Operative steps. a) Reduction of the stomach from the thorax into the abdomen; b) Resection of the hernial sac started below the hiatal rim with division of the phreno-oesophageal ligament to correctly identify the plane between the mediastinal sac and the right crus; c) Dissecting the sac from the mediastinum; d) The wide hiatus visualized after dissection; e) Lateral releasing incision made adjacent to the right crus; f) Posterior approximation of the crura using Ethibond™ 2/0 sutures; g) Overlying of the composite mesh over the diaphragmatic defect and crus, secured with tacks; h) Formation of the Toupet fundoplication.

Operative steps. a) Reduction of the stomach from the thorax into the abdomen; b) Resection of the hernial sac started below the hiatal rim with division of the phreno-oesophageal ligament to correctly identify the plane between the mediastinal sac and the right crus; c) Dissecting the sac from the mediastinum; d) The wide hiatus visualized after dissection; e) Lateral releasing incision made adjacent to the right crus; f) Posterior approximation of the crura using Ethibond™ 2/0 sutures; g) Overlying of the composite mesh over the diaphragmatic defect and crus, secured with tacks; h) Formation of the Toupet fundoplication.

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Paraesophageal hernia with intrathoracic mesentericoaxial type of gastric volvulus is a rare clinical entity. The rotation occurs because of the idiopathic relaxation of the gastric ligaments and ascent of the stomach adjacent to the oesophagus through the hiatus defect, while the gastroesophageal junction remains in the abdomen. The open approach...

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... 2,3 The increase in intra-abdominal pressure creates a transdiaphragmatic pressure gradient between the thorax and abdominal cavity at the gastroesophageal junction. 2 This leads to weakening and stretching of the phrenoesophageal membrane and subsequently widening of the diaphragmatic hiatus aperture, resulting in progressive herniation of the stomach into the 4 The presentation for PEHs, unlike sliding hernias, is often non-specific with many patients being asymptomatic. For symptomatic patients, they may experience either reflux or mechanical symptoms or combination of both. 1 Infrequently, there is a small proportion of patients presenting with anemia due to chronic blood loss from large hiatal hernias. ...
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Intrathoracic organo‐axial gastric volvulus is a rare clinical entity associated with paraesophageal hernia. It is characterized by migration of the stomach into the thoracic cavity through an enlarged hiatal defect and rotation around its long axis connecting the cardia and the pylorus. A 72‐year‐old woman presented with epigastric pain that radiated to the left scapula for 1 week prior to presentation. Computed tomography scan of her thorax and abdomen demonstrated paraoesophageal hernia with organo‐axial intrathoracic gastric volvulus. Laparoscopically, the stomach was returned to its abdominal position, the mediastinal sac was excised and after adequate intra‐abdominal length of the esophagus was attained, the hiatal defect was closed primarily and reinforced with a composite mesh. An anterior 180° partial fundoplication was performed as both an anti‐reflux procedure and also as a form of gastropexy. She had an uneventful recovery and remains well after 2 years.
... Sporadic cases of intrathoracic organoaxial gastric volvulus associated with para-oesophageal hernia have been reported. Most of these cases are treated with open approach [1][2][3]. We present a case of successful laparoscopic management of a giant para-oesophageal hernia composed of part of the transverse colon and part of the stomach with volvulus. ...
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Type IV para-oesophageal hernias are characterized by the presence of structure other than the stomach in mediastinum and account for a minimal rate of all hiatal hernias. This condition is a predisposing factor for organoaxial gastric volvulus. Organoaxial volvulus is the most common type of gastric volvulus and is characterized by the rotation of the stomach along its long axis. Sporadic cases of intrathoracic organoaxial gastric volvulus associated with para-oesophageal hernia have been reported. Most of these cases are treated with open approach [1-3]. We present a case of successful laparoscopic management of a giant para-oesophageal hernia composed of part of the transverse colon and part of the stomach with volvulus. A 66-years-old male had recurrent episodes of epigastric post-prandial spastic pain that were resolved with vomiting, causing a weight loss of 20kg. A gastroscopy showed a grade II esophagitis that was treated with proton pump inhibitors without resolution of symptoms. A barium swallow showed the herniation of the gastric fundus and of part of the transverse colon. A CT scan confirmed this finding and found the presence of an intrathoracic organoaxial volvulus of the stomach. The patient was referred to our Centre where he was submitted to para-oesophageal hernia repair with laparoscopic approach. Technique The procedure was performed in the French position with the surgeon between the patient's legs, the camera surgeon at the patient's right side and the assistant at the left side. Under direct visualization, the entrance into abdomen was obtained with a sopraumbilical 10 mm camera port. With the pneumoperitoneum, under telescopic visualization with a 10mm 30 º Abstract Introduction: Few cases of intrathoracic gastric volvulus associated with para-oesophageal hernia have been reported and most of these cases were treated with open approach. We present a case of a giant type IV para-oesophageal hernia composed of part of the transverse colon and part of the stomach with volvulus.
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