Strangulated Paraesophageal Hiatal Hernia

Videolaparoscopic surgical treatment of strangulated paraesophageal hiatal hernia (clinical observation)

Relevance. Paraesophageal hiatal hernias are much less common than other types of diaphragmatic hernias. The risk of strangulation in this pathology is about 21 %. It is often very difficult to establish the correct diagnosis in time, because patients are admitted with an atypical clinic of acute cardiological or pulmonary pathology. Usually, the correct diagnosis is established only on the 4th day. Due to late diagnosis, necrosis and perforation of the strangulated organ occur, which causes high mortality; sometimes the correct diagnosis is established only at autopsy.

Clinical observation. The patient was admitted to the surgical department on an emergency basis with complaints of intense pain in the lower chest and epigastric region, vomiting of eaten food. From the anamnesis it is known that about a year ago, periodic nausea and vomiting of food eaten began to bother. The last 12 hours before admission to the hospital, pain in the chest and epigastrium intensified, all eaten food came out with vomiting. X-ray diagnosed strangulated paraesophageal hernia of the esophageal opening of the diaphragm. During esophagogastroduodenoscopy it was impossible to pass into the distal parts of the stomach; hyperemia and petechial hemorrhages were detected in the zone of strangulation. Video-laparoscopic reduction of the hernial contents, resection of the hernial sac and anterior diaphragm crurorrhaphy were urgently performed. The early postoperative period was uneventful. The presented clinical observation indicates the promise of using video-endoscopic technologies for diagnosis and treatment of strangulated diaphragmatic hernias. The key to success is the timely establishment of the correct diagnosis. We consider it impractical to perform an antireflux intervention simultaneously in conditions of an acute inflammatory process. 

Anesthetic Management for Paraesophageal Hernia Repair

Paraesophageal hernia repairs are complex surgical cases frequently performed on patients of advanced age with multiple comorbidities, both of which create difficulties in the anesthetic management. Preoperative evaluation is challenging because of overlapping cardiopulmonary symptoms. The patient's symptoms and anatomy lead to an increased aspiration risk and the potential need for a rapid sequence induction. Depending on the surgical approach, lung isolation may be required. Communication with the surgeon is vital throughout the case, especially when placing gastric tube and bougies. Multimodal analgesia should include regional and/or neuraxial techniques, in addition to the standard intravenous and oral pain medications.