PMC6849156_01
CT showing the gastric volvulus.
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The scan showed a vastly dilated stomach with a transition line between the antral and fundic air bubbles due to a volvulus (Fig. 1).
CT showing intra-thoracic transverse colon and pancreas.
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The stomach, spleen, distal pancreas and transverse colon were within the left thoracic cavity, passing through a postero-lateral diaphragmatic defect measuring 6 x 6.7 cm, with resultant compression of the ipsilateral lung and a rightward mediastinal shift (Fig. 2).
Pendulum shaped incision over the diaphragm (upper), thoracoscopic port placement (lower).
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The defect was widened with a 2 cm incision medially, resembling a pendulum arm (Fig. 3). Isolated right-lung ventilation greatly aided the insertion of ports as depicted in Fig. 3.
Drawing the stomach out of the diaphragmatic defect.
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This facilitated reduction of the stomach under gentle traction (Fig. 4).
Thoracic location of the spleen as visualised transabdominally through the defect after replacing the stomach in the abdomen.
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Close apposition of the abdominal viscera with the lung necessitated prudent use of energy with most dissection progressing in blunt fashion (Figs. 5, 6).
Adhesions between the lung and the stomach in the thorax.
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Close apposition of the abdominal viscera with the lung necessitated prudent use of energy with most dissection progressing in blunt fashion (Figs. 5, 6).
Combined thoracosopic and laparoscopic views of the spleen.
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At the end of adhesiolysis with reduction of all viscera (Fig. 7), the posterior lip of diaphragmatic defect was seen to consist of only a narrow rim of muscle and peritoneum (Fig. 8).
15 x 15 bilaminar mesh placement.
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The laparoscopic team augmented defect closure by placing a 15 x 15 cm bilaminar mesh over the defect, fixing it to the diaphragm with interrupted nonabsorbable sutures (Fig. 9).
Post operative scan.
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A CT scan on the 2nd postoperative day showed full expansion of the left lung without any evidence of herniation (Fig. 10).