Background

This is a video case report of a 53 year-old female with morbid obesity (BMI 41) who originally underwent robotic-assisted gastric band removal, splenectomy due to band erosion, sleeve gastrectomy, and hiatal hernia repair with mesh (June 2022 at an outside facility). The patient then presented a month after her index operation with abdominal pain and was found to have a gastric sleeve leak at the cardia in the area of the band removal, with associated abscess requiring percutaneous drainage. The leak was initially managed with antibiotics and distal feeding access; however, with persistent leak, the patient was transferred to our bariatric center. Other endoscopic therapies, including endovac and endoscopic sutures were attempted, but unsuccessful in closing the gastric defect. Therefore, she underwent robotic-assisted repair of her recurrent hiatal hernia with mesh excision, partial gastrectomy, and Roux-en-Y esophagojejunostomy. Intraoperatively, a large full thickness gastric defect was noted just distal to the gastroesophageal junction. This defect was associated with mesh erosion that extended into the gastroesophageal junction. Mediastinal dissection was performed with at least 3 cm of intra-abdominal esophageal mobilization. The proximal stomach resection included the gastroesophageal junction, and perfusion to the distal esophagus and remnant distal stomach was confirmed with indocyanine green fluoroscopy. Postoperatively, the esophagram demonstrated no leak, and the diet was advanced per bariatric pathway. Her BMI had decreased to 25 at the 6 month follow-up.