Laparoscopic management of a giant hiatal hernia with gastric volvulus: a case report

Giant hiatal hernias represent a small subset of diaphragmatic hernial disease. Characterized by supramesocolic or multidistrict intrathoracic evisceration, they are at greater risk of complications due to the tendency to strangulation and to meso- or organoaxial volvuli as a result of the end -stage of dysautonomic and dysmotilic processes involving the esophagogastric junction. Giant hiatal hernias fall into the category of well-being pathologies and are often concomitant with obesity. Since congenital aetiology is rare, the underlying pathophysiological mechanisms are increased intra-abdominal pressure, morbid obesity, Caucasian race. Nevertheless, this is usually an incidental finding in the absence of suggestive clinical findings and if symptoms arise, they are usually nonspecific (epigastralgia, bloating, reflux). On the other hand, the occurrence of hematemesis, epigastric or atypical chest pain represent worrisome symptoms that may underlie the onset of local complications such as incarceration and volvuli. Surgical management usually appears challenging, usually involving inveterate compartment defects as far as tissue loss of strength making repair complex and usually demanding mesh cruroplasties. A minimally invasive approach has a double utility: an accurate direct dissection control and the undeniable advantages of postoperative functional recovery. However, superiority of minimally invasive surgical approach still claims debate, especially concerning long-term outcomes. A clinical case of a patient with a giant hiatal hernia with organo-axial gastric volvulus and laparoscopic surgically repaired is reported.