez, Joseph Garrett, Maki Yamamoto, Tannous Fakhry, Carla Moodie, Kenneth Meredith

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