371 LARGE HIATAL HERNIAS: WATCH AND WAIT, OR SURGICAL REPAIR?

Laparoscopic-assisted hiatal hernia (HH) repair has been reported to be safe and feasible. However, uncertainty exists regarding whether asymptomatic large HHs (L-HH) should be treated or if a watch-and-wait strategy should be used. The latter might expose the patient to the risk of progression and gastric incarceration. In this study, we investigated this issue by analyzing perioperative outcomes of patients who underwent HH repair at our high-volume center. Methods After obtaining approval from the Institutional Review Board, we queried a prospectively maintained database for data on patients who underwent primary minimally invasive HH repair between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). Hernias were classified in 4 groups: small (S-HH [sliding]), moderate (M-HH [<50% herniated stomach]), large (L-HH [50%–75% herniated stomach]) and giant (G-HH [≥75% herniated stomach]). Data on preoperative assessment, surgical procedure, and postoperative morbidity were analyzed and compared across groups. Complications were defined according to the Clavien-Dindo (CD) classification. Results In total, 170 patients met inclusion criteria. Mean age was 58.5 ± 11, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years for S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35), respectively (p < 0.001). The mean operative time (minutes) increased by group as the HH size increased (69.6 ± 20.9, 83.5 ± 26.1, 99 ± 29.1, and 98.6 ± 24.9, respectively; p < 0.001). Eight of 35 patients with G-HH (22.9%) were treated urgently due to gastric incarceration. Postoperative complications were significantly more common after L-HH and G-HH repair (Figure 1). CD complications Grade II, IIIb, and IVa were observed only in patients with L-HH or G-HH. There was no mortality. Conclusion Patients with L-HH and G-HH are significantly older than those with S-HH or M-HH; this reflects the likely progressive nature of this pathology. Laparoscopic HH repair is associated with higher morbidity in patients with L-HH and G-HH. Furthermore, patients with G-HH are at risk of gastric incarceration, which requires emergency surgery. Our findings suggest that in patients with M-HH (even asymptomatic), a watch-and-wait strategy should be discouraged. Surgical repair, in experienced hands, is preferred.

Internal hernia of the stomach through the lateral space of the colostomy: a case report

An 81-year-old woman had undergone laparoscopic abdominoperineal resection for rectal cancer. A permanent colostomy was created through an intraperitoneal route. Three months after the surgery, the patient presented with lower abdominal pain and vomiting. Computed tomography showed gastric incarceration through the lateral space of the lifted sigmoid colostomy. Although the herniated stomach was reduced by nasogastric tube decompression, the patient experienced a recurrence of gastric hernia shortly thereafter. A laparoscopic operation was performed, and a new colostomy was constructed through an extraperitoneal route. The patient had no hernia recurrence during the 20 months of follow-up after the operation. Gastric internal hernia associated with colostomy can occur as a rare complication. Although reduction of the incarcerated stomach is possible by nasogastric tube decompression, surgical repair of the hernia may be the optimal management to prevent recurrence.

Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma

ABSTRACTRupture of the diaphragm is almost always due to major trauma and is most commonly associated with road-traffic accidents. We report a case of delayed presentation of a 35-year-old woman with a ruptured diaphragm, 11 days following apparent minor blunt trauma. This case illustrates how the diagnosis of ruptured diaphragm can be missed and demonstrates the importance of considering this diagnosis in all cases of blunt trauma to the trunk. It also demonstrates the potential pitfall of misinterpreting the chest radiograph, and the value of repeat imaging after insertion of a nasogastric tube.