Combined minimally invasive para-esophageal hernia repair and lobectomy for lung cancer

摘要

Central MessageCombined ipsilateral para-esophageal hernia repair and lobectomy prevented life-threatening complications such as intrathoracic gastric volvulus from the presence of hernia after lobectomy. Combined ipsilateral para-esophageal hernia repair and lobectomy prevented life-threatening complications such as intrathoracic gastric volvulus from the presence of hernia after lobectomy. Herein, we report a combined minimally invasive surgical approach to manage ipsilateral para-esophageal hernia, and lung cancer concurrently, to alleviate potentially detrimental complications from the presence of hernia after lobectomy. A 61-year-old morbidly obese woman (weight: 91 kg, body mass index: 41) with a history of arterial hypertension and chronic obstructive pulmonary disease (COPD) and with a known preexisting para-esophageal hernia was referred to our attention for management of early-stage lung adenocarcinoma of the left lower lobe (T1 cN0 M0) (Figure 1, A). No other lesions were found on whole body positron emission tomography scan. The patient complained only of occasional gastroesophageal reflux; for that her local gastroenterologist did not recommend surgical correction. After preoperative multidisciplinary assessment, the patient was scheduled for concomitant laparoscopic hernia repair and thoracoscopic lobectomy. The patient was intubated with a double-lumen tube and the para-esophageal hernia was repaired through a standard laparoscopic approach. The hernia containing the stomach was reduced, and the hernia sac was excised. The gastric lipoma and gastric vessels were resected using LigaSure (Medtronic) up to the left crura of the diaphragm. The hiatal hernia defect was closed with interrupted sutures, followed by a Dor fundoplication. Then, the patient was placed in a right lateral decubitus position and a standard triportal thoracoscopy with anterior access was performed. The pulmonary ligament was carefully resected from the hernia sac using a Harmonic device (Ethicon Endo-Surgery Inc), and the inferior pulmonary vein was isolated and mechanically resected. Then, the fissure between the S5 and S7 segment, the A6 artery branch, the basal pyramid artery, and the lower bronchus were sequentially stapled. After retrieval of the specimen, a radical lymphadenectomy completed the procedure, and 1 chest tube for drainage was left in the pleural cavity. Video 1 summarizes the procedure. Total operative duration was 235 minutes, with 100 minutes for hernia repair and 135 minutes for lobectomy. The total estimated blood loss was 270 mL and no intraoperative issues were found. Surgical pathology confirmed a pT1 cN0 M0 adenocarcinoma, with negative surgical margins. Postoperative course was unremarkable. Chest drainage was removed 3 days later, and the patient was discharged 5 days after the operation. At 1-month follow-up, a computed tomography scan (Figure 1, B) and barium swallow radiograph showed expansion of the remaining lobe without hernia recurrence. The patient did not have symptoms of reflux and was able to tolerate an oral diet. The patient was followed with computed tomography scan every 3 months for the first 2 years for lung cancer and with yearly esophagogram for hernia repair. The patient gave a written informed consent for this publication. Thoracoscopic lobectomy is the recommended approach for management of early-stage lung cancer in high-risk patients at present, due to incurring less surgical trauma compared with thoracotomy,1Paul S. Altorki N.K. Sheng S. Lee P.C. Harpole D.H. Onaitis M.W. et al.Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database.J Thorac Cardiovasc Surg. 2010; 139: 366-378Abstract Full Text Full Text PDF PubMed Scopus (623) Google Scholar but a preexisting para-esophageal hernia may increase the risk of postoperative morbidity and mortality. Ten previous cases reported intrathoracic gastric volvulus resulting f