Paraesophageal Hernia Repair
ward.
Followed by Cardiac Tamponade
Caused by ProTacks
Wojciech Makarewicz, MD, PhD, Łukasz Jaworski, MD,
Maciej Bobowicz, MD, Krzysztof Roszak, MD,
Krzysztof Jaroszewicz, MD, Jan Rogowski, MD, PhD,
Tomasz Jastrze˛bski, MD, PhD, and
Janusz Jaśkiewicz, MD, PhD
Department of Oncological Surgery, Academic Clinical
Center, Medical University of Gdansk, Gdansk; General
Surgery Department, Specialist Hospital in Koscierzyna,
Koscierzyna; and Department of Cardiac Surgery, Academic
Clinical Center, Medical University of Gdansk, Gdansk,
Poland
We describe a case of cardiac tamponade caused by
ProTacks Autosuture used for mesh fixation during a
laparoscopic Nissen operation with giant paraesopha-
geal hernia repair. Perforations of the posterior descen-
dent artery and epicardial vein of the right ventricle
were caused by ProTacks used for Parietex Composite
Mesh fixation. Protruding ProTacks were secured from
inside the pericardiac sac with a synthetic vascular
patch during emergency sternotomy. Quick and multi-
disciplinary cooperation ended with emergency car-
diothoracic procedure saving the patient’s life and
preventing further damage to the heart muscle and its
vessels.
(Ann Thorac Surg 2012;94:e87–9)
© 2012 by The Society of Thoracic Surgeons
W e report a case of cardiac tamponade caused by
ProTacks Autosuture (Covidien, Norwalk, CT)
used for mesh fixation during a laparoscopic Nissen
operation with giant paraesophageal hernia repair. The
treatment of choice for advanced gastrointestinal reflux
disease (GERD), especially accompanied by large para-
esophageal hernia, is the laparoscopic tension-free
(floppy) Nissen procedure. Frequently, esophageal hiatus
requires additional reinforcement with synthetic mesh
that can be sutured or stapled. Among possible compli-
cations of such procedures are: postoperative leak, recur-
rent hernia, wound infection, esophageal erosion, and
migration of mesh [1, 2].
We describe the initial operation with its postoper-
ative course as well as the emergency operation and its
findings to make surgeons aware of possible life-
threatening complications of antireflux surgery. Most
of the cases of cardiac tamponade described previously
were fatal [3–5].
A 69-year-old female patient (American Society of An-
aesthesiology score 2; body mass index, 40 kg/m2), with
comorbid arterial hypertension suffering from GERD and
stage III paraesophageal hernia (Fig 1), was qualified
to undergo a laparoscopic “floppy” 360-degree Nissen
Accepted for publication March 23, 2012.
Address correspondence to Dr Bobowicz, Department of Oncological
Surgery, Academic Clinical Center, Medical University of Gdansk,
Debinki 7, Gdansk 80-211, Poland; e-mail: mbobowicz@gumed.edu.pl.
© 2012 by The Society of Thoracic Surgeons
Published by Elsevier Inc
operation with mesh reinforcement in a general surgical
Standard principles of the laparoscopic, tension-free
Nissen operation were followed. Short gastric vessels
were clipped, and the gastric fundus was dissected
free. Mediastinal adhesions were dissected, and gastric
fundus and trunk were retrieved from mediastinum.
Next, paraesophageal adhesions were liberated, allow-
ing mobilization of the abdominal portion of esopha-
gus. Two nonabsorbable stitches were applied to the
diaphragmatic crura. Gastric fundus was carried be-
hind the esophagus toward its front, and three nonab-
sorbable sutures were applied to fix the plication.
Hiatoplasty was performed with use of Parietex Com-
posite Mesh (Sofradim Production; Covidien, Trevoux,
France) that was fixed to the diaphragm with six
ProTacks Autosuture (Covidien, Norwalk, CT). The
operative time was 180 min, and the blood loss was
minimal.
At the third postoperative day, the patient collapsed
with signs of acute heart failure and low output syn-
drome secondary to cardiac tamponade. The patient
was transferred to the Department of Cardiac Surgery
of the Medical University of Gdansk as an emergency.
