Parahiatal hernia with volvulus and incarceration: laparoscopic repair of a rare defect

Unusual Presentation of Incarcerated True Parahiatal Hernia: Management of a Rare Clinical Entity

True parahiatal hernia is a type of diaphragmatic hernia in which herniation occurs through a defect in the diaphragm, adjacent to the normal oesophageal hiatus. Its reported incidence is very rare, and it is commonly misdiagnosed as paraoesophageal hernia. Although the clinical distinction between paraoesophageal and parahiatal hernia is difficult, it is essential to recognise these two separate entities clinically as their management differs. Clinical presentation of parahiatal hernia includes symptoms related to gastro-oesophageal reflux disease (GERD). Patients may also present emergently with symptoms of respiratory distress and chest symptoms. With that in mind, we describe a compelling case of a young lady who initially presented with symptoms suggestive of acute coronary syndrome. However, she was found to have an incarcerated parahiatal hernia.

Type II hiatal hernias: do they exist or are they actually parahiatal hernias?

BACKGROUND

Type II hiatal hernias (HH) are characterized by a portion of the gastric fundus located above the esophageal hiatus adjacent to the esophagus while the gastroesophageal junction (GEJ) remains fixed below the esophageal hiatus. This type of HH has been called the "true" paraesophageal hernia (PEH) because the fundus appears to the side of the esophagus. In our experience, Type II HHs are occasionally identified on radiographic testing, however they are rarely, if ever, confirmed intraoperatively. This led to our question: Does Type II HH exist?

METHODS

We searched for evidence of type II HH in three locations: 1. Retrospective review of all first-time PEH repairs (excluding Type I HHs and re-operative cases) performed at the University of Washington Medical Center from 1994 to 2021; 2. Operative videos available on YouTube and WebSurg websites; and 3. Abstracts from the SAGES annual meetings from 2005 to 2021.

RESULTS

We found no evidence of Type II HH in any of our three searches. We performed 846 PEH repairs: 760 Type III, 75 Type IV, and 11 parahiatal. Upon website video review, we found only one possible type II hernia, though it too was likely a para-hiatal hernia. No video or case presentations of a type II HH were identified within SAGES annual meeting abstracts.

CONCLUSION

Type II HHs do not exist as they are currently defined. Although uncommon, parahiatal hernia can easily be misinterpreted as Type II HH. We should consider changing the hiatal hernia classification system to prevent ongoing clinical confusion.

Laparoscopic mesh repair and Toupet fundoplication for parahiatal hernia complicated by sliding hiatal hernia: A case report

Introduction

The parahiatal hernia is a rare type of diaphragmatic hernia in adults. Although there have been occasional reports of parahiatal hernias, few have reported simultaneous laparoscopic mesh repair of a parahiatal hernia with a hiatal hernia. This report describes laparoscopic mesh repair and fundoplication for a parahiatal hernia combined with an esophageal hiatal hernia.

Presentation of case

A 39-year-old woman presented with left-side postprandial abdominal pain. Esophagogastroduodenoscopy revealed a parahiatal hernia and sliding hiatal hernia. Computed tomography (CT) showed that the stomach had prolapsed into the thorax from the outside of the left diaphragm. The preoperative diagnosis was parahiatal hernia with a hernial sac complicated by sliding hiatal hernia. Laparoscopic mesh repair was planned. The stomach had prolapsed on the left side of the esophagus and was extruded. The diagnosis of a parahiatal hernia with a hernial sac complicated by a sliding hiatal hernia was confirmed. The esophageal hiatal hernia was repaired using two non-absorbable sutures. The congenital defect was further reinforced with mesh fixed to the orifice of the adjacent parahiatal hernia. We performed Toupet fundoplication to treat gastroesophageal reflux disease and sutured the right diaphragmatic crus and stomach to prevent migration. The patient was discharged home on postoperative day 5.

Conclusion

We encountered a patient with a parahiatal hernia complicated by a sliding hiatal hernia. The parahiatal hernia can be diagnosed by CT imaging. Preoperative diagnostic imaging can lead to appropriate treatment.

