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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 259-263

Minimally invasive therapy of upside-down stomach: A single-center experience

1 Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc; University Hospital Olomouc, Olomouc, Czech Republic
2 Department of Social Medicine and Public Health, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
3 Department of Surgery I, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic

Date of Web Publication11-Oct-2017

Correspondence Address:
Martin Lovecek
Department of Surgery I, University Hospital Olomouc, I.P. Pavlova 6, 77520 Olomouc
Czech Republic
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_43_17

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Introduction: The aim of this study is to evaluate short-term and long-term outcomes of minimally invasive therapy in Type IV hiatal hernia (upside-down stomach). Patients and Methods: A retrospective study of 58 consecutively operated patients with Type IV hiatal hernia between 1998 and 2015 was conducted. Short-term outcome was evaluated using Clavien-Dindo classification and long-term outcomes using phone survey and subjective assessment of patients at least 1 year following surgery. Results: Laparoscopic hiatoplasty was performed in all patients, with gastropexy in 55.2%, fundoplication in 39.6%, and combination of fundoplication and gastropexy in 5.2%. Complications were observed in 6.9%. Two early reoperations (within 30 days) due to acute reherniation were necessary. Adverse events occurred in seven cases – pleural opening and peroperative bleeding. Three patients were reoperated laparoscopically 2–17 months after the first surgery due to receiving partial stomach herniation. In 67.2% of patients, long-term subjective quality of life assessment was available. Eighty percent of them were completely satisfied, without recurrence of preoperative symptoms. Conclusion: Elective laparoscopic surgery of hiatal hernia Type IV is a safe procedure, which has all the benefits of minimally invasive therapy with favorable short- and long-term results.

Keywords: Gastroesophageal reflux disease, minimally invasive surgery complications, upside-down stomach surgery

How to cite this article:
Vrba R, Neoral C, Aujesky R, Stasek M, Bebarova L, Janda P, Vrbova T, Bohanes T, Vomackova K, Lovecek M. Minimally invasive therapy of upside-down stomach: A single-center experience. CHRISMED J Health Res 2017;4:259-63

How to cite this URL:
Vrba R, Neoral C, Aujesky R, Stasek M, Bebarova L, Janda P, Vrbova T, Bohanes T, Vomackova K, Lovecek M. Minimally invasive therapy of upside-down stomach: A single-center experience. CHRISMED J Health Res [serial online] 2017 [cited 2021 Aug 5];4:259-63. Available from: https://www.cjhr.org/text.asp?2017/4/4/259/216475

  Introduction Top

Type IV hiatal hernia (upside-down stomach) is a dislocation of the entire stomach through the diaphragmatic esophageal hiatus into the mediastinum.[1] Due to the high risk of possible serious complications of the disease, which can have fatal consequences for patients, surgical therapy is considered to be the best therapeutic option. The minimally invasive laparoscopic approach is currently the dominating technique. The principle of the procedure is resection of hernial sac, reposition of the stomach back into the abdominal cavity, hiatoplasty, and fundoplication or gastropexy.[2] The aim of this study was to assess the outcomes of minimally invasive therapy in short and long term.

