A Case of Internal Hernia into the posterior Mediastinal Route following Laparoscopic Esophagectomy

Abstract

We report a rare case of internal hernia following thoracoscopic and laparoscopic esophagectomy. The patient was a 79-year-old man who had been followed after thoracoscopic and laparoscopic subtotal esophagectomy with reconstruction via the posterior mediastinal route in 2013. He was brought into our hospital because of about postoperative 6-month history of vomiting and abdominal pain in 2014. An abdominal contrast-enhanced computed tomography revealed a small intestine impacted into the left thoracic cavity through the esophageal hiatus. He was diagnosed with bowel necrosis due to an internal hernia and received an emergency operation. During this operation, a 20 cm-long ileum with necrosis was seen to have been impacted into the esophageal hiatus through which a gastric tube was elevated at the previous esophageal operation. Since the impacted intestine became necrotic, partial ileectomy was performed.
Hiatal hernia through a reconstruction route after esophageal operation for esophageal cancer is rare and the causes vary. Postoperative internal hernias may be classified as early or delayed type. This case was of delayed type because it occurred 6 months after operation. On presentation of this case, the patient had an extremely reduced food intake after the initial operation, showing a BMI of 19.1. Therefore, reduction of omental fat of the elevated gastric tube might cause increase of the gap of esophageal hiatus that allowed impaction of a small intestine into there. It was also inferred that intraabdominal adhesions were of mild degree for the laparoscopic surgery. Tese were the likely causes of this hiatal hernia involving the small intestine.