PMC5702857_01
Preoperative radiology findings. (A) Chest radiograph depicting a large diaphragmatic hernia located in the right hemithorax. (B) Views of CT scan showing contents of the hernia sac and (C) point of herniation in the anterior part of the diaphragm.
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A further CT scan initially revealed a massive paraoesophageal hiatal hernia, with part of the stomach body, antrum and duodenum along with part of the greater omentum protruding inside the right thoracic cavity (Fig. 1).
Intraoperative pictures. (A) Identification of the anterior diaphragmatic defect with gastric portions, small bowel parts and omentum. (B) Reduction of the hernia's contents back in the abdominal cavity. (C) The esophagogastric junction is thoroughly investigated and identified in its normal anatomic position. (D) Excision of the diaphragmatic sac (the right lung can be seen from the defect). (E) Tension free closure of the defect with absorbable sutures. (F) Reinforcement of the diaphragmatic wall through fixation of an intraperitoneal mesh.
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The esophageal hiatus along with both right and left diaphragmatic crura and esophagogastric junction were identified in their normal anatomical position, so no further anti-reflux operation (360  or partial) was performed (Fig. 2).