Laparoscopic Management of Totally Intra-Thoracic Stomach with Chronic Volvulus

Surgical video case: an intra-thoracic gastric volvulus is an uncommon entity and it occurs when the entire stomach migrates into the thorax through a giant hiatal defect by rotating around its longitudinal or transverse axis. Whether this rare condition is an extension of a paraesophageal hernia or an evolution of a longstanding sliding hernia is subject to controversy. The clinical features of giant hiatal hernias are nonspecific and the majority of patients are asymptomatic. Dysphagia, heartburn, postprandial discomfort and chest pain are the most common presenting symptoms. Patients presenting with chest pain usually undergo a cardiac work-up and a PEH is incidentally found in chest scans. Patients with IGV are usually symptomatic. We usually start with a gastroscopy in the preoperative work-up. In addition to detecting esophagitis and/or Barrett metaplasia, an upper gastrointestinal endoscopy can reveal other concomitant gastric neoplasias. Following gastroscopy, we obtain a radiographic evaluation with a barium swallow study and thoraco-abdominal CT. We think the barium swallow is very useful in identifying the presence and the type of volvulus, the location of the GEJ and in assessing the length of the esophagus. Preoperative evaluation of patients with a pH meter and manometry is controversial. The approaches include trans-abdominal vs trans-thoracic procedures, open vs laparoscopic procedures, hiatal closure with primary suture vs the use of meshes, fundoplication, gastroplasty and total sac excision. The debate over total excision of the hernia sac is the least controversial issue. Many surgeons believe total excision of the sac eliminates the tension on the GEJ and minimizes the risk of recurrence. Short esophagus  have remained a subject of clinical debate.  If a 2.5-3 cm intra-abdominal esophagus can be achieved by mediastinal dissection, there is no need to perform a Collis procedure. There is a tendency to overestimate the esophageal length during a laparoscopy. The pneumoperitoneum elevates the diaphragm and misleads surgeons. Surgeons should keep in mind that these maneuvers can lead to an overestimate of intra-abdominal esophageal length. The use of prosthetic grafts for a reinforced hiatoplasty is another controversial issue. Although the use of a prosthetic mesh seems to significantly reduce the risk for recurrence, it is not free of complications. Erosion into the gastrointestinal organs is the most feared complication when a mesh is used in the hiatus. In conclusion, laparoscopic management of IGV is a safe procedure and should be the first option in the treatment algorithm. With careful attention the details, such as total excision of the hernia sac, provision of an adequate esophageal length with full mobilization of the esophagus, tensionless hiatoplasty, and a floppy fundoplication, long-term success is possible.