A rare presentation of gastric outlet obstruction following a robotic-assisted Nissen fundoplication: a case report

Background: There has been wide adoption of robotically assisted anti-reflux operation amongst thoracic surgeons in the last decade. Improved ergonomics, dexterity and visualization have overcome the limitations of laparoscopy, but the outcome differences remain widely debated. Currently, there is limited data to suggest robotic assisted anti-reflux operations reduce post-operative morbidity in comparison to laparoscopic approach. Transmediastinal wrap migration, slippage, crural and wrap disruption are known short and longterm complications following anti-reflux operations. There are few reports that discuss gastric volvulus as a long-term failure finding after robotic-assisted anti-reflux operations. We highlight a rare presentation of acute gastric volvulus 6 months after robotic assisted Nissen fundoplication. Case Description: A 75-year-old female underwent a robot-assisted Nissen fundoplication for refractory gastroesophageal reflux disease (GERD), and presented with gastrointestinal disturbances, 6 months following index surgery. She underwent radiographical studies that demonstrated a subdiaphragmatic gastric volvulus. Resultantly, she underwent emergency takedown of the fundoplication and subsequent gastropexy. No resection was required as endoscopic evaluation intraoperatively did not yield frank necrosis. She tolerated the operation well and was discharged on post-operative day 3. Conclusions: Gastric volvulus after robotic assisted Nissen fundoplication is a rare but potentially lethal complication. Prompt diagnosis and emergency surgical intervention is needed to salvage the stomach. Potential intervention may include taking down the fundoplication to return the stomach to its original anatomical position by gastropexy.