Giant Hiatal Hernia with Respiratory Complications in an Elderly Patient

5 Mar 2025 16:00 18:00
Geneva
Michael F. Chevallay Host
Stefan Moenig Host

Patient Profile & Clinical History

  • Patient: 72-year-old female

  • Medical History: Asthma.

  • Pulmonary Embolism: 2015.

  • Respiratory History: Multiple respiratory infections (pneumonia) with increased frequency of asthma exacerbations, chronic cough, and dyspnea.

Diagnostic Workup

Upper Endoscopy (Figure 1)

  • Large hiatal hernia, no signs of esophagitis.

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Esophageal Manometry

  • Hiatal hernia of 4 cm.

  • Obstruction at the level of the esophagogastric junction, likely secondary to the large hiatal hernia.

  • Hypotonic esophageal contractions.

EGD with Contrast Transit (Figure 2)

  • Type III hiatal hernia with reflux, contrast stasis in the esophagus.

CT Scan of Chest and Abdomen (Figure 3)

  • Very large hiatal hernia with 2/3 of the stomach displaced.

  • Infiltration of the lower pulmonary lobe suggestive of subclinical infections.

Figure 1

Upper endoscopy showing a large hiatal hernia with no signs of esophagitis.

Figure 2

EGD with contrast transit showing type III hiatal hernia with reflux and contrast stasis in the esophagus.

Figure 3

CT scan showing a very large hiatal hernia with 2/3 of the stomach displaced and infiltration of the lower pulmonary lobe suggestive of subclinical infections.

Clinical Considerations

Given the severity of the hiatal hernia, associated reflux, and impact on pulmonary function, surgical intervention is considered.

Surgery

  • Approach: Robot assisted laparoscopy.

  • Procedure: Mobilisation of the esophagus and fundus with complete resection of the sac.

  • Hiatoplasty: With non-resorbable sutures and reinforced by pledges.

  • Fundoplication: Dor fundoplication.

  • Postoperative Course: No complications. Patient discharged on day 5.

Postoperative Follow-up

At 3 months postoperative, no problems and no new infection were reported.

Panel for Discussion

S. Mönig (Switzerland) | M. Chevallay (Switzerland) | J. Zacherl (Austria) | G. Schumacher (Italy) | O. Scrobic (Serbia) | Y. Borbély (Switzerland) | S. Giacopuzzi (Italy) | D. Bertolini (Switzerland) | S. Preston (United Kingdom)

Topics for Discussion

  1. Indications for surgery:

    • In elderly patients with comorbidities, when should surgery be prioritized?

    • What are the main determinants for choosing surgery over conservative management?

  2. Advantages of robotic surgery:

    • Is robotic-assisted hiatal hernia repair superior to laparoscopy in terms of patient outcomes and complication rates?

    • Does robotic surgery improve precision and reduce recurrence rates in large hernia repairs?

  3. Optimal hernia repair and use of mesh:

    • When is mesh reinforcement indicated in giant hiatal hernia repair?

    • What are the risks of mesh-related complications in this patient population?

  4. Choice of fundoplication:

    • Partial vs. complete fundoplication: what is the best approach for patients with hypotonic esophageal motility?

    • How does the choice of fundoplication impact postoperative reflux control and dysphagia?