Esophageal Duplication Cyst -- A Guest Case in Robotic and Computer-Assisted Surgery From the University of Nebraska Medical Center

Chad Ringley, MD; Victor Bochkarev, MD; Dmitry Oleynikov, MDSeries Editors: Brant K. Oelschlager, MD; Carlos A. Pellegrini, MD

Disclosures

November 02, 2006

Case Report

The patient is a 23-year-old woman with a history of dysphagia and chest pain. As part of the initial work-up, she underwent an abdominal/pelvic CT scan that revealed a distal esophageal mass. She then underwent an upper gastrointestinal study (Figure 1), chest CT scan (Figure 2), and upper endoscopy to further evaluate the radiographic finding.

Upper gastrointestinal study shows mass effect of the cyst.

CT scan shows typical round mass displacing the esophagus.

The upper gastrointestinal double-contrast study revealed a submucosal mass in the distal esophagus with concave margins. The mass was located in the right posterior esophagus, 10 cm proximal to the gastroesophageal junction. The chest CT scan with oral and intravenous contrast revealed a 2.1- x 2.2-cm intramural distal esophageal mass on the right side. The lesion appeared to cause some mass effect on the esophageal lumen, without obstruction. There was some hypodensity noted within the mass. Likewise, the esophagogastroscopy revealed an extrinsic mass effect on the esophageal mucosa proximal to the gastroesophageal junction. Except for a small hiatal hernia, no other mucosal abnormalities were revealed. The remainder of the patient's medical history was unremarkable, including no chronic illness or previous surgery. Physical examination was normal.

The patient was scheduled for a laparoscopic robotic-assisted enucleation of the esophageal mass via a transhiatal approach.

Video clip: da Vinci Cystectomy Click "Play" to view the video.

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Following induction of general anesthesia and endotracheal intubation, 4 ports were placed. The camera port was placed 3 cm above the umbilicus just left of the midline. Two 10-mm ports were introduced just caudal to the costal margin on the left, one at the midclavicular line and one in the anterior axillary line. The final port was introduced in the right upper quadrant in the midclavicular line, 5 cm below the costal margin. A laparoscopic liver retractor was placed through the epigastrium to lift the left lobe of the liver anteriorly.

Conventional laparoscopy was used to expose the esophageal hiatus. The gastrohepatic ligament was divided with ultrasonic shears exposing the right crus of the diaphragm. The remainder of the hiatus was then exposed and defined with both blunt and sharp dissection, again with ultrasonic shears. Upon exposure of the esophagus at the hiatus, a penrose drain was placed around the gastroesophageal junction to provide caudal retraction. Extended mediastinal esophageal mobilization was then undertaken until the proximal extent of the cyst was identified.

The robotic cart was positioned and docked. An esophageal myotomy was initiated 2 cm distal to the cyst with hook cautery and continued over the cyst until its anterior surface was completely exposed. With the use of blunt and sharp dissection, the cyst was enucleated and separated from the esophageal mucosa. It was subsequently placed in a specimen bag and extracted from the abdominal cavity. A thorough inspection of the mucosa, including a leak test, did not reveal any lacerations of the mucosa or communication with the esophageal lumen.

The myotomy was loosely reapproximated with 2-0 silk suture in a running fashion over the endoscope. A posterior cruroplasty was performed with 0 silk stitches, and then a standard Dor fundoplication was created covering the myotomy site.

On postoperative day 1, an upper gastrointestinal exam showed no evidence of a leak. The patient was started on a liquid diet and reported no dysphagia; she was discharged home on postoperative day 1. Pathologic examination of the specimen revealed characteristics consistent with a developmental esophageal duplication cyst.

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