  Patients and Methods Top

A retrospective study of 58 consecutively operated patients with Type IV hiatal hernia (upside-down stomach) using the laparoscopic procedure was held at a tertiary center between 1998 and 2015. The Institutional Revision Board approved the collection and analysis of data associated with this study. The diagnosis of upside-down stomach was based on endoscopic examination and barium swallow. In most cases, computed tomography (CT) scan was also performed to accurately assess the contents of hernial sac. Three senior upper gastrointestinal (GI) surgeons performed all the procedures. The surgery was performed under general anesthesia in the supine anti-Trendelenburg position with abducted legs. The surgeon was positioned between the patient's legs, the first assistant on the left side and the second assistant on the right side. Capnoperitoneum was inducted by Veress needle 5 cm above the umbilicus, under pressure of 10 mmHg. The standard operation was performed using four 10-mm trocars and one 5-mm trocar. The laparoscope with 30° optics was introduced through the trocar above umbilicus. The surgeon used the 10-mm trocar left of the central axial line; his right hand handling the dissector with monopolar coagulation, scissors, and harmonic scalpel. With his left hand, he worked with the Endo Clinch grasper in a 5-mm trocar, which was located below the right ribcage, 5 cm from the linea alba. The trocar under the breastbone served to introduce the retractor to elevate the left liver lobe. The last trocar below the left costal arch on the frontal axial line was intended for an assistant to use an atraumatic Babcock clamp. After exploration of the abdominal cavity and surgical field, gradual repositioning of the stomach (and other organs, if applicable) from the mediastinum back into the abdominal cavity was performed. The harmonic scalpel was used to perform dissection of the pars flaccida of the lesser omentum and to open the Leimer membrane; resection of the bulky hernial sac followed. Gradually, both diaphragmatic crura were isolated and the distal esophagus was mobilized. A posterior hiatoplasty was performed by single nonabsorbable Z-stitches. Two or three stitches were used according to the diameter of the diaphragmatic hiatus. Mesh implantation to strengthen the diaphragmatic hiatus was not performed in primary procedures. Calibration of the hiatoplasty was done after insertion of a 42Fr nasogastric tube into the stomach. Gastropexy with three individual nonabsorbable U-sutures to the ventral peritoneum was performed in patients without reflux symptoms. In patients with preoperative reflux symptoms or endoscopically confirmed reflux esophagitis, Nissen fundoplication was added. A wrap was created by four single 2-0 Endo stitches; the last stitch was fixed to the distal esophagus to prevent the occurrence of the telescopic phenomenon. Drainage of the abdominal cavity was established individually, based on blood loss during surgery, and was removed on the 2nd postoperative day (POD) at the latest. After the surgery, patients were hospitalized at a standard ward; in case of thoracic drainage or significant internal comorbidities, patients were hospitalized in the Intensive Care Unit. Patients were gradually realimented on the 4th POD. If uncomplicated postoperative course and realimentation, patients were released to home care on the POD 5–7.

Clavien-Dindo classification was used for evaluation of complications and morbidity. Early redo surgery was defined as revision in the first 30 days after the first operation. Long-term results were evaluated according to the telephone contact at least 1 year after the surgery, regarding the presence of preoperative symptoms and subjective evaluation of quality of patients' life. Descriptive statistical analysis methods were used.

  Results Top

The study group consisted of 24 men (41.4%) and 34 women (58.6%), with median of age 68 years (range 43–83). Symptom characteristics are described in [Table 1]. A combination of these symptoms occurred in most patients in their history. In two cases, the finding was entirely incidental during a chest X-ray examination. Eighteen (31%) patients had a history of previous abdominal surgery [Table 1].
Table 1: Symptoms, previous surgeries

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The procedure was completed laparoscopically in all patients. In 6 patients (10.3%), a small pneumothorax occurred due to opening of the right pleura, managed by thoracic drainage. Perioperative bleeding was seen in one patient (left gastric artery) – 250 ml and was managed by endoclips. These situations were classified as perioperative adverse events grade I according to the Satava classification without further consequences [Table 2]. No other perioperative complication was seen. No transfusion was administered. In the early postoperative period (30 days), two reoperations had to be performed on the POD 10 and 25 due to severe epigastric pain with suspicion of hernia recurrence, both by open procedure [Table 3]. Another three patients with recurrence of hiatal hernia required laparoscopic revision 2, 5, and 17 months following the primary procedure.
Table 2: Types of surgeries, complications, operation times, and hospital days

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Table 3: Clavien-Dindo complications of patient with upside-down stomach

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Overall morbidity of the operated group was 6.9%. In total, 39 (67.2%) patients were successfully contacted by telephone. Thirty-one (79.4%) patients evaluated the operation result as very good, without recurrence of preoperative symptoms. Shortness of breath was experienced in 5 patients (12.8%); cardiac etiology was confirmed in all patients. Three patients (7.7%) described epigastric pain, and one female patient (2.6%) experienced typical reflux symptoms managed by antireflux medication [Table 4].
Table 4: Phone survey results of the patients after surgery for upside-down stomach

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The last clinical examination was carried out 1 year after the procedure. If asymptomatic, the patients exhibited no disease symptoms, they were dispatched to their general practitioners' care, and further checkups were on an individual basis. According to the available documentation, except for patients who were operated for recurrence of hernia, there were no records or indicators of further complications in our group of patients.

