Robotic transabdominal repair of giant hiatal hernia with upside-down stomach

An 82-year-old female was referred for a symptomatic large hiatal hernia that was incidentally noted on computed tomography scan obtained for aortic vasculitic pseudoaneurysm. She presented with chronic intermittent dyspnoea, globus and frequent cough. Preoperative evaluation included a barium swallow study demonstrating an upside-down stomach within the thorax. Computed tomography scan confirmed a giant retrocardiac hiatal hernia containing the majority of the stomach. She consented to robotic giant hiatal hernia repair. On initial inspection in the operating room, we noted a giant hiatal hernia containing the entire stomach and part of the pancreas. Hernia sac reduction was accomplished with meticulous mediastinal dissection, with special attention to given to the aortic vasculitic pseudoaneurysm. After hernia sac reduction and resection, the lesser sac was entered and the short gastric arteries were ligated. We cleared the hiatus and bilateral crura, then resected the gastro-oesophageal junction fat pad. Next, we performed a modified three-stitch Dor fundoplication and finally a single-stitch gastropexy. The patient had an uneventful postoperative course, was discharged on postoperative Day 3 on a soft diet and was doing well at 6-month follow-up without postoperative complications or hernia recurrence.