Adam S Weltz, MD, Nolan Marks, Javaneh Jabbari, MHS, Alex Addo, MD, Zachary Sanford, MD, Adrian Park, MD, FACS. Anne Arundel Medical Center
Summary of Surgical Case: We discuss a 67 year-old male presenting with presumed large paraesophageal hernia. CT demonstrated presumed Type IV paraesophageal hernia with acute gastric volvulus. He was medically optimized and taken to the OR during hospitalization. Laparoscopy revealed a large diaphragmatic defect containing all of the patient’s stomach, much of the small bowel, and colon as well. These structures were reduced under tension. Their attachments to the diaphragm, omentum, and sac were taken down with a combination of sharp and blunt dissection. Further dissection included taking down the pars flaccida, allowing visualization of the right and left crura of the diaphragm. We then realized this was a large parahiatal hernia. Reinforcement of the repair was necessary as the left crus was flimsy. We mobilized the left triangular ligament at the level of the diaphragm and mobilized it laterally. We then closed the parahiatal defect. We incorporated the triangular ligament which we previously mobilized to buttress and reinforce this closure. With the parahiatal defect completely closed, there remained a sizable hiatal hernia defect. The esophagus was fully mobilized and it was necessary to mobilize the falciform ligament for posterior hiatoplasty in a retroesophageal position. Four of five points of fixation of the falciform ligament were in the retroesophagus. Final survey revealed complete repair of the parahiatal defect.
Educational/Technical Points: This presentation discusses the challenges associated with correctly diagnosing paraesophageal and parahiatal hernias. Utilization of the falciform ligament, when possible, is able to provide durable and lasting repair in the hands of an experienced hernia surgeon.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95154
Program Number: V386
Presentation Session: Video Loop Day 4
Presentation Type: VideoLoop