Intrathoracic omental herniation after laparoscopic sleeve gastrectomy and hiatal hernia repair

Ashish Padnani, MD¹, James McGinty, MD¹, Darshak Shah². ¹Mount Sinai St. Luke’s, ²Mount Sinai Hospital

Overview: Herniation of omentum through esophageal hiatus is uncommon. We present a rare case of omental herniation through esophageal hiatus after laparoscopic sleeve gastrectomy (LSG) and hiatal hernia repair.

Case Presentation: A 27 years old female with no significant past history underwent LSG for morbid obesity. Intraoperatively she was found to have type 1 sliding hiatal hernia. A primary posterior crural repair with nonabsorbable sutures was performed. Postoperative day (POD) 0-1 patient had severe nausea and retching. Her vital signs were stable throughout. An esophagram obtained on POD 1 demonstrated no leak. Postoperative day 2 patient became tachypneic, tachycardic to 110s and requiring supplemental oxygen maintaining oxygen saturation around 96%. Pulmonary embolism was suspected. So patient underwent CTA chest which demonstrated large amount of omental fat herniating into left chest with large left pleural effusion. No pulmonary embolus was identified. Patient was taken back to OR immediately. Large amount of omentum had herniated through esophageal hiatus anteriorly into the left chest. This was reduced back to abdominal cavity. About 1 liter of clear fluid was also drained. Mediastinal drain was placed. On further inspection, posterior repair of the hiatus was intact. Additional anterior sutures were placed to close the hiatal opening, with non-absorbable sutures. Patient was started on clear liquid diet POD 1, mediastinal tube was removed and patient was discharged home on POD 3 from second operation.

Conclusion: Omental herniation through esophageal hiatus after posterior repair of hiatal hernia is rare. It can cause severe respiratory distress and symptoms can mimic pulmonary embolism. Urgent operative repair is indicated with reduction of omentum and closure of defect.