Laparoscopic mesh repair of large hiatal hernia and upside-down stomach with intraoperative treatment of an esophageal lesion

Abstract

Purpose: Upside-down stomach (UDS) is a rare type of large paraoesophageal hernia, characterized by migration of the entire or large parts of the stomach into the posterior mediastinum. UDS is associated with severe complications like strangulation or volvulus development, possibly leading to acute gastric outlet obstruction and incarceration. Surgical repair is the only curative treatment option and therefore recommended for these patients. Standard procedure includes a hiatoplasty followed by an anti-reflux procedure. In a variety of studies, the use of mesh proved to be superior with respect to reduction of anatomical recurrences.

Methods: A 78-year old woman presented to us with reflux symptoms, dysphagia, dyspnea and tachyarrhythmias. She reported a weight loss of 14 kg in the last 6 months. CT scan and esophagogastroscopy showed a large paraoesophageal hernia, measuring approximately 10 cm, with intrathoracic UDS.

Results: We performed a laparoscopic hernia repair with dissection of the hernia sac from the posterior mediastinum, tension-free intrabdominal reposition of stomach and distal esophagus and hiatoplasty with biologic mesh (Tutomesh™) augmentation. Finally, a Toupet fundoplication was performed to recreate the anti-reflux valve. In consequence of pronounced adhesions, a lesion of the muscularis of the distal esophagus occurred during surgery. The esophageal mucosa was unaffected. We treated the lesion laparoscopically with a simple interrupted suture (Vicryl™ 3-0). An intraoperative Patent Blue V leak test did not identify any leaks. The recovery was uneventful. The patient was discharged on day 12 after surgery and was free of symptoms in her follow-ups.

Conclusion: Patients with large hiatal hernias and UDS can be treated successfully and effectively with laparoscopic mesh repair. Intraoperative complications can be handled laparoscopically in a safe manner.