Case Report

A 79 year old woman was transferred to the intensive care unit a week following hemiarthroplasty to the right hip. She complained of epigastric pain and nausea. Examination demonstrated a tender epigastrium but there was no evidence of peritonism. Her lactate was 6 mmol/l and a chest radiograph demonstrated an obvious paraoesophageal hernia (Figure 1).

Figure 1

Figure 1: Chest radiograph clearly demarcating the boundry of a parapespohageal hernia.

The working diagnosis was a gastric volvulus. A nasogastric tube was immediately placed to decompress the stomach to reduce the ischaemia secondary from the distension.

Her condition was stabilised and she was taken to theatre for a laparotomy. At surgery, there was necrotic small bowel in the distribution of the superior mesenteric artery as well as patchy necrosis to the transverse colon. There was gross distension of the proximal small bowel with a reducible and viable stomach.

The point we would like to highlight in this case, is not only the way the bowel ischeamia presented, but the approach to repair of a paraoesophageal hernia. On reviewing the literature, there has been no documentation of bowel ischaemia causing distension of the proximal structures to the extent it causes herniation of the stomach through a lax hiatus. This was well demonstrated in this patient as her previous chest radiograph on admission did not show a paraoesophageal hernia.

There are 2 approaches when considering open repair of a paraoesophageal hernia, a transthoracic or transabdominal route. Both have their associated morbidities and benefits. A transthoracic approach is of value when there is concern of diaphragmatic rupture (delayed presentation) or in a chronic paraoesophageal hernia where there might be adhesion to the lung. It also gives one the choice to extend the incision and convert it to a thorocolaparotomy. A transabdominal approach is of value in the elderly with associated co-morbidities and in those with poor pulmonary functions. It is especially of value in the acute setting of a trauma patient suspected of having a diaphragmatic rupture to rule out other intra-abdominal injuries.

A transabdominal route was decided in this lady not only due to her age and significant co-morbidities, but also we wanted to perform a safe and expedient operation with minimal impact to her physiological status. In this patient group, we would reduce the stomach, excised the sac, close the crura and perform a gastropexy. The gastropexy usually involves anchoring the fundus to the diaphragm and the greater curvature along the anterior abdominal wall, sufficient enough to allow good closure of the laparotomy wound. A gastrostomy is not performed as there is no added benefit to the above gastropexy. An antireflux procedure is usually performed but is dependent on the patient symptoms as well as the pre-operative oesophageal function tests.

In conclusion, one should consider all factors including age, urgency of operation, possibility of diaphragmatic rupture, chronicity of hernia giving rise to adhesions, co-morbid factors and performance status in deciding the approach to surgery.

Correspondence to

Mr.R.Jeganathan, Thoracic Surgery, Ground Floor West Wing, Royal Victoria Hospital, Grovenor Road, Belfast BT12 6BA N.Ireland, United Kingdom Tel: 0044-2890-632016 / 0044-2890-633345 E-mail: reubenj@hotmail.com