CASE STUDYPARAESOPHAGEAL

HERNIA

Repair of Paraesophageal Herniation Post Mini- Gastric Bypass Using MIROMESH™ Biologic MatrixStudy conducted by Frank J. Borao, MD, FACS, FASMBS, Foregut Surgeon, Director for theCenter of Minimally Invasive Esophageal and Gastric Surgery and Director of Bariatric Surgery,Monmouth Medical Center, Long Branch, New Jersey

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Overview 68-year-old female

Height 5' 7"

Weight 195 lbs.

BMI 30 kg/m2

Previous Surgeries Mini-gastric bypass

Incarcerated ventral hernia repair with mesh

Abdominoplasty

Total abdominal hysterectomy with bilateral salpingo-oophorectomy

Cholecystectomy

Spinal fusion

Relevant History Hypertension

Chronic anemia

Motor vehicle accident in 2012, resulting in abdominal trauma

Presenting Symptoms Retrosternal pain, diffi culty eating, GERD, vomiting and recurrent

pneumonia from aspiration

Evaluation CT scan noted the gastric pouch in the posterior mediastinum

Hernia Type Paraesophageal hernia

PATIENT INFORMATION

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ProcedureThe patient was positioned in lithotomy, and five trochars were inserted along the subcostal margin. There were extensive adhesions from prior multiple abdominal surgeries. The gastric pouch from her “mini-gastric bypass” was herniated into the posterior mediastinum (Image 1). The stomach was reduced out of the chest after placement of a Penrose drain to provide traction, and the hernia sac was excised, obtaining 3 centimeters of intra-abdominal esophageal length (Image 2). Posterior diaphragmatic crural closure was performed with non-absorbable sutures (Image 3) followed by placement of a 6 x 8 cm MIROMESH, which was secured with two sutures to prevent movement (Image 4), and then fibrin glue was used for additional support (Image 5). Intra-operative upper endoscopy was performed noting no obstruction to the passage of the endoscope across the hiatus and into the loop gastro-jejunostomy (Image 6).

Image 4 Image 5 Image 6

Image 1 Image 2 Image 3

Duodenum

Jejunum

Bypassed portion of small intestine

New stomachBypassed portion of stomach

MINI-GASTRIC BYPASS

Digestive Juice

Food

customerservice@miromatrix.com 952.942.6000 miromatrix.com

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Hospital CourseOn post-operative day one, an upper GI series was performed with no obstruction to passage of contrast into the gastric pouch and filling of both jejunal limbs (image below). The patient was started on a liquid diet and discharged home later that evening.

Follow UpAt two-month follow up, the patient had complete resolution of her pre-operative symptoms and was eating with no difficulty.

Clinical EvaluationCompared to various different biologic meshes that we have used in several hundred cases, MIROMESH is unique in regards to its composition (hepatic versus dermal) and ease of placement. Suture fixation is quite simple, and the flexibility of the product allows it to sit nicely along the diaphragmatic surface. Further evaluation is still needed to see if long-term recurrence rates will decrease.

Post-Operative Day 1

INTENDED USE: The Miromatrix Biologic Mesh is intended to be implanted to reinforce soft tissue.

The physician’s views represented in this case study do not necessarily represent the views of Miromatrix Medical Inc.