SAGES Web Quiz #26 -- Laparoscopic Treatment of Hernia

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1. 84-year-old female presents to the emergency room with sudden onset of chest pain and retching, no vomiting. Cardiac work-up is negative, an UGI is obtained. What is the diagnosis?

a) Gastric Bezoar
b) Paraesophageal Hiatal Hernia with gastric volvulus
c) Sliding Hiatal Hernia with gastric volvulus
d) Type IV Hiatal Hernia without gastric volvulus
e) Pulmonary abscess
f) Don't Know

2. Initial treatment would include:

1. Attempt to nasogastric decompression
2. Emergency upper endoscopy and removal of a bezoar
3. Plan for possible thoracotomy or thoracoscopy
4. Plan for possible laparotomy or laparoscopy
5. Thoracoscopic or percutaneous drainage of pulmonary abscess
a) 2
b) 1 and 3
c) 1 and 4
d) 1,3 and 4
e) 5
f) Don't Know

3. During the surgical procedure the following steps should always be performed:

1. Complete dissection of the hernial sac
2. Complete excision of the hernial sac
3. An antireflux procedure
4. Mobilization of the esophagus to obtain at least 8 cm of intra-abdominal esophagus
a) 1 and 2
b) 1, 2 and 3
c) 1
d) 1 and 4
e) 4
f) Don't Know

4. After surgery an esophagogram demonstrated complete reduction of the hernia and no evidence of a leak. The patient was immediately started on PO diet with good tolerance. On postoperative day number five however, she presented new onset chest pain and she was no longer able to take PO diet as before. The CXR shown here was obtained.

The next step should be:
a) Take patient back to the operating room
b) Placement of a chest tube
c) Antibiotic therapy
d) Repeat esophagogram
e) None of the above
f) Don't Know

5. The following study was obtained.

Diagnosis and appropriate courses of action are:

1. Post surgical changes, keep patient NPO and gradually re-start PO feeding as tolerated
2. Recurrent herniation, seek assistance from a surgeon with more experience in this area
3. Recurrent herniation, consider a partial gastrectomy
4. Recurrent herniation consider a Collis-Nissen procedure
5. None of the above
a) 1
b) 2, 3, and 4
c) 2 and 4
d) 3 and 4
e) 5
f) Don't Know

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