Hiatus hernia Gastric volvulus
- ED
- Assess and resuscitate
- Single attempt at placement of NG tube
- Endoscopic
- Endoscopic guided NG tube placement
- If possible it will allow decompression of the stomach and then semi-acute hiatus hernia repair can be performed
- Assessment of the mucosa of the stomach can also be performed and if evidence of necrosis then gastrectomy is required
- Endoscopic guided NG tube placement
- Surgical
- If NG placement/endoscopic decompression not possible
- Steps
- Laparotomy/laparoscopy
- Reduce the stomach back into the abdomen
- Can incision the (left) crus of the diaphragm is difficulty reducing
- Decompression & de-rotation
- Assess stomach viability
- Resection if required
- Unstable
- Laparostomy + return for GI continuity at re-look with UGI surgeon
- Stable
- Distal gastrectomy = loop gastrojejunostomy, R&Y or Billroth 2
- Total or proximal gastrectomy = oesophago-jejunostomy
- Unstable
- Hiatus hernia repair
- Cruroplasty with 0 Ethibond
- Tricks to oppose the cura
- Mobilise the left lobe of the liver
- Divide any tissue between the right crus and the IVC
- Divide the pleura to drop the diaphragm down from the lungs (only in lap cases)
- Release the retractors down to take the tension off
- Create a vertical relaxing incision in the left hemi-diagram around where the spleen is - this allows the crua to be pulled across. This incision can then be closed in a transverse fasion and re-enforced with mesh.
- Tricks to oppose the cura
- Consider partial wrap - I perform an anterior Dor 180 degree wrap
- The reason for this is to decrease the risk of recurrence of a HH
- Procedure
- Progress sutures starting from the left crus and ending right crus, which progressively fold the fundus of the stomach over the distal oesophagus
- Cruroplasty with 0 Ethibond
- Volvulus
- Gastric suture pexy
- 3-0 PDS to the anterior abdominal wall in multiple places
- Gastrostomy assisted pexy
- 2x gastrostomies created to pexy the stomach to the abdominal wall
- Gastric suture pexy