Minimally invasive laparoscopic and robot-assisted emergency treatment of strangulated giant hiatal hernias: report of five cases and literature review

Abstract

Background: Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature.

Methods: During 10 years (December 2009-December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review.

Results: The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences.

Conclusion: Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations.

Keywords: Emergency surgery; Giant hiatal hernia; Laparoscopy; Paraesophageal hernia; Robotic surgery.

Fig. 1

Trocar positions. a Laparoscopic approach. b Robotic-assisted approach

Fig. 2

Case 1: Preoperative CT scan and intraoperative images. a CT scan showed a giant incarcerated hiatal hernia. b Intraoperative image of incarcerated hernia. c Hernia sac removed. d Crura closure

Fig. 3

Case 1: Intraoperative images and postoperative X-ray. a–b Dacron pledgets reinforcement. c Nissen fundoplication. d X-ray showing a normal esophagogastric contrast transit

Fig. 4

Case 2: Preoperative radiologic exams and intraoperative images. a–b Chest radiography and chest-abdomen CT scan showing an air-fluid level at the posterior mediastinum. c–d Gastric reduction after hiatal defect enlargement

Fig. 5

Case 2: Intraoperative images and postoperative X-ray. a Hiatoplasty. b–c A 10 postoperative days X-ray swallow showing a good oesophagogastric transit with antrum stenosis, treated by several pneumatic dilatation after patient discharge from the hospital

Fig. 6

Case 3: Preoperative radiologic exams and endoscopic treatment. a Chest radiography showing migration of the stomach in the chest. b CT scan showing the stomach volvulus. c Crura closure by intracorporeal stitches. d Percutaneous endoscopic gastrostomy (PEG)