A 71-year-old male patient of Asian Origin referred by a general physician, without significant comorbidities, family, and personal history presented with a one-month history of regurgitation of acid, retrosternal burning and vomiting after eating. Physical examination revealed bowel sounds upon chest auscultation and decreased breath sounds in the base of the right lung. Clinical findings were as follows: blood pressure, 110/76 mm Hg; pulse rate, 88/min; his body temperature, 36.3  C; and oxygen saturation, 94%. Upper GI esophagogastroduodenoscopy revealed an upward migration of Z line with Grade III Hiatus Hernia (Fig. 1A). Chest X-ray showed an air-fluid level with obscuration of right heart border (Fig. 1B). A manometric examination revealed the average pressure of lower esophageal sphincter was ten mmHg.
CT demonstrated a significant 3.4 cm defect in the anterior diaphragmatic wall, with herniation of bowel on the right side of the chest. The stomach is present on the left side with the anterosuperior displacement of the gastric antrum along with a grade III Para-esophageal hernia (Fig. 2). The Diagnosis of Morgagni Hernia, Para-esophageal Hernia (Grade III) with Organo-Axial Gastric volvulus was made based on the patient symptoms, clinical findings, imaging, and endoscopy results. Because of the patient's symptoms and possible severe complications caused by the two hernias, the decision was taken to go for mesh reinforcement, laparoscopic Hiatal reconstruction with fundoplication.
Before the elective surgery, the patient was started on Incentive Spirometry and administered antibiotic and VTE prophylaxis. Under general anesthesia in the Fowler position, with the surgeon (specializing in minimal access surgery) standing between the patient's legs, a laparoscopic approach was achieved. A Morgagni Hernia containing omentum, stomach and transverse colon was noticed (Fig. 3A, B). The contents were removed from the hernia sac relatively easily using two atraumatic graspers (Fig. 3C). We also found the gastric fundus herniated into the thoracic cavity at a diameter of about 5 cm (Fig. 4A). The stomach is pulled back into the abdominal cavity, and then the hiatus was reconstructed with interruptedly tied 2/0 Prolene sutures behind the esophagus after ensuring that the lower esophagus was at least 3 cm in length in the abdominal cavity (Fig. 4B). Mesh Reinforcement of the Hiatus defect with the bioabsorbable composite mesh. The gastrophrenic ligament mobilized, short gastric vessels ligated, and gastro-splenic ligament was cut to have an adequate Fundic wrap. The vagus nerves were recognized and preserved. Intra-operative esophagogastroduodenoscopy was performed to confirm that the dentate line was 3 cm below the hiatus. A 360  Nissen's fundoplication was then performed to complete the Hiatal closure (Fig. 4C). The 3.4 cm Subcosto-sternal defect was too large to approximate using the trans-abdominal trans-fixation suture. Hence, the decision was taken to close the anterior diaphragmatic defect with the Polypropylene mesh. The mesh was fastened to the diaphragm with the help of tackers and interrupted sutures using Prolene 2/0, taking special precaution to avoid damage to the pericardium (Fig. 4D). The patient was kept Nil by mouth for three days after which he was resumed on a liquid diet advancing to soft food one week after the surgery. The patient reported a single port site infection, which required removal of the skin suture without any need of an antibiotic [Clavien-Dindo classification Grade I]. The patient returned home eight days post operation on proton pump inhibitors medication. At one-month follow-up, the patient did not report any dysphagia, heartburn or symptoms related to reflux. The scars were normal without any pain. Follow-Up CT showed adequate repair of a diaphragmatic and Para-esophageal hernia without any evidence of herniation of Greater Omentum, stomach, and bowel (Fig. 5). There were no gastric complaints at follow-up six months after discharge.