Post-operative gastric outlet obstruction of giant hiatal hernia repair: a case report

Abstract

Background: Giant hiatal hernia is defined as those with more than 30% of the stomach herniating into the chest cavity. The transabdominal laparoscopic approach is the well-established repair form for giant hiatal hernia. To our best knowledge, reports on post-operative gastric outlet obstruction of giant hiatal hernia repair have been scanty up till now.

Case presentation: A 45-year-old female patient was referred to the Emergency Department of our hospital with a chief complaint of acute right epigastric pain for 2 days. Physical examination revealed mild tenderness in the right epigastrium, without rebound tenderness or guarding. The abdominal computed tomography scan revealed a large low-density gastric artifact in the lower mediastinum-giant hiatal hernia. The barium swallow esophagogram and gastroscopy also confirmed the presence of a giant hiatal hernia. A transabdominal laparoscopic operation for reduction of the hernia contents and repair of the hiatal defect was performed. Her right epigastric pain alleviated obviously on the first postoperative day. On post-operative day five, however, she was presented with nausea and vomiting independent of meals. The nasogastric tube was inserted and kept in the stomach for 7 days. After removing the nasogastric tube, severe nausea and vomiting of the patient occurred again. Barium swallow revealed gastroptosis and enfoldment in the duodenal bulb, which indicated the presence of gastric outlet obstruction. Gastrojejunostomy was performed for her to relieve the gastric outlet obstruction. The patient was discharged on the tenth day after the second operation without any discomfort. During the regular follow-up period, she felt well and was satisfied with her status.

Conclusions: Facing the giant hiatal hernia repair, the reduction of the hernia contents and repair of the hiatal defect being well operated on are insufficient, and we must watch out the anatomical variation, like the deviation of partial intra-abdominal organs from their normal positions, as well as paying attention to the protection of abdominal vagal nerve during the operation. Post-operative gastric outlet obstruction of giant hiatal hernia repair is rare, while gastrojejunostomy can successfully relieve the gastric outlet obstruction.

Keywords: Case report; Complications; Giant hiatal hernia; Laparoscopy; Surgery.

Fig. 1

Pre-operative imaging evaluations of the patient. a CT-scan of the abdomen exhibiting the giant hiatal hernia (white arrows). b Barium swallow showing the giant hiatal hernia (black arrows)

Fig. 2

The intra-operative pictures of laparoscopic giant hiatal hernia repair. a The entire stomach, greater omentum and partial transverse colon protruding into the thoracic cavity. b All of them were sent back into the peritoneal cavity. c Suturing the defective diaphragm continuously. d Mesh reinforcement

Fig. 3

Imaging evaluations and operative pictures of post-operative gastric outflow obstruction. a Barium swallow showing the distension of the stomach, gastroptosis and enfoldment in duodenal bulb (white arrows). b Laparoscopic view of the distension of the stomach, gastroptosis and enfoldment in duodenal bulb (white arrows). c Laparoscopic view of the gastro-jejunal anastomosis (white arrow). d Barium swallow showing the gastrointestinal tract smooth (black arrow)