  Discussion Top

When entering the keyword “upside-down stomach” in the PubMed database, there are 74 articles available, and the oldest is dated from 1952. The patient set ranges from a dominating 23 case reports to a study comprising 40 patients operated minimally invasively for upside-down stomach.[3] Compared to this database, our referred group of patients represents the largest set of patients operated by minimally invasive method for upside-down stomach. Upside-down stomach is a Type IV hiatal hernia with organoaxial torsion of the stomach, which is localized in the thoracic cavity, while the cardia remains at the proper anatomical position. The content of the hernial sac, in addition to the entire stomach, can consist of other abdominal organs, most commonly the colon, spleen, and omentum.[4],[5] Unlike the axial, paraesophageal, and mixed hiatal hernia, reflux symptoms are not expressed in the clinical symptomatology of upside-down stomach.[5] Most commonly, the disease is manifested by postprandial chest discomfort and shortness of breath. Dysphagia, vomiting, and anemia can appear among other symptoms. In some cases, a Type IV hiatal hernia can be asymptomatic and recognized as an incidental mediastinal expansion on the chest radiograph. Subsequent CT and endoscopy may reveal upside-down stomach. On the other hand, acute manifestation of the disease with the possibility of serious complications, such as strangulation, obstruction of the stomach, and acute peptic ulcer bleeding, is very serious.[4],[6] Strangulation of the whole stomach with subsequent ischemia may lead to gangrene with perforation and develop into life-threatening mediastinitis with septic shock. If gastric obstruction by food occurs, there is a risk of aspiration of gastric content into the respiratory tract with subsequent development of pneumonia or respiratory failure.[7] Upside-down stomach is diagnosed on the basis of endoscopic examination or barium swallow, which depicts the stomach in the thoracic cavity above the diaphragm and the gastroesophageal (GE) junction in the proximity of the diaphragmatic hiatus.[4] A complete endoscopic examination of the upper GI tract is not possible in case of gastric torsion. CT scanning helps describe and locate the hernia and stomach in the mediastinum accurately and confirms possible herniation of other organs. The indication for surgery is emergent in patients with acute symptoms; the type of procedure is modified according to perioperative findings.[6] Obeidat describes a 5% incidence of incarceration in bulky hiatus hernias, including upside-down stomach, and he reports 27% mortality unless adequate treatment.[3] All patients diagnosed with upside-down stomach are candidates for surgical elective therapy due to the presented high mortality rate. The current consensus among foregut surgeons favorizes the minimally invasive approach to surgical treatment.[8],[9] The principle of surgical treatment is resection of the hernia sac, reposition of the stomach or other organs into the abdominal cavity, closure of the defect in the esophageal hiatus, and performing fundoplication or gastropexy.[5],[10] When repositioning the stomach back into the abdominal cavity, a problem may occur due to a short esophagus, which is defined as at least a 5-cm long distance of GE junction above the diaphragm. However, short esophagus occurs quite exceptionally in typical upside-down stomach.[11] If the esophagus cannot be mobilized back into the abdominal cavity, a Collis gastroplasty is the appropriate procedure; 20%–70% of patients appreciate this for its minimal incidence of postoperative dysphagia, acid reflux into the esophagus, and hernia recurrence.