On admission, the patient was anuric, anemic (hemo-
globin, 6.7 g/dL), acidotic (pH, 7.3; plasma concentra-
tion of lactate, 3.5 mmol/L), and the blood pressure was
stabilized with the use of high-dose catecholamines.
Echocardiography showed a layer of up to 3 cm of fresh
blood with clots in the pericardium.
On emergency sternotomy, approximately 1500 mm3
of hemolyzed blood with clots was retrieved from
pericardial sac. Two ProTacks autosutures (3 cm medi-
ally from the inferior vena cava) penetrating into the
pericardial sac were noted (Fig 2). An actively bleeding
perforation of the posterior descendent artery (up to 1
mm) was found on the inferior surface of the heart
muscle. Following heparinization with 5000 IU of hep-
arin and closure of the right cardiac artery with clamps
and heart surface stabilization with Octopus system
(Medtronic, Minneapolis, MN), perforation of the pos-
terior descendent artery was sewn with interrupted
Prolene 7.0 suture (Ethicon, Johnson & Johnson Com-
pany, San Lorenzo, PR). Moreover, the damage to the
heart muscle of the right ventricle and epicardial vein
of the right ventricle was noted and it was sewn with
interrupted Prolene 6.0 sutures. Protruding ProTacks
were covered and secured with a synthetic vascular
patch (Bard Peripheral Vascular, Inc, Tempe, AZ) from
the inside of pericardiac sac (Fig 3). The drain was left
and the chest was closed in standard fashion with
metal sutures for sternum. The patient remains in good
health and asymptomatic of preoperative GERD, para-
esophageal hernia, and postoperative cardiac
complications.
Comment
Laparoscopic Nissen operation with mesh reinforce-
ment remains the most popular operation for symp-
tomatic GERD with paraesophageal hernia. Use of
mesh for hiatal closure decreases the recurrence rates
from 15% to 2.6% [6]. Surgical complications of the
Nissen procedure include: postoperative leak, recur-
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2012.03.107
e88 CASE REPORT MAKAREWICZ ET AL
CARDIAC TAMPONADE AND PROTACKS
Fig 1. Preoperative computed tomographic
image of a hiatal hernia. (A) Lateral. (B)
Anteroposterior.
rent hernia, visceral injury, wound infection, obstruct-
ing fundoplication, empyema, small bowel obstruction,
retained foreign body, periesophageal hematoma, and
incisional hernia [7]. Serious complications include
intraoperative esophageal or gastric perforation, pneu-
mothorax, postoperative esophageal erosion, and mi-
gration of the mesh [1, 2, 8]. Among the most serious
and life-threatening complications is pericardiac
tamponade.
To our knowledge, there are just a few reports on
pericardiac tamponade following a Nissen operation
with mesh reinforcement, and none secondary to the
use of ProTacks, probably because of the fatal course of
these events [3–5]. We would like to emphasize the
importance of careful intraoperative assessment of the
diaphragm and adequate choice of the mesh fixation
approach.
Fig 2. ProTacks visible on the cardiac side of pericardium during
emergency surgery.
Ann Thorac Surg
2012;94:e87–9
ProTacks Autosuture approved by the U.S. Food and
Drug Administration and designed for mesh fixation in
most of the conditions should not cause any damage to
the pericardium. Nevertheless, in some patients it
might not be the best option because of the thin
diaphragm and pericardium, and consideration should
be given to other approaches. In our opinion the
interrupted suture in these patients seems to be supe-
rior to ProTacks in regard to safety, although it is
difficult to educe such patients from the general pop-
ulation. There might be a future use for the spray
tissue glue that holds the mesh and does not seem to
cause serious side-effects, although there are still is-
sues concerning its laparoscopic application.
We describe a dramatic complication of a standard
procedure of fundoplication that, thanks to the quick and
multidisciplinary cooperation, resulted in emergency
cardiothoracic surgery saving the patient’s life and pre-
Fig 3. Vascular patch sewn over the ProTacks.
Ann Thorac Surg
2012;94:e87–9
venting further damage to the heart muscle and its
vessels.
The authors thank Joanna Jassem-Bobowicz, MD, (Medical Uni-
versity of Gdansk) for help in preparing the manuscript.
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