Wednesday, September 5, 2007

Mega Hernia

This 84 year old lady presented to me last week with complaints of epigastric pain and reflux. She had actually been hospitalized several times over the past year for similar symptoms. In addition, she was hospitalized last summer for an episode of melena and anemia which, after an extensive work-up, was deemed to be secondary to gastritis. For an 84 yo lady, she was pretty sharp and pleasant. History of hypertension, controlled with lisinopril and atenolol. She also had a severe case of scoliosis, rendering her wheelchair-bound. Here's a couple cool CT slices:

Any ideas on diagnosis? Approach and kind of repair?


Sid Schwab said...

You're probably more familiar with it than I, but I've been impressed with a hybrid mesh for h. hernias, sort of broadly U-shaped with a lip that fits under the goose, and which can be attached to the crura with those screw thingys. See how knowledgeable I am? Anyhow, I've helped on a few lately and thought they were pretty slick. Assuming you can get it down laparoscopically.

Jeffrey Parks MD FACS said...

The precut mesh thingies the rep brought wouldn't work because the hiatus was so damn large. So I improvised; cut my own U-shaped hybrid from a piece of Parietex and tacked/sutured it to the diaphragm/crura laparoscopically. Tough case, though. Taking down the entire sac from the mediastinum can be rather tedious. One of those cases that you look forward to all weekend and then, halfway through, you're wondering why the hell you got yourself involved. But pretty satisfying when it's over.

Bongi said...

well done if you pulled it off!!! i'm pretty impressed. mesh up against stomach and esophagus makes me nervous, but in this case, i'm not sure there is an alternative. with your permission, i'd like to ask our south african guru's opinion.

Bongi said...

wasn't sure how to get your opinion, so i asked the guru anyway.

he said:-
"This seems to be an intra-thoracic stomach.
They can be awkward at times but then again sometimes delightfully easy.
I NEVER put in a Mesh on the first round.
Careful followup with scopes are needed to go back as soon as it looks like re-herniation is taking place to prevent breakdown.
(6 weeks, 3 months, 6 months, 1 year and again at 2 years). One must not wait until they fail. I see this as a staged procedure and not a redo.
One needs to close the hiatus quite snugly in these cases and sometimes anterior sutures must be placed.
That's it in a nutshell"