2An 18 years old male presented with abdominal pain for 1 day and vomiting of blood for 2 days. The pain started suddenly mainly in epigastrium .Hematemesis 4 times per day of medium amount for 2 days with dizziness no other GI symptoms.
3He is previously healthy and not known to have any chronic diseases. Patient reported a history of Blunt Abdominal trauma 5 months earlier and recovered without and significant impairment.
4On examination, he was unwell, with tachycardia 140/min and Resp Rate of 22/min Abdomen was soft with guarding and tenderness over the epigastrium, positive bowel sound and no organomegally.
5U/S of the abdomen was negative for free fluid and there was fluid in left pleural space. WBC: Hgb: Hct: Plt:340Glu: Urea: Creat: Na: K:4.1LDH: AST: ALT: T.bili: 1.82D-bili: In-bili: Amyl:472
7Repeated CBC showed a Hgb of 2.o Patient was rushed to the operation room for a diagnostic laparoscopy and possible laparotomy .Intra-Operative Endoscopy reports gastric ulceration and bleeding with stenotic opening just below the cardia
8With laparoscopy there was strangulated hiatus hernia ( stomach & omentum ) cannot be reduced laparoscopically and the procedure was converted to laparotomy.The stomach and omentum was reduced from mediastinum.
9Finding of Gangrenous, not perforated, stomach and omentum from the lower end of the esophagus till the antrum .Gasterectomy with oesphegeo-jejenostomy and jejenojejenostomy side to side anastmosis ( Roux-en-Y )done for the patient. The patient was transferred to intensive care unit right after.
10Histopathology reported Transmural hemorrhagic infarction of the resected part and moderated chronic gastritis .
11His ICU course was not complicated with acute or serious event and was extubated in POD # 2 with a total stay of 7 days.Patient been shifted to surgical floor with good and stable condtion.
12At the floor, patient recovered slowly and had low grade fever on and off. Upper GI gastrograffin done and showed intact and no leak at anastmosis sites .Patient had a spike of fever of 39 for two nights (POD#11 and 12) and CTscan of Abdomen and pelvis revealed no intra-abdominal or pelvic collection.
13Patient encouraged for more ambulation and incentive spirometer use. Patient been discharged in POD # 14 with pain free , tolerating diet and stable vital signs.
17Bochdalek Hernia Congenital hernia through the lumbocostal trigone. Can expand to includealmost wholehemidiaphragm. Morecommon on left.Sac present in 10–15%.Contents: small intestine usual;stomach, colon, spleen, frequent.Pancreas and liver rare. Liver only in right-sided hernia.
18Morgnani hernia and other Anterior hernia Congenital potential herniathrough muscular hiatuson either side of thexiphoid process.Usually on the right;bilateral hernias areknown. Actual herniationusually the result ofpostnatal traumaSac present at first and Can rupture later, leaving no trace. Contents: Infants: liver. Adults: omentum. Can be followed by colon and stomachlater.
19Congenital hernia through central tendon and pericardium. Peritoneopericardial hernia (defect of the central tendon, defect of the transverse septum)Congenital hernia throughcentral tendon andpericardium.Sac rarely present.Contents: stomach,colon.
20Hiatal Hernia There are 3 types of hiatal hernias. The sliding hernia or type I is the most common.
21Type I Hiatal HerniaThe E-C junction moves through the hiatus to the visceral mediastinum.Increased abdominal pressure( pregnancy, obesity, or vomiting ) and vigorous esophageal contraction may contribute the development of the hernia.G-E reflux and esophagitis may occur due to loss of tone of the LES
29SYMPTOMS Many type I and type II hernia have few or no symptoms. Bleeding results from gastritis and ulcer can induce IDA, resulting in fatigue and exertional dyspnea.Postprandial discomfort may occur. The substernal fullness is often mistaken MI
30ComplicationsBleeding, incarceration, volvulus, obstruction, strangulation and perforation.Gastritis and ulceration have been seen. The ulcer are the result of poor gastric emptying and torsion of the gastric wall.
