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provided by Elsevier - Publisher Connector International Journal of Surgery (2008) 6, 490e492

www.theijs.com

Thoracic aortic during laparoscopic fundoplication for reflux esophagitis

Fumiaki Yano, Nobuo Omura*, Kazuto Tsuboi, Hideyuki Kashiwagi, Katsuhiko Yanaga

Department of Surgery, Jikei University School of Medicine, Nishi-Shinbashi 3-25-8, Minato-ku, Tokyo 105-8461, Japan

Published online 8 September 2006

KEYWORDS Abstract A 72-year-old man with reflux esophagitis visited our department with a chief com- Thoracic aortic injury; plaint of coughing at night. Since he had a large sliding esophageal hiatal hernia that was Reflux esophagitis; increasing in size, he underwent laparoscopic fundoplication. While dissecting the left side Laparoscopic of the esophagus with laparosonic coagulating shears, the wall of the thoracic started fundoplication to bleed. The procedure was urgently converted to open surgery, and the pinhole aortic injury site was suture-obliterated. Thereafter Toupet fundoplication was performed, and the patient did not develop any postoperative complications. To our knowledge, only one other case of aortic injury unrelated to trocar insertion has been reported. ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Introduction We report a case of a patient who developed massive bleeding due to injury of the thoracic aorta during laparo- Laparoscopic surgery is a standard approach for the surgical scopic Toupet fundoplication for the treatment of reflux treatment of gastroesophageal reflux disease (GERD), and esophagitis. To the best of our knowledge, this is the the Nissen and Toupet methods are mainly used for this second case of intraoperative aortic injury unrelated to trocar insertion occurring during laparoscopic anti-reflux purpose. The outcome of surgery using these methods has 4 been reported to be excellent with a success of over 90%.1 surgery. The complications of laparoscopic surgery for GERD include intraoperative and postoperative ones. Intraoper- Case report ative complications include , bleeding and 2,3 . The frequencies of these complications A 72-year-old man regularly visited our hospital for the as well as the rate of conversion to laparotomy have treatment of heartburn. He was prescribed lansoprazole decreased with increasing our experience of laparoscopic (15 mg p.o.). His esophagitis was in Grade M of the Los surgery. Angeles classification. He then suffered from coughing at night. Since he had a large sliding esophageal hiatal hernia * Corresponding author. Tel.: þ81 3 3433 1111; fax: þ81 3 5472 that was increasing in size, he underwent laparoscopic 4140. Toupet fundoplication in September 2003. During the opera- E-mail address: [email protected] (Nobuo Omura). tion, the first trocar was inserted by the open method. Four

1743-9191/$ - see front matter ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2006.07.007 Aortic injury during fundoplication 491 other trocars were placed under videoscopic guidance. The patient was then placed in the head-up position. All short gastric vessels were separated using laparosonic coagulating shears (LCS) to mobilize the stomach. Next, the right side of the esophagus was mobilized. The abdominal esophagus was encircled and pulled down using a 10-F Penrose drain. While dissecting the left side of the esophagus with LCS (Fig. 1), the wall of the thoracic aorta started to bleed (Fig. 2). The hemorrhage decreased when the Penrose drain was pushed cephalad. However, fresh pulsatile bleeding recurred when the pressure was released. For the next 20 min, we tried unsuccessfully to detect the bleeding point. We therefore urgently converted the procedure to a laparotomy. As soon as we opened the patient’s abdomen, we visualized a 2 mm pinhole on the anterior wall of the supraceliac aorta. We dissected the crus of the diaphragm while the bleeding point was manually obliterated with finger pressure. Using Figure 2 Bleeding from the thoracic aorta was encountered a 3-0 Prolene suture, the bleeding point was suture-obliter- immediately after the procedure described in Fig. 1. ated. After complete hemostasis was obtained, Toupet fun- doplication was performed. The operation time was 255 min and intraoperative blood loss was 4000 ml. Postoperatively, symptoms.7 Increased experience and the improvement in the patient was admitted to the intensive care unit (ICU) due operative techniques and instruments have resulted in a de- to deterioration of gas exchange and metabolic acidosis. By creased rate of conversion to laparotomy (5% or less) and the first day after surgery, metabolic acidosis had disap- the mortality rate is now between 0% and 0.1%.8,9 The rea- peared and his respiratory status improved. Therefore, the sons for conversion to laparotomy are mostly adhesions in patient was extubated and was transferred to the regular the abdomen, and in some cases bleeding or splenic surgical ward. Water intake was started on the third postop- injury.10 However, the occurrence of these complications erative day and meals on the next day. He was discharged is low and we consider that in our hands laparoscopic on the 13th postoperative day. He has been followed up as anti-reflux surgery is now a much safer procedure. an outpatient, and up to the present time (34 months) has We have been performing laparoscopic surgery since remained in good condition without reflux or bloating 1994 and have experienced perioperative complications in symptoms. 13 (7.6%) out of 170 cases. Hemorrhage from short gastric vessels and splenic injury was the most frequent complica- Discussion tion, accounting for 5.2% of all laparoscopic surgical cases. Other complications consisted of esophageal perforation and a tension pneumothorax. This patient is the first case of Laparoscopic anti-reflux surgery is a standard approach for thoracic aorta injury. Leggett et al. reported the first case treatment of GERD. The outcome has been reported to be of such a complication at the level of the abdominal comparable to that of laparotomy with favorable long-term esophagus during laparoscopic fundoplication.4 In that results.5 In addition, this procedure has been reported to case, the patient died due to uncontrollable hemorrhage, be effective for the typical symptoms of GERD,6 including and the bleeding point was finally confirmed at autopsy. cough, chest pain and odynophagia, as well as for atypical To our knowledge, 96 cases of aortic injury caused at the time of trocar insertion during laparoscopic surgery have been reported,11 while only one report has documented aortic injury unrelated to trocar insertion. It was a needle injury of the aorta at the level of the hiatus. In our patient, the thoracic aorta was injured the de- tachment of the left side of the mediastinal esophagus. After the operation, we checked the video showing the operative procedures and found that the bleeding had occurred when the operator had detached the connective tissue surrounding the esophagus without confirming the location of the blade of the LCS. Actually, we could not confirm whether the blade of the LCS touched the aorta or not, but we believe that the bleeding was caused by the contact of the LCS with the aorta or by cavitation. Surgical treatment of GERD is performed in many elderly patients, and the thoracic aorta may be twisted in these patients. Thus, we believe that in order to avoid severe complications such as massive bleeding, it is impor- Figure 1 Periesophageal tissues was dissected to expose the tant to confirm the location of the LCS blade when detaching esophagus. The left crus of the diaphragm is shown with the connective tissues and vessels from the esophagus as arrows. well as the course of the aorta during the operation. 492 F. Yano et al.

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