PMC5964430_01
Preoperative CAT images show paraoesophageal herniation of the antrum into the thoracic cavity.
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Repeat CAT imaging confirmed paraesophageal reherniation of the antrum (Figure 2), and the patient was referred to our institute for laparoscopic reoperative intervention.
Surgical steps for giant hiatal hernia repair with dermis graft reinforcement: (a) initial intraoperative finding during redo surgery, 60% of the stomach is in the thoracic cavity; (b) adhesiolysis; (c) retraction of the mobile lesser curvature into the abdominal cavity; (d) stomach in the intra-abdominal position; (e) visualization of the crural stitch failure; (f) Belsey rear suture line left in place, fundoplication adequately mobilized; (g) suture repair of the defect; (h) harvesting site for dermis graft; (i) deepithelized skin flap; (j) dermis graft free of adipose tissue; (k) graft introduced into the abdomen; (l) graft fixation to the left diaphragmatic crura; (m) graft fixation to the right diaphragmatic crura; (n) excess graft removed; (o) anterior Dor's fundoplication; (p) final position of fundoplication wrap and the reinforced hiatal repair; (q) scar at 1-month follow-up.
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There was failure of the diaphragmatic crural stitches along with herniation of the antrum, pylorus, and greater omentum into the thorax (Figure 3(a)). The graft was placed covering the suture line, also surrounding the esophagus in a U-shaped form, and was fixed to the diaphragm using titanium staples (Figures 3(l) and 3(m)), essentially resulting in a tensile repair with an onlay allograft reinforcement.