PMC3199939_01
Preoperative mobile chest X-ray showing a large gastric shadow (G), absence of the left diaphragmatic outline and rightward displacement of the cardiac silhouette and trachea (T).
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fig1
An urgent mobile chest X-ray (Figure 1) showed a loss of left diaphragmatic outline and a large gastric shadow occupying the left hemithorax and displacing the mediastinum to the right.
Intra-operative picture showing the diaphragmatic defect after reduction of the stomach. Shown here is the spleen (S). The gastric fundus is retracted by the gloved hand.
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fig2
An upper midline laparotomy incision was used to access the abdominal cavity where an 8 cm rent was noticed in the left dome of the diaphragm (Figure 2) as well as the herniated stomach, greater omentum, and spleen.
Intra-operative picture demonstrating the sharp demarcation between the viable portions of the stomach and areas of questionable viability. Also seen is the area on the fundus with sloughed off seromuscular layers and pouting mucosa with two small perforations (P).
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After reduction of the abdominal viscera, about 1000 mL of dark blood-stained fluid was observed in the left hemithorax as well as gangrene of the fundus (with two small perforations) and areas on the anterior wall of the stomach of questionable viability (Figure 3) even after administering 100% oxygen and hot abdominal towels.
Completed gastroplasty. The liver (L) is shown to the right of the stomach.
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However, since there was a pulsatile right gastroepiploic artery, a gastroplasty was done by invaginating the involved gangrenous and suspicious areas with seromuscular Lambert sutures of silk 2/0 applied on adjoining viable tissues (Figure 4) with the intention of having a second-look laparotomy 48-72 hours later to assess the stomach.
Immediate post-operative chest X-ray demonstrating a well formed left diaphragmatic outline (D), cardiac silhouette and an intra-abdominal gastric gas shadow (G).
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She made an uneventful postoperative recovery and an immediate post-operative chest X-ray showed an intra-abdominal relocation of the stomach and a well-defined diaphragmatic outline (Figure 5).