Incidental Mediastinal Lipoma During Laparoscopic Nissen Fundoplication. What is the Surgical Strategy?

Lipomas in the mediastinum are very rare. They only constitute about 1.6–2.3% of all primary mediastinal tumors. When they grow large, they may exert a mass effect and compress adjacent structures (esophagus, airways, heart, vessels), leading to dysphagia, respiratory symptoms, arrhythmia, and even cardiac compression in severe cases. Case reports exist of large mediastinal lipomas compressing the esophagus and leading to dysphagia, or compressing the heart and leading to cardiovascular disorders. The presence of a "significantly sized lipoma" in the hiatus may complicate proper dissection and make it difficult to create a proper fundoplication. If not properly addressed, it can predispose the individual to postoperative dysphagia. In other words: the lipoma may interfere with adequate mobilization of the esophagus, closure of the crura, and creation of the wrap and carry the risk of an unfavorable anti-reflux operation or mechanical problems.