[12] Prassas,[13] in his group of 55 patients operated for a bulky hiatal hernia, did not notice a single short esophagus. Neither we had such a problem, nor the Collis procedure was performed in our cohort. Closure of the defect in the hiatus may be done by single stitches or by mesh implantation. Most authors incline to suture without mesh implantation due to its higher rate of dysphagia and esophageal erosions.[14] On the other hand, defenders of mesh implantation, Zehetner and Oelschlager, report a lower rate of recurrences of hernia after mesh implantation into the diaphragmatic hiatus.[1],[15] Based on the experience of our institution, posterior hiatoplasty by single stitches is the method of choice. The mesh is implanted on the individual basis if the single stitch cannot guarantee safe realization of the hiatoplasty. In this cohort, the mesh was used once in a patient with recurrence. Fundoplication is added in patients with reflux symptoms. Based on several studies, 90% of reported patients underwent the Nissen modification.[9],[16],[17] The direct antireflux procedure in the form of a Nissen fundoplication is performed in all patients with gastroesophageal reflux disease who undergo surgery for hiatal hernia, including upside-down stomach at our department. Further options of antireflux procedure comprise partial fundoplication by Toupet or Dorr.[17],[18] In the presented cohort, only the Nissen fundoplication was used. Many authors recommend performing gastropexy as a prevention of recurrent hiatal hernia in the absence of reflux symptoms.[14],[17] In our patient set, gastropexy was performed in all patients without reflux symptoms and without endoscopic findings of reflux esophagitis. The combination of fundoplication and gastropexy was indicated on an individual basis in patients with reflux symptoms, where the performed wrap tended to migrate to the hiatus risking the postoperative cuff dislocation into the mediastinum. The most common perioperative complications are bleeding and trauma of the liver, spleen, stomach, and esophagus; in most cases, these complications can be successfully managed without conversion. However, if the laparoscopic treatment of complications fails, conversion and management by open approach may be beneficial.[9] Higher rate of pleural opening and the subsequent development of pneumothorax occur in bulky mixed hiatal hernias and upside-down stomach cases, due to the resection of the bulky hernial sac adjacent to the pleural membrane.[18] This situation cannot be considered a complication. In our cohort, this situation was classified as an adverse event according to the Satava classification.[19] Patti et al. describe the recurrence of reflux complaints after primary antireflux surgery ranging from 10% to 20%.[20] Therapy is chosen individually based on the symptoms, from conservative therapy (proton pump inhibitor, prokinetics) to minimally invasive or open revision surgery, consisting of correction of the primary surgery (redo fundoplication). If the described treatment fails, open procedure is more appropriate in the form of the indirect antireflux procedure with gastric resection and Roux-Y loop.[21] Reoperations are performed mostly due to recurrent hernia. Neither recurrence of the primary symptoms nor the occurrence of new reflux problems was observed in our cohort. The reason for reoperation was dislocation of the stomach or gastric wrap into the mediastinum with dysphagia in all cases.

