Incarcerated Hiatal Hernia

Primary paraesophageal hernia is a distinct anatomical and clinical entity that leads to incarceration and volvulus of the stomach in the chest. Because of the volume of herniated abdominal contents, large hiatal defect, and frail crura, the optimal repair requires both axial and radial tension vectors to be addressed. A large incarcerated hiatal hernia may also occur after failed antireflux repairs or esophagectomy and gastric conduit reconstruction and can lead to outlet obstruction and strangulation. In the absence of prohibitive surgical risk factors, all symptomatic patients should undergo elective laparoscopic repair to prevent severe complications, and even mortality, which can occur should an urgent surgical procedure become necessary. Extended transmediastinal dissection with complete sac excision is mandatory to release axial tension and to reduce at least 3 cm of distal esophagus into the abdomen. Posterior suture crural repair with a biosynthetic mesh patch onlay has the potential to reduce short-term recurrence rates. A Collis gastroplasty may be added with a short esophagus in order to further reduce axial tension. Whenever feasible, a partial fundoplication should be performed after repair of the crura to decrease the risk of postoperative gastroesophageal reflux. In emergency situations, resuscitation and decompression of the intrathoracic stomach is the first priority. Partial gastric or bowel resections may be required because of intraoperative findings of ischemia and/or perforation. In such circumstances, anterior gastropexy may be a reasonable alternative to hiatal repair to prevent recurrent hernia and minimize morbidity. Recurrent incarcerated hernia and para-conduit postesophagectomy hiatal hernia pose additional technical challenges and increase both complication and mortality rates.