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The parahiatal hernia is a rare type of diaphragmatic hernia in adults

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This report describes laparoscopic mesh repair and fundoplication for a parahiatal hernia combined with an esophageal hiatal hernia.

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The parahiatal hernia can be diagnosed by CT imaging and preoperative diagnostic imaging can lead to appropriate treatment

Life-threatening presentation of a parahiatal hernia after esophagectomy: a case report and review of the literature

A woman presented to our hospital with acute abdominal pain 7 months following an oesophagectomy. A chest X-ray revealed a new elevation of the left diaphragm. CT demonstrated a large left diaphragmatic hernia incarcerated with non-enhancing transverse colon and loops of small bowel. She deteriorated rapidly into obstructive shock and was urgently brought to the operating room for a laparotomy. The diaphragmatic orifice was identified in a left parahiatal position, consistent with a parahiatal hernia. Incarcerated necrotic transverse colon and ischaemic loops of small bowel were resected, and the diaphragmatic defect was closed primarily. Because of haemodynamic instability, the abdomen was temporarily closed, and a second look was performed 24 hours later, allowing anastomosis and definitive closure. Parahiatal hernias are rare complications following surgical procedures and can lead to devastating life-threatening complications, such as an obstructive shock. Expeditious diagnosis and management are required in the acute setting.

Primary parahiatal hernias: A case report and review of the literature

BACKGROUND

Parahiatal hernias (PHHs) are rare occurring disease, with a reported incidence of 0.2%-0.35% in patients undergoing surgery for hiatal hernia. We found only a handful of cases of primary PHHs in the literature. The aim of this paper is to present a case of a primary PHH and perform a systematic review of the literature.

CASE SUMMARY

We report the case of a 60-year-old Caucasian woman with no history of thoraco-abdominal surgery or trauma, which accused epigastric pain, starting 2 years prior, pseudo-angina and bloating. Based on imagistic findings the patient was diagnosed with a PHH and an associated type I hiatal hernia. Patient underwent laparoscopic surgery and we found an opening in the diaphragm of 7 cm diameter, lateral to the left crus, through which 40%-50% of the stomach had herniated in the thorax, and a small sliding hiatal hernia with an anatomically intact hiatal orifice but slightly enlarged. We performed closure of the defect, suture hiatoplasty and a “floppy” Nissen fundoplication. Postoperative outcome was uneventful, with the patient discharged on the fifth postoperative day. We performed a review of the literature and identified eight articles regarding primary PHH. All data was compiled into one tabled and analyzed.

CONCLUSION

Primary PHHs are rare entities, with similar clinical and imagistic findings with paraesophageal hernias. Treatment usually includes laparoscopic approach with closure of the defect and the esophageal hiatus should be dissected and analyzed. Postoperative outcome is favorable in all cases reviewed and no recurrence is cited in the literature.

Laparoscopic repair of parahiatal hernia after esophagectomy: a case report

Background

Diaphragmatic hernia is a potential complication of esophagectomy, which usually occurs as a hiatal hernia and more frequently after minimally invasive esophagectomy. Parahiatal hernia is a rare form of diaphragmatic hernia, and to the best of our knowledge, parahiatal hernia after esophagectomy has not been previously reported. Here, we report a case of parahiatal hernia after esophagectomy that was successfully managed laparoscopically.

Case presentation

A 73-year-old man underwent thoracoscopic esophagectomy for esophageal cancer with gastric tube reconstruction via the posterior mediastinum. Postoperative morbidity was ileus, which required conservative treatment, and intestinal obstruction for which operation with laparotomy was necessary. He was admitted with abdominal pain and vomiting at 15 months after esophagectomy. Abdominal X-ray revealed colon gas in the intrathoracic space. A barium enema examination showed a transverse colon incarcerated in the intrathoracic space. The patient was preoperatively diagnosed with hiatal hernia after esophagectomy, and laparoscopic hernia repair was performed. During the surgery, the hiatus was found to be intact, and the defect was clearly separated from the left crus of the diaphragm. Parahiatal hernia was the operative diagnosis. The incarcerated colon was repositioned in the abdominal cavity, and the defect was repaired using a composite mesh.

