Massive hiatal hernia through a prior diaphragmatic relaxing incision: case report with a literature review

This case report presents a rare complication of a massive Type IV hiatal hernia occurring through a diaphragmatic relaxing incision (DRI) created during a previous Nissen fundoplication. An 82-year-old female presented with abdominal pain, shortness of breath, and small bowel obstruction. Imaging revealed herniation of the small bowel, colon, and spleen through a diaphragmatic defect. Seven years prior, the patient underwent a Nissen fundoplication with mesh repair, during which bilateral DRIs were created to reduce diaphragmatic tension. Despite prior concerns about operative risks, emergent surgery was performed to reduce the hernia and resect infarcted bowel. Postoperative recovery was complicated by hypotension requiring vasopressor support, but the patient ultimately recovered well. This case highlights the potential for catastrophic herniation through DRIs and underscores the need for careful surgical technique and postoperative surveillance. Literature review suggests that more focused research is needed to establish optimal management and prevention strategies for this complication.