PMC6000763_01
Upper esophagogastroduodenoscopy showing proximal migration of Z line along with Hiatus Hernia [1A]. Chest X-Ray showing showed an air-fluid level with obscuration of right heart border [1B].
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Upper GI esophagogastroduodenoscopy revealed an upward migration of Z line with Grade III Hiatus Hernia (Fig. 1A). Chest X-ray showed an air-fluid level with obscuration of right heart border (Fig. 1B).
CT (Axial, Coronal, Sagittal) showing a 3.4 cm Defect in the anterior diaphragmatic wall, with herniation of bowel loops on the right side of the chest along with a grade III Para-esophageal hernia.
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The stomach is present on the left side with the anterosuperior displacement of the gastric antrum along with a grade III Para-esophageal hernia (Fig. 2).
A Morgagni Hernia containing omentum, stomach and transverse colon was noticed [3A, 3B]. The contents were removed from the hernia sac relatively easily using two atraumatic graspers [3C].
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A Morgagni Hernia containing omentum, stomach and transverse colon was noticed (Fig. 3A, B). The contents were removed from the hernia sac relatively easily using two atraumatic graspers (Fig. 3C).
Herniation of gastric fundus herniated into the thoracic cavity [4A]. Post Hiatoplasty [4B]. Mesh Reinforcement of the Hiatus defect along with 360  Nissen's fundoplication [4C]. The 3.4 cm Subcosto-sternal defect closed with the use of mesh, fastened to the diaphragm with the help of tackers and interrupted sutures using Prolene 2/0 [4D].
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We also found the gastric fundus herniated into the thoracic cavity at a diameter of about 5 cm (Fig. 4A). The stomach is pulled back into the abdominal cavity, and then the hiatus was reconstructed with interruptedly tied 2/0 Prolene sutures behind the esophagus after ensuring that the lower esophagus was at least 3 cm in length in the abdominal cavity (Fig. 4B). A 360  Nissen's fundoplication was then performed to complete the Hiatal closure (Fig. 4C). The mesh was fastened to the diaphragm with the help of tackers and interrupted sutures using Prolene 2/0, taking special precaution to avoid damage to the pericardium (Fig. 4D).
Follow-Up Computed Tomography showed adequate repair of a diaphragmatic and Para-esophageal hernia without any evidence of herniation of Greater Omentum, stomach, and bowel.
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Follow-Up CT showed adequate repair of a diaphragmatic and Para-esophageal hernia without any evidence of herniation of Greater Omentum, stomach, and bowel (Fig. 5).