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Chronic mesenteroaxial gastric volvulus and congenital diaphragmatic hernia: successful laparoscopic repair

Borkar NB, Pant N, Ratan S, Kumar A, Aggarwal SK
Maulana Azad Medical College, New Delhi, India

 

Correspondence

Dr. Satish Aggarwal
Type V, No V Quarter, Maulana Azad Medical College,
110002 New Delhi, India
Tel: +91-11-23234641
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Gastric volvulus is a rare cause of acute abdomen in children. Usually it is associated with diaphragmatic pathology. Traditional treatment of gastric volvulus has been derotation and gastropexy with the anterior abdominal wall. We report a case of 9 year old boy presented with recurrent abdominal pain and vomiting. Investigations confirmed a volved stomach in the left chest and a left diaphragmatic hernia. Laparoscopic reduction and repair of diaphragmatic hernia was performed successfully. The stomach was devolved and reduced into the abdomen. No gastropexy was performed. The patient is asymptomatic two year after surgery. Our case shows that gastropexy may not be needed in all cases. Also this is perhaps the first case to undergo laparoscopic repair of CDH and gastric volvulus in pediatric population.

Key words: gastric volvulus, congenital diaphragmatic hernia, laparoscopic repair.

 

Introduction

Congenital diaphragmatic hernia (CDH) results from failure of pleuroperitoneal canal to close around 6th and 8th weeks of gestation. Although neonatal presentation with respiratory distress is common presentation, delayed presentation and incidental detection is also well known. Association of CDH with mesentero axial volvulus of the stomach is also well known. In children, mesentero- axial is the most common type of gastric volvulus and association with anatomic defects is a rule [1]. Although laparoscopic repair of congenital diaphragmatic hernia was reported as early as 1995, there is no report of concomitant correction of symptomatic gastric volvulus [2]. Also the traditional treatment of gastric volvulus has been reduction and gastropexy. Here we report a case of CDH with mesenteroaxial gastric volvulus, which was managed laparoscopically. No gastropexy was done.

Case report

A 9 year old boy presented with history of episodic non bilious vomiting, recurrent abdominal pain and abdominal distension for a year. There was no history of constipation, fever or a prior surgery. On examination there was fullness in upper abdomen but no tenderness. Bowel sounds were normal. Systemic examination was normal. Plain abdominal film showed elevated left dome of diaphragm and a large air fluid level just beneath it. Rest of the bowel gas pattern was normal. Visualised lung fields were normal. A nasogastric tube could be easily passed. About 500 ml gastric non bilious fluid was aspirated with relief from distension. Eventration of diaphragm with volvulus was suspected. A contrast enhanced CT scan was done, which showed a volved stomach with air fluid level in the left chest and diaphragmatic hernia.

In view of associated gastric volvulus, laparoscopic approach was used rather than thoracoscopy. Under general anaesthesia in supine position, ports were inserted as shown in diagram. Open cannulation was used fro the primary port. The pressure was kept between 10-12 mm Hg. The left side was elevated to facilitate the operation. Additionally the falciform ligament was hooked up with a stitch. The left triangular ligament was taken down to retract the left lobe of liver. A large posterolateral defect in the diaphragm was found, through which the stomach, spleen and part of small bowel and large bowel was herniating (fig.1). Intestines were reduced with gentle pull. The spleen was reduced with the help of the shaft of the 5mm Babcock forceps. The margins of the defect were freshened with diathermy. The defect was closed by interrupted polypropelene sutures using intracorporeal knotting (fig 2). Chest tube was inserted under guidance before taking last bites. The viscera was placed in normal anatomical position. Hemostsis was checked and port sites closed. A nasogastric tube s left for three days (fig. 3). Patient was discharged on fifth postoperative day and doing well during two year of follow up.

7.1.11

Fig 1: Post operative Chest X ray showing normal position of diaphragm.


7.1.10

Fig 2: Laparoscopic view of the defect. Chest wall is seen through the defect.

 

7.1.9

Figure 3: Laparoscopic view showing suturing of the defect.

Discussion

Acute gastric volvulus is an event that may happen in both adults and children. In 1866 Berti published a case of death secondary to an isolated acute gastric volvulus [3]. In 1904 Borchardt’s described the clinical features acute gastric volvulus which later denominated as a “Borchardt’s triad”: acute localised epigastric distension, inability to pass the nasogastric tube and unproductive retching [4]. This triad may not always present in children, as in our case where we were able to pass the nasogastric tube and derotate the stomach. Delayed presentation of CDH has been reported at all ages and account for 5% to 10% of all CDH [5]. Patients can present with either digestive or respiratory symptoms. Pulmonary hypoplasia, usually a major prognostic factor in neonate, is often minor or non-existent in this setting. Cameron and Howard found congenital diaphragmatic hernia in 65% of children with gastric volvulus and 84% of those less than 1 month [6]. The high frequency of this association may be explained by the increased space around the stomach under the left diaphragmatic defect and by the laxity of gastrophrenic and gastrosplenic ligament. Surgical treatment is the primary mode of therapy. It should include reduction, primary repair of the anatomic defect, and fixation of the stomach.

We have not done any gastric fixation on contry to the popular belief of fixating the stomach after its reduction and repair. Once the defect was repaired all the viscera occupied the normal anatomical position. Therefore the extra space around the stomach was obliterated. No gastropexy was therefore, performed. If volvulus is idiopathic then surgeon should consider gastropexy. Review done by Miller et al. of 77 patients of gastric volvulus in paediatrics population where he described 3 recurrences two of these three recurrences were in the patients who undergone reduction only and the third had underwent combined reduction and anterior gastropexy only [1]. There is no recurrence in patient in the group where reduction and repair of associated defect done. No study available in paediatric population describing only the repair of the anatomical defect in mesenteroaxial volvulus but think that if the defect is causing the volvulus then repair of the defect must treat the disease. But this needs more study and evaluation of this aspect.

 

 

References

1. Miller DL, Pasquale MD, Seneca RP, Hodin E. Gastric volvulus in the pediatric population. Arch Surg. 1991 Sep; 126(9):1146-9.

2. Van der Zee DC, Bax NM. Laparoscopic repair of congenital diaphragmatic hernia in a 6-month-old child. Surg Endosc. 1995 Sep; 9(9):1001-3.

3. Berti A. Singolare attortigliamento dell esofago colduodeno seguito da rapido morte. Gazz Med.1866. Ital 9:136.

4. Borchardt M. Zur Pathologie und Therapie des Magen Volvulus. Arch Klin Chir. 1904.74, 243-260.

5. Berman L, Stringer DA, Ein S, Shandling B. Childhood diaphragmatic hernias presenting after the neonatal period. Clin Radiol. 1988 May; 39(3):237-44.

6. Cameron AE, Howard ER. Gastric volvulus in childhood. J Pediatr Surg. 1987 Oct; 22(10):944-7.