Conclusions

Laparoscopic surgery was found to be effective for the diagnosis and repair of parahiatal hernia.

Para-oesophageal and parahiatal hernias in an Asian acute care tertiary hospital: an underappreciated surgical condition

INTRODUCTION

The prevalence of hiatal hernias and para-oesophageal hernias (PEHs) is lower in Asian populations than in Western populations. Progressive herniation can result in giant PEHs, which are associated with significant morbidity. This article presents the experience of an Asian acute care tertiary hospital in the management of giant PEH and parahiatal hernia.

METHODS

Surgical records dated between January 2003 and January 2013 from the Department of Surgery, Changi General Hospital, Singapore, were retrospectively reviewed.

RESULTS

Ten patients underwent surgical repair for giant PEH or parahiatal hernia during the study period. Open surgery was performed for four patients with giant PEH who presented emergently, while elective laparoscopic repair was performed for six patients with either giant PEH or parahiatal hernia (which were preoperatively diagnosed as PEH). Anterior 180° partial fundoplication was performed in eight patients, and mesh reinforcement was used in six patients. The electively repaired patients had minimal or no symptoms during presentation. Gastric volvulus was observed in five patients. There were no cases of mortality. The median follow-up duration was 16.3 months. There were no cases of mesh erosion, complaints of dysphagia or recurrence of PEH in all patients.

CONCLUSION

Giant PEH and parahiatal hernia are underdiagnosed in Asia. Most patients with giant PEH or parahiatal hernia are asymptomatic; they often present emergently or are incidentally diagnosed. Although surgical outcomes are favourable even with a delayed diagnosis, there should be greater emphasis on early diagnosis and elective repair of these hernias.

Mutation screen reveals novel variants and expands the phenotypes associated with DYNC1H1

Dynein, cytoplasmic 1, heavy chain 1 (DYNC1H1) encodes a necessary subunit of the cytoplasmic dynein complex, which traffics cargo along microtubules. Dominant DYNC1H1 mutations are implicated in neural diseases, including spinal muscular atrophy with lower extremity dominance (SMA-LED), intellectual disability with neuronal migration defects, malformations of cortical development, and Charcot-Marie-Tooth disease, type 2O. We hypothesized that additional variants could be found in these and novel motoneuron and related diseases. Therefore, we analyzed our database of 1024 whole exome sequencing samples of motoneuron and related diseases for novel single nucleotide variations. We filtered these results for significant variants, which were further screened using segregation analysis in available family members. Analysis revealed six novel, rare, and highly conserved variants. Three of these are likely pathogenic and encompass a broad phenotypic spectrum with distinct disease clusters. Our findings suggest that DYNC1H1 variants can cause not only lower, but also upper motor neuron disease. It thus adds DYNC1H1 to the growing list of spastic paraplegia related genes in microtubule-dependent motor protein pathways.

Laparoscopic mesh repair of parahiatal hernia: a case report

We report a case of a primary parahiatal hernia that was repaired laparoscopically with a composite mesh. A 51-year-old woman presented with vomiting and epigastric pain. CT scan showed a giant paraesophageal hernia with intrathoracic gastric volvulus. Intraoperatively, a diaphragmatic muscular defect was found lateral to an attenuated left crus of the diaphragm, distinct from the normal esophageal hiatus. The defect ring was fibrotic, making a tension-free primary repair difficult. A laparoscopic mesh repair was performed with a composite mesh, which was covered with the hernia sac to prevent potential erosion into the esophagus or stomach. Recovery was uneventful and the patient was discharged on the 5 days postoperatively. She remained asymptomatic at subsequent follow-up. Laparoscopic repair of parahiatal hernia can be safely performed. In circumstances where a large or fibrotic defect prevents a tension-free primary repair, the use of a composite mesh can provide effective repair of the hernia.

