Is rotation of the stomach into a large hiatal hernia a surgical emergency?

Rotation of the Body of the Stomach into a Large Hiatal Hernia is a Surgical Emergency

Rotation of the stomach into a large hiatal hernia (gastric volvulus) is a surgical emergency requiring immediate intervention to prevent potentially lethal outcomes including strangulation, ischemia, and necrosis. 1

Pathophysiology and Presentation

Hiatal hernias with gastric rotation can lead to several life-threatening complications:

• Strangulation: When the blood supply to the herniated stomach becomes compromised
• Incarceration: When the stomach becomes trapped in the thoracic cavity
• Volvulus: Rotation of the stomach that can lead to obstruction and ischemia

Patients typically present with:

• Severe epigastric or retrosternal pain
• Multiple episodes of vomiting
• Signs of intestinal obstruction
• Potential signs of systemic inflammatory response syndrome (SIRS) in advanced cases 2, 1

Diagnostic Approach

Diagnosis should be made promptly through:

• Clinical evaluation for signs of strangulation (severe pain, tenderness, erythema)
• Chest radiography and CT scan to visualize the herniated stomach in the thoracic cavity
• Assessment for signs of ischemia or necrosis 1, 3

Management

Immediate Intervention Required

The World Society of Emergency Surgery guidelines clearly indicate that strangulated hernias require immediate surgical intervention 2. Delayed diagnosis and treatment beyond 24 hours significantly increases mortality rates 2, 3.

Key management principles include:

1. Urgent surgical repair is mandatory for incarcerated types of hiatal hernias that cannot be manually reduced 2, 1
2. Hemodynamically unstable patients or those with suspected bowel compromise require immediate open surgical approach 2
3. Stable patients without signs of peritonitis may be candidates for laparoscopic repair 2, 1

Surgical Approach

The surgical procedure typically involves:

• Reduction and excision of the hernia sac
• Ensuring at least 3 cm of intra-abdominal esophageal length
• Crural closure, potentially with mesh reinforcement
• An anti-reflux procedure when appropriate 4

In cases of gastric necrosis or esophagogastric junction gangrene, more extensive procedures may be necessary:

• Transmediastinal esophagectomy with resection of proximal stomach and gastric pull-up
• Esophagogastrectomy with delayed reconstruction in cases of complete gastric gangrene 3

Complications and Outcomes

Untreated strangulated hiatal hernias with gastric rotation can lead to:

• Gangrene of the esophagogastric junction
• Complete gastric necrosis
• Sepsis
• Death (mortality rates of 60-88% with non-operative management of complicated cases) 2, 3

Important Considerations

• Asymptomatic hiatal hernias can be managed with watchful waiting, as they become symptomatic at a rate of only 1% per year 4
• However, once symptoms of incarceration, strangulation, or volvulus develop, the condition becomes a true surgical emergency 1, 3
• Delayed diagnosis is common as initial symptoms may be misdiagnosed as cardiovascular disorders 3

Early recognition and prompt surgical intervention are critical to prevent the progression to tissue necrosis and potentially fatal outcomes in cases of stomach rotation within a hiatal hernia.