WOFAPS 2025 8th World Congress of Pediatric Surgery

Esma Sehoviç Keçik ¹, Samir Hasan ², Zafer Dökümcü ²

¹ İstinye Üniversite Hastanesi Medical Park Gaziosmanpaşa Çocuk Cerrahisi AD, İstanbul, Türkiye
² Ege University Faculty of Medicine, Department of Pediatric Surgery, Izmir, TURKEY

Background:
Congenital hiatal hernia (CHH) is a rare but recognized condition in infants. However, not all CHHs are simply “hernias.” In rare cases, they may conceal a congenital short esophagus (CSE), where the gastroesophageal junction (GEJ) remains intrathoracic despite full mobilization, requiring a different surgical strategy.

Case Presentation:
A 4-month-old male infant (approx. 7 kg) was referred for surgical evaluation after a routine echocardiogram incidentally revealed a mass adjacent to the heart. The only clinical symptom was feeding fatigue—short breastfeeding sessions with frequent pauses, without vomiting or weight loss. Imaging suggested CHH.

Robotic exploration revealed a fixed intrathoracic GEJ, no hernia sac, and a severely foreshortened, thin-walled esophagus. These findings confirmed the diagnosis of true CSE — a condition sometimes debated, but clearly evident here. Anatomical markers included the absence of a hernia sac, failure to reduce the GEJ despite full mediastinal mobilization, and a high phrenoesophageal ligament insertion site.

A Collis gastroplasty was performed to achieve esophageal length, followed by a Nissen fundoplication and hiatal closure—entirely robotically. All trocars were placed through a low Pfannenstiel incision, under the diaper line, for a scar-free outcome. Due to the small working space, ports were placed before robotic docking.

The postoperative course was uneventful. The patient was discharged on full oral feeds without vomiting, retching, or other complaints.

Conclusion:
To our knowledge, this is the youngest reported case of robotic Collis-Nissen repair for CSE. At 4 months of age and ~7 kg, this case approaches the lower practical limits for robotic surgery, highlighting its feasibility in complex foregut pathology. CSE is not a myth, but a rare anatomical reality requiring surgical precision and individualized planning.