Laparoscopic Repair Of Perforated Giant Paraesophageal Hernia In The Nonagenarian With Staging Endoscopic Decompression Of Volvulus
Carlos J. Anciano, MD, Mark Bowling, MD, James Speicher, MD, Aundrea Oliver, MD, Mark Iannettoni, MD.
East Carolina University, Greenville, NC, USA.
A 90 year old female with extensive past medical and surgical history is admitted under diagnosis of urosepsis, undergoing progression of an incarcerated giant paraesophageal hernia with complete intrathoracic stomach to a perforated ischemic gastric volvulus with both organoaxial and mesentericoaxial twist. Management was staged with endoscopic-fluoroscopic volvulus decompression followed by medical optimization and eventual laparoscopic hernia repair, partial gastrectomy, and gastropexy.
Complete live video record of endoscopic, fluoroscopic, and laparoscopic interventions was obtained. Emphasis at editing was made on radiologic indicators of the hernia, endoscopic maneuvers for volvulus decompression, laparoscopic principles of giant hernia management, and intraoperative decisions for damage assessment and control.
Patient was satisfactorily managed, with eventual discharge tolerating diet to a skilled rehabilitation facility. Follow up imaging including postoperative esophagram and CT imaging at 6 weeks is presented.
Endoscopic fluoroscopic decompression of giant paraesophageal hernia is feasible as a means to temporize and optimize acute patient for eventual intervention. Laparoscopic approach is then tolerated and allows for required aspects of hernia repair, damage control partial gastrectomy, and gastropexy.
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