  Conclusion Top

Minimally invasive elective surgical therapy is the treatment of choice in patients with upside-down stomach. There is a clear consensus among surgeons in the performance of a hernial sac resection and repositioning of the stomach into the abdominal cavity. Hiatoplasty can be done according to the philosophy of the particular workplace by suture of the diaphragmatic crura or by mesh implantation. In case of reflux symptoms or endoscopic findings of reflux esophagitis, the surgery consists of a direct antireflux procedure in the form of complete or partial fundoplication. Gastropexy is performed in patients without these symptoms to prevent hernia recurrence. Elective laparoscopic surgery performed by an experienced surgeon offers a very beneficial minimally invasive therapy with favorable short- and long-term results.

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  References Top

Zehetner J, Lipham JC, Ayazi S, Oezcelik A, Abate E, Chen W, et al. Asimplified technique for intrathoracic stomach repair: Laparoscopic fundoplication with Vicryl mesh and BioGlue crural reinforcement. Surg Endosc 2010;24:675-9.  Back to cited text no. 1
Peters JH. SAGES guidelines for the management of hiatal hernia. Surg Endosc 2013;27:4407-8.  Back to cited text no. 2
Obeidat FW, Lang RA, Knauf A, Thomas MN, Hüttl TK, Zügel NP, et al. Laparoscopic anterior hemifundoplication and hiatoplasty for the treatment of upside-down stomach: Mid- and long-term results after 40 patients. Surg Endosc 2011;25:2230-5.  Back to cited text no. 3
Cherukupalli C, Khaneja S, Bankulla P, Schein M. CT diagnosis of acute gastric volvulus. Dig Surg 2003;20:497-9.  Back to cited text no. 4
Krähenbühl L, Schäfer M, Farhadi J, Renzulli P, Seiler CA, Büchler MW. Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach. J Am Coll Surg 1998;187:231-7.  Back to cited text no. 5
Ekelund M, Ribbe E, Willner J, Zilling T. Perforated peptic duodenal ulcer in a paraesophageal hernia – A case report of a rare surgical emergency. BMC Surg 2006;6:1.  Back to cited text no. 6
Athanasakis H, Tzortzinis A, Tsiaoussis J, Vassilakis JS, Xynos E. Laparoscopic repair of paraesophageal hernia. Endoscopy 2001;33:590-4.  Back to cited text no. 7
Andujar JJ, Papasavas PK, Birdas T, Robke J, Raftopoulos Y, Gagné DJ, et al. Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation. Surg Endosc 2004;18:444-7.  Back to cited text no. 8
Wiechmann RJ, Ferguson MK, Naunheim KS, McKesey P, Hazelrigg SJ, Santucci TS, et al. Laparoscopic management of giant paraesophageal herniation. Ann Thorac Surg 2001;71:1080-6.  Back to cited text no. 9
Gantert WA, Patti MG, Arcerito M, Feo C, Stewart L, DePinto M, et al. Laparoscopic repair of paraesophageal hiatal hernias. J Am Coll Surg 1998;186:428-32.  Back to cited text no. 10
Oelschlager BK, Yamamoto K, Woltman T, Pellegrini C. Vagotomy during hiatal hernia repair: A benign esophageal lengthening procedure. J Gastrointest Surg 2008;12:1155-62.  Back to cited text no. 11
Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic Collis gastroplasty is the treatment of choice for the shortened esophagus. Am J Surg 1996;171:477-81.  Back to cited text no. 12
Prassas D, Rolfs TM, Schumacher FJ. Laparoscopic repair of giant hiatal hernia. A single center experience. Int J Surg 2015;20:149-52.  Back to cited text no. 13
Stadlhuber RJ, Sherif AE, Mittal SK, Fitzgibbons RJ Jr., Michael Brunt L, Hunter JG, et al. Mesh complications after prosthetic reinforcement of hiatal closure: A 28-case series. Surg Endosc 2009;23:1219-26.  Back to cited text no. 14
Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt M, Sheppard B, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: A multicenter, prospective, randomized trial. Ann Surg 2006;244:481-90.  Back to cited text no. 15
Livingston CD, Jones HL Jr., Askew RE Jr., Victor BE, Askew RE Sr. Laparoscopic hiatal hernia repair in patients with poor esophageal motility or paraesophageal herniation. Am Surg 2001;67:987-91.  Back to cited text no. 16
Dahlberg PS, Deschamps C, Miller DL, Allen MS, Nichols FC, Pairolero PC. Laparoscopic repair of large paraesophageal hiatal hernia. Ann Thorac Surg 2001;72:1125-9.  Back to cited text no. 17
Yano F, Stadlhuber RJ, Tsuboi K, Gerhardt J, Filipi CJ, Mittal SK. Outcomes of surgical treatment of intrathoracic stomach. Dis Esophagus 2009;22:284-8.  Back to cited text no. 18
Kazaryan AM, Røsok BI, Edwin B. Morbidity assessment in surgery: Refinement proposal based on a concept of perioperative adverse events. ISRN Surg 2013;2013:625093.  Back to cited text no. 19
Patti MG, Allaix ME, Fisichella PM. Analysis of the causes of failed antireflux surgery and the principles of treatment: A review. JAMA Surg 2015;150:585-90.  Back to cited text no. 20
Grover BT, Kothari SN. Reoperative antireflux surgery. Surg Clin North Am 2015;95:629-40.  Back to cited text no. 21


  [Table 1], [Table 2], [Table 3], [Table 4]


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