J Gastric Cancer.  2019 Mar;19(1):132-137. 10.5230/jgc.2019.19.e7.

Incarcerated Hiatal Hernia with Perforation after Laparoscopic Total Gastrectomy with Roux-en-Y Reconstruction: a Case Report

• Wang NY
• Tsai CY
• Liu YY
• Chen IS
• Ho KH

• KMID: 2458825
• DOI: http://doi.org/10.5230/jgc.2019.19.e7

Abstract

The occurrence of hiatal hernia after total gastrectomy with Roux-en-Y reconstruction is rare. We report the case of a 76-year-old man who presented with dyspnea, vomiting, and fever around 8 days after total gastrectomy with Roux-en-Y reconstruction. Abdominal computed tomography revealed a hiatal hernia containing part of the small intestine in the left thoracic cavity. Emergent reduction and repair of the hiatal hernia were performed later. Operative findings revealed that the Roux limb was incarcerated in the left pleural cavity. Esophagojejunostomy leakage, perforation of the small intestine with transient ischemic change, and pyothorax were also found. Thus, feeding jejunostomy, thoracoscopic decortication, and diversion T-tube esophagostomy were performed. Considering that the main cause of hiatal hernia is blunt dissection with division of the phrenoesophageal membrane, approximating the crus with 1 or 2 figure-8 sutures, according to the size of the defect, to prevent the incidence of hiatal hernia after total gastrectomy may be performed.

Keyword

Stomach neoplasms; Hernia; Hiatal; Gastrectomy

MeSH Terms

Aged
Dyspnea
Empyema, Pleural
Esophagostomy
Extremities
Fever
Gastrectomy*
Hernia
Hernia, Hiatal*
Humans
Incidence
Intestine, Small
Jejunostomy
Membranes
Pleural Cavity
Stomach Neoplasms
Sutures
Thoracic Cavity
Vomiting

Figure

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  Fig. 1 Preoperative upper gastrointestinal panendoscopy. (A, B) The arrow indicates the hyperemic area at the posterior wall of the high body to the cardia. (C) The arrow indicates the submucosal mass at the lesser curvature side of the antrum. No preoperative hiatal hernia was observed.

• 

  Fig. 2 (A) Pre- and (B) post-gastrectomy hiatus.

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  Fig. 3 (A) Chest radiograph showing the intestine in the left lung field. (B) Abdominal computed tomography image showing distended loops of the small intestine in the left thoracic cavity.

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  Fig. 4 Intraoperative finding showing the orifice of the hernia (yellow arrow). The red arrow indicates the crural approximation.

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  Fig. 5 (A) The latest chest radiograph. (B) The latest esophagogram showing no recurrent hiatal hernia before hospital discharge.

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