Background

Roux-en-Y gastric bypass is a common treatment for patients with obesity. Long-term complications include strictures, ulcers, and hiatal hernias. Hiatal hernias can cause serious complications such as necrosis, perforation, or obstruction. Here, we report a minimally invasive surgical (MIS) approach to an intrathoracic gastric perforation due to pouch necrosis.A 52-year-old male with a Roux-en-Y gastric bypass 17 years prior presented emergently overnight with acute epigastric pain and dyspnea. Computed tomography revealed complete intrathoracic pouch migration into a large hiatal hernia containing free fluid and gas. During an emergent robotic diagnostic laparoscopy with fluorescent cholangiography by an acute care surgeon, a gastric pouch perforation with surrounding necrosis was identified. An advanced foregut surgeon then performed a stapled partial pouch resection with a simultaneous hiatal hernia repair using biologic mesh. The patient was discharged home after 3 days and continues to do well.Intrathoracic gastric perforations are uncommon with serious complications. Furthermore, pouch necrosis as the etiology in patients with remote bariatric surgical history is rare when compared to marginal ulcers. This is the first case report to our knowledge over 20 years that presents a combination of such pathology managed robotically. We suggest that with early recognition the trans-abdominal MIS approach is a viable option that can avoid the morbidity and mortality associated with open abdominal and thoracic approaches. Additionally, this case demonstrates the benefit of the collaboration between acute care surgeons and foregut specialists as well as the emergent availability of advanced technology.