72 - Freie Mitteilung
Bariatry & hernia I
16. Mai 2019, 17:30 - 19:00, Bellavista 3+4, 6. OG
Video: Hepatic shoulder technique – future or dream? A rarely used method for surgical management of large (incarcerated) hiatal hernia
L. Pietrogiovanna, J. Janczak, R. Strahm, N. Pfeifer, W. Brunner, Presenter: L. Pietrogiovanna (St. Gallen/Rorschach)
Large hiatal hernia usually affects elderly, often obese patients. A relaxation of the ligamentous apparatus around the esophagogastric junction and a change in the physiological angle of His are predisposing. Surgical options are different, including mesh repair, notoriously difficult and the postoperative recurrence rate is still significant. We present a fairly recent operative approach used in two patients with voluminous hiatal hernia with upside down stomach.
Two patients (71- and 83- year-old) were admitted to emergency unit after one week of recurrent vomiting. CT scan revealed upside down stomach with incarceration and large hiatal hernia. New diagnosed atrial fibrillation and pericardial effusion in one patient and aspiration pneumonia in the other was also detected. After an initial treatment with the nasogastric tube for decompression, the surgical treatment was planned.
Laparoscopic tension-free gastric repositioning, partial posterior and if necessary anterior cruroraphia was performed. To cover the diaphragmatic defect hepatic shoulder technique was performed in using the left hepatic lobe interposition posterior to esophagogastric junction. Postoperative course showed a tension pneumothorax on day 4 in one patient, and anemia due to gastrointestinal bleeding by a severe reflux esophagitis LA D, treated conservatively. Gastroscopy after seven weeks revealed completely healed esophagitis. Discharge was on day 12 resp 15. Both patients had no recurrence of symptoms of their hiatal hernia at 4, 12, 24 weeks and 1 year after the operation.
Operative treatment of large hiatus hernia can be carried out by various methods. Laparoscopic approach is seen as gold standard but the best method to cover and close the diaphragmatic defect is still in debate. The hepatic shoulder technique offers a good alternative to mesh reinforcement without the disadvantages shrinkage, erosion and related morbidity.