V-10. Mechanical Phenotype in Acute Paraesophageal Hernia: Durable Repair With Biosynthetic Reinforcement and Toupet Fundoplication

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ID: 325638
2026
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Ranked #22 of 453 articles by views in diseases of the esophagus : official journal of the international society for diseases of the esophagus

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Abstract
Abstract Topic Benign Disease: Gastro-Esophageal Reflux and Hiatal Hernia Background Acute paraesophageal hernia with volvulus represents a mechanical presentation requiring urgent intervention. Operative priorities differ from reflux-dominant disease, with emphasis on restoration of anatomy and durable repair. A phenotype-based approach may clarify operative intent and guide selection of adjuncts in complex presentations. Methods We present a video case of a patient presenting with acute gastric volvulus secondary to a large paraesophageal hernia. The case is contextualised within a phenotype-based decision framework. Preoperative assessment identified a dominant mechanical phenotype, with operative intent focused on restoration of anatomy and durability. The surgical approach included complete mediastinal mobilisation, crural repair with biosynthetic reinforcement, and partial posterior fundoplication. Key technical steps are demonstrated, including reduction of herniated contents, oesophageal length assessment, hiatal closure under tension control, and tailored fundoplication. The rationale for mesh reinforcement and partial fundoplication is discussed in relation to phenotype-specific operative priorities. Results Complete reduction of the hernia and restoration of intra-abdominal oesophageal length were achieved. Crural repair was reinforced with a biosynthetic mesh to support durability in the context of a large defect. A posterior partial fundoplication was performed to restore functional anatomy while minimising the risk of postoperative dysphagia. The patient recovered without major complication. Early postoperative assessment demonstrated resolution of obstructive symptoms and restoration of oral intake. No early recurrence was identified. This case illustrates alignment between phenotype, operative strategy, and outcome priorities, with technical choices driven by the need for durable anatomical repair rather than reflux control. Conclusion In acute paraesophageal hernia with a dominant mechanical phenotype, operative strategy should prioritise anatomical restoration and durability. This video demonstrates how phenotype-based decision-making informs selection of adjuncts such as mesh reinforcement and tailored fundoplication. The approach highlights the importance of aligning technical execution with operative intent in complex foregut surgery. Video Description This video demonstrates the management of acute gastric volvulus due to a large paraesophageal hernia within a phenotype-based decision framework. The case represents a dominant mechanical presentation, where operative priorities are restoration of anatomy and durable repair. Key steps include complete mediastinal mobilisation, tension-controlled crural repair with biosynthetic reinforcement, and tailored posterior fundoplication. The video highlights how operative strategy and technical choices are driven by phenotype-specific objectives rather than uniform practice. It provides a structured approach to managing complex mechanical presentations and illustrates the practical application of a decision-making framework linking presentation, operative intent, and outcome priorities.
Reference Key
openalex_W7203889420 Use this key to autocite in the manuscript while using SciMatic Manuscript Manager or Thesis Manager
Authors Francesco Di Maggio
Journal diseases of the esophagus : official journal of the international society for diseases of the esophagus
Year 2026
DOI
10.1093/dote/doag077.410
URL
https://doi.org/10.1093/dote/doag077.410
Keywords Keywords not found

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