Acute Gastric Strangulation: A Diagnostic Dilemma

Alberto S Gallo, MD, Cristina Harnsberger, MD, Ryan C Broderick, MD, Martin Berducci, MD, Hans Fuchs, Cristopher Ducoin, MD, Joshua Langert, MD, Garth R Jacobsen, MD, Brian J Sandler, MD, Santiago Horgan, MD. Minimally Invasive Surgery Department. University of California San Diego

We are presenting the case of a 39 year old obese female patient that was transferred from an outside hospital with a diagnosis of incarcerated paraesophageal hernia by CT scan.

This video shows the laparoscopic approach for repair of an incarcerated and strangulated diaphragmatic hernia initially thought to be a paraesophageal hernia.
The abdominal cavity is entered and a diagnostic laparoscopy is performed. A large diaphragmatic hernia is found. The procedure starts by gently reducing the stomach into the abdominal cavity. Evidence of chronic incarceration is found. The omental attachments to the stomach are taken down with ultrasonic shears. The gastro hepatic ligament is transected and the dissection of the right crus is performed. The dissection continues at the greater curvature, the short gastric vessels are taken down and the stomach is slowly reduced into the abdominal cavity. An endoscopy is performed to better delineate the anatomy and showed a well-positioned GE junction and a defect lateral to the left crus consistent with a diaphragmatic hernia. The left crus is recognized and dissected from its attachments. The hernia sac is then dissected with a combination of blunt dissection and harmonic scalpel. The hernia contents are retracted into the abdominal cavity and dissection continues. A retro esophageal window is created and a Penrose drain introduced for retraction. Dissection continues at the lateral border of the left crus. A plane between the pleura and hernia sac is initially found. The remaining plane is found to be fused. Because of this, two with loads of linear stapler are used to transect the plane between the hernia sac and the pleura. The hernia contents are completely reduced and the defect sutured without tension with running non-absorbable braided sutures. The hiatus is closed with the same technique. An absorbable mesh is used to reinforce the defect and is secured in place with surgical glue. Final endoscopy showed a completely reduced diaphragmatic hernia. The patient had an uneventfully postoperative course. She was discharged on full liquid diet on day 2.

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