Laparoscopic Posterior Cruroplasty and Anterior Gastropexy for Type IV Hiatal Hernia Repair in an Elderly Patient: A Case Report and Review of the Literature.

A hiatal hernia describes a defect of the portion of the esophageal hiatus of the diaphragm, which leads to herniation of the abdominal contents into the chest cavity. Type IV paraesophageal hernias (PEH) have been associated with relatively large defects and are usually symptomatic. Surgical intervention is indicated in patients with symptoms or complicated paraesophageal hernias. The elderly age group represents a challenge in terms of management approach. Our purpose is to emphasize the safety and efficacy of early laparoscopic posterior cruroplasty and anterior gastropexy during PEH repair in the elderly age group. A 90-year-old male without significant past medical or surgical history was admitted for a five-day history of left upper quadrant abdominal pain associated with multiple episodes of vomiting. The physical exam revealed left upper quadrant pain and rebound tenderness. Abdominal CT with IV contrast showed a large hiatal hernia containing the entire stomach and part of the duodenum with an abrupt transition zone at the duodenum. The patient underwent laparoscopic hiatal hernia repair, posterior cruroplasty, and anterior gastropexy. Postoperatively, the patient tolerated the procedure, and further follow-up in the clinic showed resolution of his symptoms without complications. Prompt identification and proper management represent a crucial step in the management of PEH, especially in elderly comorbid patients. Laparoscopic anterior gastropexy is a safe and effective method for type III/IV hiatal hernias in elderly patients.