Hiatal hernia involving prolapse of the entire stomach into the mediastinum after distal gastrectomy: a case report

Abstract

Background: Prolapse of a small part of the proximal stomach through the hiatus into the mediastinum is relatively common. Hiatal hernia involving the postoperative stomach has been reported previously, but the degree of hernia was not so severe, and hiatal hernia involving the prolapse of the entire stomach following gastrectomy into the mediastinum has never been reported. We describe a very rare case of large hiatal hernia involving the entire postoperative stomach.

Case presentation: A 79-year-old man with a history of distal gastrectomy for submucosal benign tumor 40 years ago was referred to our hospital because of dysphagia and weight loss. Computed tomography revealed prolapse of the entire postoperative stomach into the mediastinum, and a radical operation was performed. There was a strong adhesion in the hernial sac of the mediastinum, but only little adhesion due to a previous open surgery in the abdominal cavity was present. After the stomach was pulled into the abdominal cavity, suture cruroplasty and Toupet fundoplication without dissection of the short gastric artery were performed. The patient experienced postoperative paralytic ileus, but the rest of the postoperative course was uneventful and the symptom of dysphagia improved.

Conclusions: We presented a very rare large hiatal hernia involving the entire postoperative stomach. Toupet fundoplication preserving the short gastric artery could be one of the optimal surgeries to prevent postoperative regurgitation of the remnant stomach.

Keywords: Fundoplication; Large hiatal hernia; Postgastrectomy.

Fig. 1

Upper gastrointestinal examination. The intrathoracic postoperative stomach with delayed barium passage was observed (a). Postoperative examination on day 2 after repair of the hiatal hernia shows the stomach located in the normal position and the absence of any obstruction and reflux of barium through the gastroesophageal junction (b). Arrow heads indicate gastroesophageal junction and arrows indicate gastroduodenal anastomotic site

Fig. 2

Upper endoscopic examination. Esophagitis was not found in gastroesophageal junction. There is no tumor in the upper digestive tract

Fig. 3

Contrast-enhanced computed tomography. A large hiatal hernia with the entire stomach (arrow heads) incarcerated through the hiatal orifice into the mediastinum, and the stomach was expanded with food remaining; in axial view (a) and in coronal view (b)

Fig. 4

Port setting for hernia repair and operative findings. In total, five ports and Nathanson liver retractor were placed in the abdomen (a). A loose adhesion was observed just under the operative scar in the abdominal cavity; in contrast, the adhesion in the hernial sac was stronger. The esophageal hiatus was dilated to 7 cm in diameter (arrow heads). The hiatal hernia was identified and found to contain the entire postoperative stomach (b). We converted laparoscopic surgery to open surgery, and upper midline abdominal incision was added (c, red line). After manual reposition of the herniated content (d), cruroplasty with non-absorbable 2–0 sutures and Toupet fundoplication were performed