Isolated colonic hernia through the oesophageal hiatus causing gastric outlet obstruction

A 79-year-old man was admitted with several days of prolific vomiting, epigastric distention and discomfort with electrolyte derangement of hypochloraemic hypokalaemic metabolic alkalosis, classically associated with gastric outlet obstruction, that resulted in intensive care unit admission. This was on the background of 3 years of intermittent gastro-oesophageal reflux, globus pharyngeus and post-prandial vomiting. He never had symptoms of gastrointestinal obstruction in the past, no history of trauma or previous thoracoabdominal surgery. The patient underwent computed tomography (CT) with portal phase images obtained using a multidetector CT scanner and reviewed by a senior radiologist. CT scan (Figs 1,2) revealed a grossly distended stomach lying entirely within the abdominal cavity with estimated volume of 3000 mL, as well as herniation of the majority of the transverse colon into the posterior mediastinum via a wide-necked oesophageal hiatus. Significant gastric pneumatosis visible on CT scan correlated with serum lactate of 5.5 raised suspicion of gastric necrosis; however, intravenous rehydration saw serum lactate drop to 1.0 rapidly. Following conclusive diagnosis and preoperative optimization with nasogastric decompression of the stomach contents totalling over 5000 mL, intravenous electrolyte replacement and rehydration, the patient underwent planned but emergent laparoscopic repair. During operation, an estimated 70% of the transverse colon was reduced with the hernia sac, which was excised. Due to the size of the defect, closure was undertaken with primary sutured repair and onlay mesh reinforcement. Anterior Dor fundoplication was performed concurrently and the stomach was found to be completely viable. No perioperative complications were encountered, recovery was uneventful and the patient was discharged on day 3 postoperatively. Hiatal hernias are classified into type I–IV. Type I (sliding type) involves migration of the gastro-oesophageal junction through the oesophageal hiatus representing 45% of all hiatal hernias. Paraoesophageal hernia (POH), comprising the remaining 55%, are represented by types II–IV. Type II POH, defined as gastro-oesophageal junction in normal anatomical position but the fundus of the stomach migrating superiorly through the hiatus in what is described as a ‘rolling’ fashion, comprises 20%. Herniation combing features