Strangulated Paraesophageal Hernia Requiring Laparoscopic Total Gastrectomy

Abstract

Introduction: Hiatal hernias are classified into four types.1 A type III hiatal hernia is a combination of types I and II where both the fundus and gastroesophageal junction herniate through the hiatus.2 Elective surgical repair is indicated for all types of symptomatic paraesophageal hernias. Emergency repair is indicated when a patient presents with associated obstruction, strangulation, uncontrolled bleeding, or perforation.3 In cases where gastric necrosis occurs, a gastrectomy may be required. A total gastrectomy can be performed either laparoscopically or open. A laparoscopic total gastrectomy has been shown to be a safe procedure with reduced length of stay but requires a well-trained laparoscopic team.4 This video illustrates a laparoscopic total gastrectomy for a necrotic stomach secondary to a gastric necrosis and perforation from an incarcerated paraesophageal hernia. Materials and Methods: A 74-year-old female presented to the emergency department with acute abdominal pain. CT of the abdomen and pelvis showed a type III hiatal hernia with intra-abdominal and intrathoracic free air. She was emergently taken to the operating room for a diagnostic laparoscopy. Intraoperatively, a large strangulated, necrotic, and perforated paraesophageal hernia involving >75% of the stomach was noted. The entire stomach was reduced with 4 cm of intra-abdominal esophagus. The distal esophagus was then transected. The duodenum was then transected distal to the pylorus. The gastric specimen was removed, and the patient was left in discontinuity because of multiple vasopressor requirements. The operation took 151 minutes with 75 mL of blood loss. Results: The patient was on multiple vasopressors throughout the case and transferred to the surgical intensive care unit for postoperative management. The patient underwent renal replacement therapy and was unable to be weaned from vasopressors. She developed severe sepsis-induced coagulopathy and was not medically stable for re-exploration the ensuing day. The patient remained on intravenous antibiotics and antifungals throughout this time. Owing to escalation of care and lack of thoracic surgery at this facility, the patient was transferred to a tertiary center. Over the next week, the vasopressors were discontinued. Bilateral chest tubes and abdominal drains were placed by interventional radiology. On postoperative day 21 from the index case, there was a change in the volume and color of the chest tube output and a CT chest showed an esophageal stump blowout. She subsequently underwent a right video-assisted thoracoscopic surgery wherein a mediastinal abscess was encountered and the distal esophagus was necrotic requiring further resection. On postoperative day 26, she returned to the operating room for placement of jejunostomy feeding tube; however, the abdomen was diffusely frozen and intra-abdominal abscesses were encountered. She remains in discontinuity without enteral access and was discharged to a long-term acute care facility. Conclusion: Strangulated paraesophageal hernias are rare but have significant morbidity when they occur. This case reinforces the need to repair paraesophageal hernias electively before severe complications. Despite the severity of the case, a laparoscopic approach was effective in performing a total gastrectomy in the acute phase and achieving source control. No competing financial interests exist. Runtime of video: 7 mins 4 secs Source: The source of the study was obtained from Trumbull Regional Medical Center. Authors have no conflict of interests or obligations from Trumbull Regional Medical Center. Patient Consent: Authors have received and archived patient consent for video recording and publication in advance of video recording of the procedure.