The traditional surgical management of gastric volvulus consists of laparotomy
with gastric detorsion and fixation, and diaphragmatic hernia repair. We report
here an 83-year-old patient whose gastric volvulus occurred through a giant diaphragmatic
defect (Figure [1]), who presented with a 1-week history of abdominal pain, distension, vomiting,
and dysphagia. At surgery, the gastroesophageal junction, the fundus and distal
half of the stomach, and the omentum were found in the thorax, and an intrathoracic
organoaxial gastric volvulus through a hiatal hernia was diagnosed (Figure [2]). We proceeded to laparoscopic herniated organ reduction, excision of the hernial
sac, mobilization of the fundus, crural repair, and a Nissen fundoplication and
gastropexy. The patient was well and had no hernia recurrence at 1-year follow-up
(Figure [3]).
Figure 1 Upper gastrointestinal series showing a diaphragmatic hernia and an intrathoracic
organoaxial gastric volvulus with gastric outlet obstruction.
Figure 2 At laparoscopy a diaphragmatic defect, 7 × 5 cm in diameter, was seen at the
esophageal hiatus, with a well-developed hernial sac inside it after herniated
organ reduction.
Figure 3 Hypaque study demonstrating adequate stomach position, good gastric emptying,
and adequate detorsion and fixation of the stomach postoperatively.
During these procedures, the first important step was to make sure we avoided
entering the pleura and creating a tension pneumothorax while making the window
behind the esophagus (Figure [4]). We also chose to approximate tissues using stout, nonabsorable sutures, taking
healthy bites into both sides of the crura posteriorly, and used pieces of mesh
to reinforce all the crural repairs (Figure [5]). This reduced the risk of ischemic necrosis and subsequent failure of the crural
repair. In addition, this meant that we did not need to place prosthetic mesh
across the hiatal defect and the complications associated with this were also
avoided [1]
[2]. We thought that suturing the fundic wrap to the right crus with a nonabsorbable
stitch would be effective for gastropexy because excessive mobility of the greater
curvature of the stomach was restricted after fundoplication (Figure [6]). The need for gastrostomy for gastropexy suggested in the study by Geha et
al. [3] was obviated.
Figure 4 The inferior parts of the right and left crura were clearly exposed after the
esophagus was pulled upward and to the left.
Figure 5 The crura were repaired posterior to the esophagus, with several interrupted nonabsorbable
sutures and pieces of mesh used as pledgets for reinforcement.
Figure 6 A standard Nissen fundoplication was performed, using a short, floppy, 2-cm fundic
wrap, and stitch fixation of the fundic wrap to right crus.
It is a long-held belief that ageing is associated with a gradual loss of cardiopulmonary
reserve and that pneumoperitoneum is dangerous in the elderly [4]. Recently, Ballesta et al. [5] concluded that pulmonary complications might be reduced after a laparoscopic
procedure compared with an open approach in elderly patients. Laparoscopic surgery
would appear to be the ideal choice of treatment for the elderly because of its
minimal invasiveness.
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