Laparoscopic repair of secondary parahiatal hernia with incarceration of the stomach: a case report

Introduction

Parahiatal hernia is an extremely rare subtype of hiatal hernia, which in turn is a type of diaphragmatic hernia in adults, and only a few cases have been reported to date. We report the case of a patient who suffered from gastric incarceration through an anatomically separate diaphragmatic defect, immediately lateral to a structurally normal esophageal hiatus, that developed after treatment of a malignant mesothelioma.

Case presentation

A 70-year-old Japanese man, who had undergone treatment for a left malignant pleural mesothelioma a year ago at another hospital, was referred to our institution following a 4-day history of epigastric pain. Esophagogastroscopy demonstrated a normal esophagogastric junction, with remarkable stenosis and active gastric ulcer of the gastric body. Histopathological examination of the gastric biopsy specimen confirmed a gastric ulcer. Furthermore, computed tomography revealed a large fluid-filled structure in the retrocardiac space. On the basis of preoperative data, we decided to attempt laparoscopic repair for the gastric volvulus. During surgery, gastric and omental herniation was observed within a peritoneal lined defect immediately lateral to the esophageal hiatus. Dissection near the esophageal hiatus revealed a discrete extrahiatal defect 3cm in diameter immediately adjacent to the left crus of the diaphragm. The parahiatal defect was closed using interrupted nonabsorbable heavy suture. The patient’s postoperative course was uneventful, and anastomotic leakage was not observed at postoperative barium swallowing.

Conclusions

Although preoperative diagnosis of parahiatal hernia is difficult, a laparoscopic approach can be a useful therapeutic procedure not only for paraesophageal hernia but also for parahiatal hernia.

Laparoscopic repair of parahiatal hernias with mesh: a retrospective study

BACKGROUND

Parahiatal hernias are very rare and distinct entities, the diagnosis of which is never made clinically. Laparoscopic repair has been reported in the literature. We present our experiences with the laparoscopic repair of this uncommon type of hernia.

PATIENTS AND METHODS

In our institute, we retrospectively identified a total of eight patients with parahiatal hernias from 1999 to 2007, of which four had primary and four had secondary defects. Laparoscopic crural repair was performed for all of the patients, fundoplication wherever indicated and meshplasty in the cases with large defects. Gastropexy was performed for the patient with volvulus.

RESULTS

The male:female ratio was 5:3, with a mean age of 46 years and a mean body mass index (BMI) of 29.3 kg/m2. The mean size of the defects was 18 cm2. The mean blood loss during surgery was 50 ml, the mean operative time was 103.5 min and the mean hospital stay was 4 days. One patient had the recurrence of symptoms 1 month after surgery. There were no conversions, recurrences or mortality.

DISCUSSION

Primary parahiatal hernias occur as a result of a congenital weakness and secondary defects follow hiatal surgery. The use of a mesh is advisable for large defects and defects of primary type. Secondary hernias following fundoplication do not need a redo fundoplication, but require an adequate crural repair with mesh. Laparoscopic repair of these uncommon hernias is safe, effective and provides all of the benefits of minimally invasive surgery.

"True" parahiatal hernia: a rare entity radiologic presentation and clinical management

BACKGROUND

True parahiatal diaphragmatic hernias are rare entities that are sparsely accounted for in the literature. The current report is intended to depict the clinical profile and assess the feasibility of laparoscopic repair of parahiatal hernias.

METHODS

We conducted a retrospective review of all patients diagnosed and treated for parahiatal hernias. Clinical presentation and radiological assessment, as well as operative findings and repair, are discussed.

RESULTS

Of the 917 laparoscopic hiatal hernia repairs, 2 (0.2%) patients were identified with a parahiatal hernia. The presenting symptoms and preoperative testing were similar to those with more common paraesophageal hernias. Laparoscopic repair was successful in repairing the diaphragmatic defect and alleviating symptoms up to 4 years postoperatively.

CONCLUSIONS

Parahiatal hernias of the diaphragm appear to be rare primary diaphragmatic defects. The clinical presentation of parahiatal hernias is often indistinguishable from the more common paraesophageal pathology. Laparoscopic repair of this rare entity can be safely and successfully accomplished in conjunction with antireflux surgical interventions when indicated.