Michael A Antiporda, MD1, Kelly R Haisley, MD1, Walaa Abdelmoaty, MD1, Steven R Demeester, MD2, Christy M Dunst, MD2, Daniel Davila Bradley, MD2, Lee L Swanstrom, MD3, Kevin M Reavis, MD2. 1Providence Portland Medical Center, 2The Oregon Clinic, Portland, Oregon, 3Institute for Image Guided Surgery (IHU-Strasbourg), Strasbourg, France
Introduction: Paraesophageal hernia (PEH) repair is associated with high anatomic recurrence rate though low rate of need for re-operation to address recurrent symptoms. Revisional operations are most commonly performed for symptomatic wrap herniation. Mesh reinforcement of the hiatus, diaphragmatic relaxing incisions, and Collis gastroplasty are adjuncts used to reduce tension during repair with the intent to lower recurrent rates of paraesophageal hernia. Crural blowout leading to para-hiatal hernia after paraesophageal hernia repair is a rare possible complication that may present in similar fashion to recurrent PEH. We present a patient who underwent two prior paraesophageal hernia repairs who developed acutely symptomatic apparent PEH found to actually have developed para-hiatal hernia.
Methods: After placement of five trocars triangulating on the hiatus, brief lysis of adhesions is performed and the hernia defect identified with incarcerated stomach and omentum. Anterior relaxing incision is performed to enable successful reduction. Endoscopy is used to confirm viability of the stomach and as an adjunct for definitive anatomic identification. With complete dissection of the hiatus and lower mediastinum, it is revealed that the patient had developed left para-hiatal hernia originating from blowout and disruption of the left crural anchoring sutures placed for paraesophageal hernia repair at the prior operation. Takedown of fundoplication and possible sub-total gastrectomy is deferred due to the viable but significantly inflamed and edematous nature of the stomach. Small recurrent posterior paraesophageal hernia is repaired, and the para-hiatal hernia is repaired with permanent mesh in similar fashion to repair of diaphragmatic relaxing incision.
Results: The patient had an uneventful post-operative course and routine UGI showed intact repair. He was discharged on post-operative day ten with toleration of pureed diet. He had no complaints of recurrent reflux symptoms at follow-up one month later.
Conclusions: Crural blowout with para-hiatal hernia is a rare complication following paraesophageal hernia repair that presents in similar fashion to recurrent PEH. Repair may be undertaken with permanent mesh in a fashion akin to repair of diaphragmatic relaxing incision.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95881
Program Number: V073
Presentation Session: Foregut III
Presentation Type: Video
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