Laparoscopic Treatment of Large Paraesophageal Hiatal Hernia with an Upside-Down Stomach

TATSUSHI SUWA, MD PhD, KAZUHIRO KARIKOME, MD, NAOKI ASAKAGE, MD PhD, EISHI TOTSUKA, MD PhD, NAOKAZU NAKAMURA, MD PhD, KEIGO OKADA, MD, TOMONORI MATSUMURA, MD. Kashiwa Kousei General Hospital

Introduction
Primary repair of large hiatal hernia is associated with a high recurrence rate. Reportedly, the use of mesh reduces this recurrence rate. The indication for mesh use, the type of mesh to use, and the placement technique are controversial. From the review of literature, 77% and 23% were performed laparoscopically vs open, respectively.

Case Report
We present a successful laparoscopic treatment of large paraesophageal hiatal hernia with an upside-down stomach. The patient was a 75-year-old man who had complaints of epigastric pain and dysphasia. A chest x-ray revealed a mediastinal air-fluid level. Chest computed tomography showed upside-down stomach in the mediastinal cavity. At laparoscopy, stomach and transverse-colon were dislocated within the hernia sac, those were repositioned to the peritoneal cavity. The crura of the diaphragm were widely open and seemed difficult be approximated with direct suturing. The defect was reinforced with Bard® Composix® E/X mesh (10 x15 cm) which had two distinctly different sides, polypropylene mesh on one side to promote tissue ingrowth and sub-micronic ePTFE (polytetrafluoroethylene) on the other side to minimize adhesions to the prosthesis. We used an absorbable tack fixation device for temporary attachment of mesh to the diaphragma. After the temporary fixation, the suturing could be performed easily and nicely.
The patient tolerated a diet on the second postoperative day and was discharged uneventfully. There were no recurrence or abdominal symptoms during the follow-up period.

Discussion
Many surgeons refrain from mesh implantation at the gastroesophageal junction owing to reported complications, such as mesh migration, strictures, and risks of tack or suture placement. The mesh type and the placement technique are important.


Session: Poster
Program Number: P323
View Poster

« Return to SAGES 2011 abstract archive