31Cont’If vovulus occurs, severe pain and pressure in the chest or epigastic region.Fever, hypovolemic shock will be present if volvulus progresses and strangulation occurs. In this situation, mortality rate is 50%.
32DIAGNOSIS The diagnosis is suspected first on the CXR. The most common finding is retrocardiac bubble with or without air-fluid level.In a giant hiatal hernia, the herniated organ may be found in the right thoracic cavity.D.D: mediastinal cyst or abscess, dilated obstructed esophagus, as end stage of achalasia.
33Cont’ The barium study of the UGI confirms the diagnosis. Endoscopy and esophageal function test can detect the function of LES.
34THERAPY There is no accepted medical treatment for hiatal hernia. Surgery is indicated to prevent complications.In type II hernia, if gastric volvulus or obstruction is present without toxic signs, NG decompression must be performed. The surgery is scheduled.
35Operative ApproachesThe operation or operative approach is controversial.The principles of operation is reduction of the hernia, resection of the hernia sac and closure of the defect.It is easy to do intrathoracic dissection via thoracotomy.However, transthoracic reduction may lead to volvulus of the gastric body.
36Operative Approaches Abdominal approach is also suggested. Additional procedures can be done, such as gastrotomy, which obviates the NG tube and decreases the risk of recurrent volvulus.Abdomional approach is difficult to do in type III hiatal hernia with G-E reflux and a foreshortened esophagus.Laparoscopic repair is also advocated.
37Should a Antireflux Procedure Be Induced? It is controversial.It is indicated in patients with esophagitis by symptoms and endoscopy, with a hypotensive LES( < 10 mmHg ) or positive 24-hour pH monitoring.
38Operative Technique: Conventional Abdominal Approach In type II hernia, the E-C junction is still in the abdomen, bounded posteriorly with a fibrous band. It is careful not to take down the attachment.Dissection is done on the lower 4 to 8 cm of the esophagus.The repair is done with nonabsorbable O sutures.
39Operative Technique: Conventional Abdominal Approach Antireflux procedure is done when significant reflux esophagitis is present.A loose Nissen fundoplication is suggested by authors.If no fundoplication is performed then the stomach can be fixed by two methods: Hill suture plication and Stamm gastrostomy.
40Operative Technique: Conventional Abdominal Approach Hill suture plication: 3 interrupted nonabsorbable sutures between lesser curve of the stomach and preaortic fasciaStamm gastrostomy: 2 functions1. It eliminates the need of NG tube.2. It fixes the stomach to the abdominal walland to prevent volvulus.
42Operative Morbidity and Mortality The operative mortality is less than 0.5%.If gasric volvulus occurs, the operative mortality is up to 14%.Pulmonary complication may be seen in patients with aspiration resulting from volvulus or obstruction.Complication of gastric stasis may result from edema of the released gastric segment.
43Operative Morbidity and Mortality Other complications include gastric perforation, gastric bleeding, slipped Nissen fundoplication, small bowel obstruction and atelectasis.
44RESULTS Long-term results are excellent. Simultaneous antireflux procedure is ineffective prophylaxis against recurrent herniation resultant G-E reflux.The long-term result after laparoscopic repair is unknown.
452nd caseA 71 years old male been presented in ER c/o Abdominal pain for 3 days .It was associated with constipation for 4 days and vomiting for 1 day prior to admission.12 hours prior to admission ,patient’s abdomen became more distended and pain increased.There was a history of Appendectomy 30 years ago.
46On examination he was a febrile ,tachy with 127/min and normotensive. His abdomen was distended till costal margin with mild tenderness and Rt irreducible inguinal hernia.PR was empty and bowel sound was negative.Wbc: Hgb: Plt: 502Glu: Urea: Creat: Na: K:4.1